OUTWITTING OUR NERVES (continued 4)

Physiological Fatigue

Fatigue, not Exhaustion. In the first place, then, fatigue very seldom means a lack of strength or an exhaustion of energy. The average man in the course of a lifetime probably never knows what it is to be truly exhausted. If he should become so tired that he could in no circumstances run for his life, no matter how many wild beasts were after him, then it might seem that he had drained himself of all his store of energy. But even in that case, a large part of his fatigue would be the result of another cause.

A Matter of Chemistry. True fatigue is a chemical affair. It is the result of recent effort,—physical, mental, or emotional,—and is the sum of sensations arising from the presence of waste material in the muscles and the blood. The whole picture becomes clear if we think of the body as a factory whose fires continuously burn, yielding heat and energy, together with certain waste material,—carbon dioxide and ash. Within man's body the fuel, instead of being the carbon of coal is the carbon of glycogen or animal starch, taken in as food and stored away within the cells of the muscles and the liver. The oxygen for combustion is continuously supplied by the lungs. So far the factory is well equipped to maintain its fires. Nor does it fail when it comes to carrying away waste products. Like all factories, the body has its endless chain arrangement, the blood stream, which automatically picks up the debris in its tiny buckets—the blood-cells and serum—and carries it away to the several dumping-grounds in lungs, kidneys, intestines, and skin.

Besides the products of combustion, there are always to be washed away some broken-down particles from the tissues themselves, which, like all machinery, are being continuously worn out and repaired. By chemical tests in the laboratory, the physiologist finds that a muscle which has recently been in violent exercise contains among other things carbon dioxid, urea, creatin, and sarco-lactic acid, none of which are found in a rested muscle. Since all this debris is acid in reaction and since we are "marine animals," at home only in salt water or alkaline solution, the cells must be quickly washed of the fatigue products, which, if allowed to accumulate, would very soon poison the body and put out the fires.

No Back Debts. The human machine is regulated to carry away its fatigue products as fast as they are made, with but slight lagging behind that is made good in the hours of sleep, when bodily activities are lessened and time is allowed for repair. Unless the body is definitely diseased, it virtually never carries over its fatigue from one day to another. In the matter of fatigue, there are no old debts to pay. Nature renews herself in cycles, and her cycle is twenty-four hours,—not nine or ten months as many school-teachers seem to imagine, or eleven months as some business men suppose. In order to make assurance doubly sure, many set apart every seventh day for a rest day, for change of occupation and thought, and for catching up any slight arrears which might exist. But the point is that a healthy body never gets far behind.

If through some flaw in the machine, waste products do pile up, they destroy the machine. If the heart leaks or the blood-cells fail in their carrying-power, or if lungs, kidneys or skin are out of repair, there is sometimes an accumulation of fatigue products which poisons the whole system and ends in death. But the person with tuberculosis or heart trouble does not usually allow this to happen. The body incapacitated by disease limits its activities as closely as possible within the range of its power to take care of waste matter. Even the sick body does not carry about its old toxins. The man who had not eliminated the poisons of a month-old effort would not be a tired man. He would be a dead man.

A Sliding Scale. If all this be true, real fatigue can only be the result of recent effort. If one is still alive, the results of earlier effort must long since have disappeared. The tissue-cells retain not the slightest trace of its effects. Fatigue cannot possibly last, because it either kills us or cures itself. Up to a certain point, far beyond our usual high-water mark, the more a person does the more he can do. As Professor James has pointed out, the rate of repair increases with the rate of combustion. Under unusual stress, the rate of the whole machine is increased: the heart-pump speeds up, respirations deepen and quicken, the blood flows faster, the endless chain of filling and emptying buckets hurries the interchange of oxygen and carbon dioxid, until the extreme capacity is reached and the organism refuses to do more without a period of rest.

The whole arrangement illustrates the wonderful provisions of Nature. Although each individual is continuously manufacturing enough carbonic-acid gas to kill himself in a very few minutes, he need not be alarmed for fear that he may forget to expel his own poisons. Nobody can hold his breath for more than a few minutes. The naughty baby sometimes tries, but when he begins to get black in the face, he takes a breath in spite of himself. The presence of carbonic-acid gas in the circulation automatically regulates breathing, and the greater the amount of gas the deeper the breath. The faster we burn the faster we blow. As with breathing, so with all the rest of elimination and repair. The body dares not get behind.

"Second Wind." A city man frequently sets out on a mountain tramp without any muscular preparation for the trip. He walks ten or fifteen miles when his average is not over one or two. Sometimes after a few hours he feels himself exhausted, but a glorious view opens out before him and he goes on with new zest. He has merely increased his rate of repair and drawn on a new stock of energy. That night he is tired, and the next day he is likely to be stiff and sore. There is a little fatigue left in him, but it takes only a day or two for the body to be wholly refreshed, especially if he hastens the process by another good walk. Up to a certain point, far beyond our usual limit, the more we do, the more we can do.

One day after a long walk my little daughter said that she could go no farther and waited to be carried. But she soon spied a dog on ahead and ran off after him with new zest. She followed the dog back and forth, running more than a mile before she reached home, and then in the exuberance of her spirits, ran around the house three times.

The Emotions Again. What is the key that unlocks new stores of energy and drives away fatigue? What is it in the amateur mountain-climbers that helps the body maintain its new standard? What keeps indefatigable workers on the job long after the ordinary man has tired? Is it not always an invigorating emotion,—the zest of pursuit, the joy of battle, intense interest in work, or a new enthusiasm? All great military commanders know the importance of morale. They know that troops can stand more while they are going forward than while running away, that the more contented and hopeful they are, the better fighters they make; discouragement, lack of interest, the fighting of a losing game, dearth of appreciation, futility of effort, monotony of task, all conspire in soldier or civilian to use up and to lock up energy which might have been available for real work. Approaching the matter from a new angle, we find once more that the difference between strength and weakness is in many cases merely a difference in the emotions and feeling-tones which habitually control.

Fatigue is a safety-device of nature to keep us within safe limits, but it is a device toward which we must not become too sensitive. As a rule it makes us stop long before the danger point is reached. If we fall into the habit of watching its first signals, they may easily become so insistent that they monopolize attention. Attention increases any sensation, especially if colored by fear. Fear adds to the waste matter of fatigue little driblets of adrenalin and other secretions which must somehow be eliminated before equilibrium is reestablished. This creates a vicious circle. We are tired, hence we are discouraged. We are discouraged, hence we are more tired. This kind of "tire" is a chemical condition, but it is produced not by work but by an emotion. He who learns to take his fatigue philosophically, as a natural and harmless phenomenon which will soon disappear if ignored, is likely to find himself possessed of exceptional strength. We can stand almost any amount of work, provided we do not multiply it by worry. We can even stand a good deal of real anxiety provided it is not turned in on ourselves and directed toward our own health.

"Decent Hygienic Conditions." If fatigue products cannot pile up, why is extra rest ever needed? Because there is a limit to the supply of fuel. If the fat-supply stored away for such emergencies finally becomes low, we may need an extra dose of sleeping and eating in order to let the reservoirs fill again. But this never takes very long. The body soon fills in its reserves if it has anything like common-sense care. The doctrine of reserve energy does not warrant a careless burning of the candle at both ends. It presupposes "decent hygienic conditions,"—eight hours in bed, three square meals a day, and a fair amount of fresh air and exercise.

"Over There." On the other hand, the stories that floated back to us from the war zone illustrate in the most powerful way what the human body can do when necessity forbids the slightest attention to its needs. One of the best of these stories is Dorothy Canfield's account of Dr. Girard-Mangin, "France's Fighting Woman Doctor." Better than any abstract discussion of human endurance is this vibrant narrative of that little woman, "not very strong, slightly built, with some serious constitutional weakness," who lived through hardships and accomplished feats of daring which would have been considered beyond the range of possibility—before the war.

Think of her out there in her leaky makeshift hospital with her twenty crude helpers and her hundreds of mortally sick typhoid patients; four hundred and seventy days of continuous service with no place to sleep—when there was a chance—except a freezing, wind-swept attic in a deserted village. Think of her in the midst of that terrible Battle of Verdun, during four black nights without a light, among those delirious men, and then during the long, long ride with her dying patients over the shell-swept roads. Listen to her as she speaks of herself at the end of that ride, without a place to lay her head: "Oh, then I did feel tired! That morning for the first time I knew how tired I was, as I went dragging myself from door to door begging for a room and a bed. It was because I was no longer working, you see. As long as you have work to do you can go on." Then listen to her as she receives her orders to rush to a new post, before she has had time to lay herself on the bed she has finally found. "Then at once my tiredness went away. It only lasted while I thought of getting to bed. When I knew we were going into action once more, I was myself again." Watch her as she rides on through the afternoon and the long dangerous night; as she swallows her coffee and plum-cake, and operates for five hours without stopping; as she sleeps in the only place there is—a "quite comfortable chair" in a corner; and as she keeps up this life for twenty days before she is sent—not on a vacation, mind you, but to another strenuous post. [51]

This brave little woman is not an isolated example of extraordinary powers. The human race in the great war tapped new reservoirs of power and discovered itself to be greater than it knew. Professor James's assertions are completely proved,—that "as a rule men habitually use only a small part of the powers which they actually possess," and that "most of us may learn to push the barrier (of fatigue) further off, and to live in perfect comfort on much higher levels of power."

How? The practical question is: how may we—the men and women of ordinary powers, away from the extraordinary stimulus of a crisis like the great war—attain our maximum and drop off the dreary mantle of fatigue which so often holds us back from our best efforts? It may be that the first step is simply getting a true conception of physical fatigue as something which needs to be feared only in case of a diseased body, and which is quite likely to disappear under a little judicious neglect.

In the second place, fatigue shows itself to be closely bound up with emotions and instincts. The great releasers of energy are the instincts. What but the mothering instinct and the love of country could uncover all those unsuspected reserves of Dr. Girard-Mangin and others of her kind? What is it but the enthusiasm for work which explains the indefatigable energy of Edison and Roosevelt? If the wrong kind of emotion locks up energy, the right kind just as surely unlocks great stores which have hitherto lain dormant. If most people live below their possibilities, it is either because they have not learned how to utilize the energy of their instinctive emotions in the work they find to do, or because some of their strongest instincts which are meant to supply motive power to the rest of life are locked away by false ideas and unnecessary repressions, and so fail to feed in the energy which they control. In such a case, the "spring tonic" that is needed is a self-knowledge which shall release us from hampering inhibitions and set us free for enthusiastic self-expression.

Nervous Fatigue

What of the Nervous Invalid? If the normal man lives constantly below his maximum, what shall we say of the nervous invalid? Fatigability is the very earmark of his condition. In many instances he seems scarcely able to raise his hand to his head. Sometimes he can scarcely speak for weariness. Frequently to walk a block sends him to bed for a week. I once had a patient who felt that she had to raise her eyelids very slowly for fear of over-exertion. She could speak only about two or three words a day, the rest of the time talking in whispers. She could not raise a glass to her lips if it were full of water, but could manage it if only half full. A person nearly dead with some fatal disease does not appear more powerless than a typical neurasthenic.

If it he true that accumulation of fatigue is promptly fatal, what shall we say of the woman who says that she is still exhausted from the labor of a year ago,—or of ten years ago? What of the business man who travels from sanatorium to sanatorium because five years ago he went through a strenuous year? What of the college student who is broken down because he studied too hard, or the teacher who is worn out because of ten hard years of teaching? There can be but one answer. No matter what their feelings, they can be suffering from no true physiological fatigue. Something very real has happened to them, but only through ignorance and the power of suggestion can it be called fatigue and attributed to overwork.

Stories of Real People. Perhaps if we look over the stories of a few people who have been members of my household, we may work our way to an understanding of the truth. We give only the barest outline of the facts, thinking that the cumulative effect of a number of cases will outweigh a more detailed description of one or two. The most casual survey shows that whatever it was that burdened these fine men and women, it was not lack of energy. No matter how extreme had been their exhaustion, they were able at once, without rest or any other physical treatment, to summon strength for exertions quite up to those of a normal person.

The second point that stands out clearly to any one acquainted with these inner histories is the conviction that in each case the trouble was related in some way to the unsatisfied love-life, to the insistent and thwarted instinct of reproduction. In some cases no search was made for the cause. The simple explanation that there was no lack of power was sufficient to release inhibited energy. But in every case where the cause was sought, it was found to be some outer lack of satisfaction, or some inner repression of the love-force.

From Prostration to Tennis. One young woman, Miss A., had suffered for ten years from the extremest kind of fatigue. She could not walk a block without support and without the feeling of great exhaustion. Before her illness she had had a sweetheart. Not understanding her normal physical sensations when he was near, she had felt them extremely wicked and had repressed them with all her strength. Later, she broke off the engagement, and a little while after developed the neurosis. Within a week after coming to my house, she was playing tennis, walking three miles to church, and generally living the life of a normal person.

Making Her Own Discoveries. Then there was Miss B. who for four years had been "exhausted." She had such severe pains in her legs that she was almost helpless. If she sewed for half an hour on the sewing machine, she would be in bed for two weeks. Although she was engaged to be married, she could not possibly shop for her trousseau. Two years before, a very able surgeon had been of the opinion that the pain in the legs was caused by an ovarian tumor. He removed the tumor, assuring the patient that she would be cured. However, despite the operation and the force of the suggestion, the pains persisted.

After she had been with me for a few days, she sewed for an hour on the machine. In a day or so she took a four-mile walk in a cañon near the house and, on returning in the afternoon, walked two and a half miles down town to do some shopping. I did not make an analysis in her case because she recovered so quickly,—going home well within two weeks. But she declared that she had found the cause while reading in one of the books on psychology. I had my suspicions that the long-drawn-out engagement had something to do with the trouble, but I did not confirm my opinion. A long engagement, by continually stimulating desire without satisfying it, only too often leads to nervous illness.

Afraid of Heat. Professor X., of a large Eastern college, had been incapacitated for four years with a severe fatigue neurosis and an intense fear of heat. Constantly watching the weather reports, he was in the habit of fleeing to the Maine coast whenever the weather-prophet predicted warm weather. After a short re.ëducation, he discovered that his fatigue was symbolic of an inner feeling of inadequacy, and that it bore no relation to his body. Discarding his weariness and throwing all his energies into the Liberty Loan Campaign, he found himself speaking almost continuously throughout one of the hottest days in the history of California, with the thermometer standing at 107 degrees. After that he had no doubt as to his cure.

In Bed from Fear. Miss C. was carried into my house rolled in a blanket. She had been confined to her bed except for fifteen minutes a day, during which time she was able to lie in a hammock! It seems that her illness was the result of fear, an over-reaction to early teaching about self-abuse. Her mother had frightened her terribly by giving her the false idea that this practice often leads to insanity. Having indulged in self-abuse, she believed herself going insane, and very naturally succumbed to the effects of such a fear. After a few days of re-education, she was as strong as any average person. Having no clothing but for a sick-room, she borrowed hat, skirt, and shoes, and walked to church, a three-mile walk.

Empty Hands. Miss Y., a fine woman of middle age, suffering from extreme fatigue could neither sleep nor eat. She could only weep. She had spent her life taking care of an invalid girl who had recently died. Now her hands were empty. Like many a mother whose family has grown up, she had no outlet for her mothering instinct, and her sense of impotency expressed itself in the only way it knew how,—through her body. As there is never any lack of unselfish work to be done, or of people who need mothering, she soon found herself and learned how to sublimate her energy in useful activities.

Defying Nature. One young man from Wyoming had felt himself obliged to give up his business because he could neither work nor eat. It soon cropped out that he and his wife had decided that they must not have any children. With a better understanding of the great forces which they were defying, his strength and his appetite came back and he went back to work, rejoicing.

Left-over Habits. Often a state of fatigue is the result of a carried-over habit. One of my patients, a young girl, had several years before been operated on for exophthalmic goiter. This is a disease of the thyroid gland, and is characterized by rapid heart, extreme fatigue, and numerous other symptoms. Although this girl's goiter had been removed, the symptoms still persisted. She could not walk nor do even a little work, like wiping a few dishes. I took her down on the beach, let her feel her own pulse and mine and then ran with her on the sand. Again I let her feel our pulses and discover for herself that hers had quickened no more than was normal and had slowed down as soon as mine. After a few such lessons, she was convinced that her symptoms were reverberations for which there was no longer any physical cause.

Another young girl, Miss L., had had a similar operation for goiter six years before. Since that time she had been virtually bedridden. During the first meal she had at my house her sister sat by her couch because she must not be left alone. By the second meal the sister had gone, and Miss L. ate at the table with the other guests. That night she managed to crawl upstairs, with a good deal of assistance and with great terror at the probable results of such an effort. After that, she walked up-stairs alone whenever she had occasion to go to her room. Her heart will always be a little rapid and her body will never be very strong, but she now lives a helpful happy life at home and among her friends.

In cases like this the exaggeration proves the counterfeit. Nobody could have been so down and out physically without dying. The exaggeration secures attention and gives the little satisfaction to the natural desires which are denied expression, and which gain an outlet through habit along the lines previously worn by the real disease. Many a person is still suffering from an old pain or an old disability whose cause has long since disappeared, but which is stamped on the mind and believed in as a present reality. Since the sensation is as real as ever, it is sometimes very hard to believe that it is not legitimate, but if the person is intelligent, a little explanation and re-education usually suffices.

Twenty Years an Invalid. Mr. S., from Ohio, had spent much of his time for twenty years going from one sanatorium to another. There was scarcely a health resort in the country with which he was not familiar. The day he came to me he felt himself completely exhausted by the two-block walk from the car. He explained that he could scarcely listen to what I was saying because his brain was so fagged that concentration was impossible. When asked to read a book, he dramatically exclaimed, "Books and I have parted company!" I set him to work reading "Dear Enemy" but it was not a week before he was devouring the deeper books on psychology, in complete forgetfulness of the pains in his head. Playing golf and walking at least six miles every day, he rejoiced in a new sense of strength in his body, which for twenty years he had considered "used up." He is now doing a man-sized job in the business and philanthropic life of his home city.

Brain-fag. This feeling of brain-fag is one of the commonest nervous symptoms; and almost always it is supposed to be the result of intellectual overwork. Some people who easily accept the idea that physical work cannot cause nervous breakdown can scarcely give up the deep-rooted notion that intense mental work is harmful. Intellectual effort does give rise to fatigue in exactly the same way as does physical exertion, but the body takes care of the waste products of the one just as it does those of the other. Du Bois says that out of all his nervous cases he has not found one which can be traced to intellectual overwork. I can say the same thing, and I know no case in all the literature of the subject whose symptoms I can believe to be the result of mental labor.

The college students who break down are not wrecked by intellectual work. In some cases, one strong factor in their undoing is the strain and readjustment necessary because of the discrepancies between some of their deepest religious beliefs and the truth as they learn it in the class-room. The other factors are merely those which play their part in any neurosis.

Re-educating the Teacher. School-teachers are prone to believe themselves worn out from the mental work and the strain of the strenuous life of teaching. Many a fine, conscientious teacher has come to me with this story of overwork. But the school-teacher is as easily re-educated as is any one else. I usually begin the process by stating that I taught school myself for ten years and can speak from experience. After I explain that there is no physical reason why the teachers of some cities are fagged out at the end of nine months while those in other cities whose session is longer can hold on for ten months, and stenographers who lead just as strenuous a life manage to exist with only a two-weeks' vacation, they begin to see that perhaps after all they have been fooling themselves by a suggestion, "setting" themselves for just so long and expecting to be done up at the end of the term. Many of these same teachers have gone back to their work with a new sense of "enough and to spare" and some of them have written back that they have passed triumphantly through especially trying years with no sense of depletion.

In any work, it is the feeling of strain which tells, the emotionalism and feeling sorry for oneself because one has a hard job. It is wonderful what a sense of power comes from the simple idea that we are equal to our tasks.

Sudden Relief. The story of Mr. V. illustrates Professor James's statement that often the fatigue gets worse up to a certain critical point, and then suddenly passes away. Mr. V. was another patient who was "physically exhausted." When the rest of "the family" went clamming on the beach, he felt himself too weak for such exertions, so I left him on the sand to hold the bag while the rest of us dug for clams. The minute I turned my back he disappeared. I found him lying flat on his back, resting, behind the bulk-head. I decided that he needed the two-mile walk home and we all set out to walk. "Doctor, this is cruel. It is dangerous. My knees can never stand this. I shall be ill!" ran the constant refrain for the first mile. Then things went a bit better. Toward the last he found, to his absolute astonishment, that the fatigue had entirely rolled away. The last half-mile he accomplished with perfect ease. Needless to say, he never again complained of physical exhaustion.

False Neuritis. Miss T. was suffering from fatigue and very severe pains in her arms, pains which were supposed to be the result of real neuritis, but which did not correspond to the physiological picture of that disease. A consultation revealed the fact that her love-instinct had been repeatedly stimulated, and then at the last, when it had expected satisfaction, had been disappointed. A discussion of her life, its inner forces, and her future aims helped to pull her together again and give her instinct new outlets. The pains and the fatigue disappeared at once.

Something Wrong. These cases are chosen at random and are typical of scores of others. In no single case was the trouble feigned or imaginary or unreal. But in every case it was a mistake. The sense of loss of muscular power was really a sense of loss of power on the part of the soul. Some inner force was reaching out, reaching out after something which it could never quite attain. As it happened, in every case that I analyzed, the force which felt itself defeated and inadequate was the thwarted instinct of reproduction. Like a man pinned to the ground by a stronger force, it felt itself most helpless while struggling the hardest. Just as we feel a thrill of fright when we step up in the dark and find no step there, so this instinct had gotten itself ready for a step which was not there. Inner repressions or outer circumstances had denied satisfaction and left only an undefined sense that something was wrong. The life-force, feeling itself helpless, limp, tired, had no way of expressing itself except in terms of the body. Since expression is itself a relief and an outlet for feeling, the denied desire had seized on suggestions of overwork to explain its sense of weariness, and had symbolized its soul-pain by converting it into a physical pain. The feeling of inadequacy was very real, but it was simply displaced from one part of the personality to another,—from an unknown, inarticulate part to one which was more familiar and which had its own means of expression.

Locked-up Energy. We do not know just how the soul can make its pain so intensely real to the body, but we do know that any conviction on the part of the subconscious mind is quickly expressed in the physical machine. A conviction of pain or of powerlessness is very soon converted into a feeling which can scarcely be denied. The mere suggestion that the body is overworked is enough to make it tired.

We know, too, that the instincts are the great releasers of energy. So it happens that when our most dynamic instinct—that for the reproduction of the race—is repressed, we lack one of the greatest sources of usable energy. The energy is there, but it is not accessible. Inhibited and locked away, it is not fed into the engine, and we feel exactly as though it were nil. Despite its name, the disease neurasthenia does not signify a real asthenia or weakness. Rather, it is a disorder in which there is plenty of energy that has somehow been temporarily misplaced. Then, too, we must remember that under the depressing influence of chronic fear, not quite so much energy is stored away as would otherwise be. All the bodily functions are slowed down; food is not so completely assimilated, the heart-beat is weakened, the breathing is more shallow, and fatigue products are more slowly eliminated. As Du Bois says, "An emotion tires the organism more than the most intense physical or intellectual work."

Avoid the Rest-Cure. It is a healthful sign that the rest-cure is fast going out of style. Wherever it has helped a nervous patient, the real curative agent has been the personality of the doctor and the patient's faith in him. The whole theory was based on ignorance of the cause of nerves. People suffering from "nervous exhaustion" are likely to be just as "tired" after a month in bed as they were before. Why not? Physical fatigue is quickly remedied, and what can rest do after that? What possible effect can rest have on the fatigue of a discouraged instinct? Since the best releaser of energy is enthusiasm, don't try to get that by lying around in bed or playing checkers at a health resort.

Summary

If you are chronically and perpetually fatigued, or if you tire more easily than the other people you know, consult a competent physician and let him look you over. If he tells you that you have neither tuberculosis, heart trouble, Bright's disease, nor any other demonstrable disease, that you are physically fit and "merely nervous," give yourself a good shake and commit the following paragraphs to memory.

A CATECHISM FOR THE WEARY ONE

WHAT?

Q. What is fatigue?

A. It is a chemical condition resulting from effort that is very recent.

Q. What else creates fatigue?

A. Worry, fear, resentment, discontent, and other depressing emotions.

Q. What magnifies fatigue?

A. Attention to the feeling.

Q. What makes us weary long after the cause is removed?

A. Habit.

WHY?

Q. Why do many people believe themselves over-worked?

A. Because of the power of suggestion.

Q. Why do they take the suggestion?

A. Because it serves their need and expresses their inner feelings.

Q. Why are they willing to choose such an uncomfortable mode of expression?

A. Because they don't know what they are doing, and the subconscious is very insistent.

WHO?

Q. Who gets up tired every morning?

A. The neurotic.

Q. Who fancies his brain so exhausted that a little concentration is impossible?

A. The neurotic.

Q. Who still believes himself exhausted as the result of work that is now ancient history?

A. The neurotic.

Q. Who lays all his woes to overwork?

A. The neurotic.

Q. Who complains of fatigue before he has well begun?

A. The neurotic.

Q. Who may drop his fatigue as soon as he "gets the idea?"

A. The neurotic.

HOW?

Q. How can he get the idea?

A. By understanding himself.

Q. How may he express his inner feelings?

A. By choosing a better way.

Q. How can he forget his fatigue?

A. By ignoring it.

Q. How can he ignore it?

A. By finding a good stiff job.

If he wants advice in a nutshell, here it is: Get understanding! Get courage! Get busy!

CHAPTER X

In which the ban is lifted

DIETARY TABOOS

Misunderstood Stomachs

Modern Improvements. Most people have heard the story of the little girl who wanted to know what made her hair snap. After she had been informed that there was probably electricity in her hair, she sat quiet for a few minutes and then exclaimed: "Our family has all the modern improvements! I have electricity in my hair and Grandma has gas on her stomach!" Judged by this standard many American families are well abreast of the times; and if we include among the modern improvements not only gas on the stomach but also nervous dyspepsia, acid stomach, indigestion, sick-headache, and biliousness, we must conclude that a good proportion of the population is both modern and improved.

Despite all this the stomach is one of the best-equipped mechanisms in the world. It, at least, is not modern. After their age-long development the organs of the body are remarkably standardized and adapted to the work required of them. It is safe to say that ninety per cent. of all so-called "stomach trouble" is due not to any inherent weakness of the organ itself but to a misunderstanding between the stomach and its owner.

Organic Trouble. Unfortunately, there are a few real organic causes for trouble. There are a few cancers of the stomach and a certain number of ulcers. But if the patients whom I have seen are in any way typical, the ulcers that really are cannot compare in number with the ulcers that are supposed to be. Patients go to physicians with so many tales of digestive distress that even the best doctors are fooled unless they are especially alert to the ways of "nerves." They must find some explanation for all the various functional disturbances which the patients report, and as they are in the habit of taking only the body into account, they find the diagnosis of stomach ulcer as satisfactory as any.

There is, of course, such a thing as an enlarged or sagging stomach. But it is only in the rarest of cases that such a condition leads to any functional disturbances unless complicated by suggestion. In most cases a person can go about his business as happily as ever unless he gets the idea that ptosis must inevitably lead to pain and discomfort.

Confusion sometimes arises when the stomach is blamed for disturbances which originate elsewhere. One day a very sick-looking girl came to me with eager expectation written all over her face. Her stomach was misbehaving and she had heard that I could cure nervous indigestion. It needed little more than a glance to know that she was suffering from organic heart trouble. A boy of sixteen had been taking a stomach-tonic for three months, but the thin, wiry pulse pointed to a different ailment. His digestive disturbances were merely the echo of an organic disease of the kidneys. When the body is burdened by disease, it may have little energy left for digesting food, but in that case the trouble must be sought in other quarters than the stomach.

Aside from a few organic difficulties, there is almost no real disease of the stomach. Its misdoings are not matters of food and chemistry, muscle-power and nerve supply, but are the end results of slips in the mental and emotional life of its owner.

Fads Dynamogenic. What is it that gives the impetus to fads about eating, or about religious belief? Are they advocated by the individual whose libido is finding abundant expression in the natural channels of business and family life, or by his less fortunate brother who can gain a sense of power only by means of some unaccustomed idea? William James says:

This leads me to say a word about ideas considered as dynamogenic agents or stimuli for unlocking what would otherwise be unused reservoirs of individual power.... In general, whether a given idea shall be a live idea depends more on the person into whose mind it is injected than on the idea itself. Which is the suggestive idea for this person and which for that one? Mr. Fletcher's disciples regenerate themselves by the idea (and the fact) that they are chewing and re-chewing and super-chewing their food. Dr. Dewey's pupils regenerate themselves by going without their breakfast—a fact, but also an ascetic idea. Not every one can use these ideas with the same success.

Because it is so adaptable and sturdy, the stomach lends itself readily to these devices for gaining self-expression; but the danger lies in bringing the process of digestion into conscious attention which interferes with automatic functioning. Still further, the disregard of physiological chemistry is likely to deprive the body of food-stuffs which it requires.

The average person is too sensible to be carried off his feet by the enthusiasm of the health-crank, but as most of us are likely to pick up a few false notions, it may be well to be armed with the simple principles of food chemistry in order to combat the fads which so easily beset us and to know why we are right when we insist on eating three regular meals of the mixed and varied diet which has proved best for the race through so many years of trial and experience.

What We Need to Eat

The Essence of Dietetics. To the layman the average discussion of food principles is, to say the least, confusing. Dealing largely, as it does, with unfamiliar terms like carbohydrate and hydrocarbon and calories, it is hard to translate into the terms of the potatoes left over from dinner and the vegetables we can afford to buy. But the practical deductions are not at all difficult to understand. Boiled down to their simplest terms, the essential principles may be stated in a few sentences. The body must secure from the food that we eat, tissue for its cells, energy for immediate use or to be stored for emergency, mineral salts, vitamins, water and a certain bulk from fruits and vegetables,—this latter to aid in the elimination of waste matter.

Food for repairing bodily tissue is called protein and is secured from meat, eggs, milk, and certain vegetables, notably peas. Fuel for heat and energy is in two forms—carbohydrate (starch and sugar) and fat. We get sugar from sugar-cane and beets, and from syrups, fruit, and honey. Starch is furnished from flour products—mainly bread—from rice, potatoes, macaroni, tapioca, and many vegetables. Fats come from milk and butter, from nuts, from meat-fat—bacon, lard and suet—and from vegetable oils. The mineral salts are obtained mainly from fruit and vegetables, which also provide certain mysterious vitamins necessary for health, but as yet not well understood.

What the Market Affords. The moral from all this is plain. The human body needs all the foods which are ordinarily served on the table. Whenever, through fad or through fear, we leave out of our diet any standard food, we are running a risk of cutting the body down on some element which it needs. They say that variety is the spice of life. In the matter of food it is more than that, it is the essence of life. Eat everything that the market affords and you will be sure to be well nourished. If you leave out meat you will make your body work overtime to secure enough tissue material from other foods. If you leave out white bread, you will lose one of the greatest sources of energy. If you leave out tomatoes and cucumbers and strawberries, you deprive your body of the salts and vitamins which are essential.

A Simple Rule. There is one point that is good to remember. The average person needs twice as much starch as he needs of protein and fat together. That is, if he needs four parts of protein and three of fat, he ought to eat about fourteen parts of starch. This does not mean that we need to bother ourselves with troublesome tables of what to eat, but only to keep in mind in a general way that we need more bread and potatoes than we do meat and eggs. The body does not have to rebuild itself every day. It is probable that a good many people eat too much protein food. If a man is doing hearty work he must have a good supply of meat, but the average person needs only a moderate amount. Here again, the habits of the more intelligent families are likely to come pretty near the dictates of science.

For the Children. The mother of a family ought to know that the children need plenty of bread, butter, and milk. Despite all the notions to the contrary, good well-baked white bread is neither indigestible nor constipating. It is indeed the staff of life. Two large slices should form the background of every meal, unless there is an extraordinary amount of other starchy food or unless the person is too fat. Milk-fat (from whole milk, cream, and butter) is by far the best fat for children. Besides fat, it furnishes a certain growth-principle necessary for development. As the dairyman cannot raise good calves on skimmed milk, so we cannot raise robust children without plenty of butter and milk. The pity of it is that poor people are forced to try! Milk is also the best protein for children, whose kidneys may be overstrained by trying to care for the waste matter from an excessive quantity of eggs and meat. Bread and butter, milk, fruit, vegetables, and sugar in ample quantities and meat and eggs in moderate quantities are pretty sure to make the kind of children we want. Above all things, let us train them not to be afraid of normal amounts of any regular food or of any combination of foods.

The Fear of Mixtures. There are many people who can without flinching face almost any single food, but who quail before mixtures. Perhaps there is no notion which is more firmly entrenched in the popular mind than this fear of certain food-combinations, acquired largely from the advertisements of certain so-called "food specialists."

The most persistent idea is the fear of acid and milk. It is interesting to watch the new people when they first come to my table. Confronted with grape-fruit and cream at the same meal, or oranges and milk, or cucumbers and milk, they eat under protest, in consternation over the disastrous results that are sure to follow. Out of all these scores of people, many of whom are supposed to have weak stomachs, I have never had one case of indigestion from such a combination. When a person knows that the stomach juices themselves include hydrochloric acid which is far more acid than any orange or grapefruit, that the milk curdles as soon as it reaches the stomach, and that it must curdle if it is to be digested, he has to be very "set" indeed if he is to cling to any remnant of fear.

Of course to say that the stomach is well prepared chemically, muscularly, and by its nerve supply to handle any combination of ordinary food in ordinary amounts is not the same thing as saying that we may devour with impunity any amount of anything. It is a good thing for every one to know when he has reached his limit, and a person with organic heart disease should avoid eating large quantities at one time, or when he is extraordinarily fatigued or emotionally disturbed, lest at such a time he may put a fatal strain on the pneumogastric nerve that controls both stomach and heart.

The Fear of Certain Foods

Physical Idiosyncrasies. Most of our false fears on food subjects come from some tradition—either a social tradition or a little private, pet tradition of one's own. Some one once was ill after eating strawberries and cream. What more natural than to look back to those little curdles in the dish and to start the tradition that such mixtures are dangerous? The worst of it is that the taboo habit is very likely to grow. One after another, innocent foods are thrown out until one wonders what is left. A patient of mine, Mr. G., told me that he had a short time before gone to a physician with a tale of woe about his sour stomach. "What are you eating?" asked the doctor. "Bran crackers and prunes." "Then," said the learned doctor, "you will have to cut out the prunes!" Needless to say, this man ate everything at my table, and flourished accordingly.

There may be such a thing as physical idiosyncrasies for certain foods. I have often heard of them, but I have never seen one. I have often challenged my patients to show me some of the "spells" which they say invariably follow the eating of certain foods, but I have almost never been given an exhibition. The man who couldn't eat eggs did throw up once, but he couldn't do it a second time. Many people have threatened to break out with hives after strawberries. One woman triumphantly brought me what looked like a nice eruption, but which proved to be the after-results of a hungry flea! After that she ate strawberries,—without the flea and without the hives.

Not Miracles but Ideas. Conversions on food subjects are so common at my table that I should have difficulty in remembering the individual stories. Scores of them run together in my mind and make a sort of composite narrative something like this: "Oh, no, thank you, I don't eat this. You really must excuse me. I have tried many times and it is invariably disastrous." Then a reluctant yielding and a day or two later some talk about miracles. "It really is wonderful. I don't understand," etc. Experiences like these only go to show the power of the subconscious mind, both in building up wrong habit-reactions and in quickly substituting healthy ones, once the false idea is removed.

Among my stomach-patients there were two men, brothers-in-law, immigrants from the Austrian Tyrol, and now resident in one of the cow-boy states. Leonardo spoke little English, and though Giovanni understood a very little, he spoke only Italian.

Several years before I knew them, Giovanni had developed a severe case of stomach trouble and had finally gone to a medical center for operation. The disturbance, however, was not relieved by the operation and before long his brother-in-law fell into the same kind of trouble. For several years the two had spent much of their time dieting, vomiting, and worrying over their sour stomachs. Giovanni finally became so ill that his sick-benefit society had actually assessed its members to pay for his funeral expenses. About this time a business man of their town, impressed by the cure of a former patient who had made a quick recovery after seven years of invalidism, persuaded the two men to take their little savings and come to California to be under my care. The evening meal and breakfast went smoothly enough, although the menu included articles which they had been taught to avoid. However, as I left the house on a necessary absence soon after breakfast, I saw Leonardo weeping in the garden and Giovanni spitting up his breakfast, out at the entrance gate. On my return, I found one of "the family" literally sitting on the coat-tails of Leonardo, while Giovanni hovered at a distance, safe from capture. Leonardo upbraided me bitterly for having undone all the gain they had made in the long months of rigid dieting, for now the vomiting had returned, because they had eaten sugar on their oatmeal at breakfast! I made Leonardo drink an egg-nog, took him into the consultation-room and held my hand on his knee to keep him in his chair, while explaining to him as best I could the physiologic action of the hydrochloric acid on the digestive juice, which he feared as a sour stomach, the sign of indigestion.

During the conversation I said, "I suppose Giovanni imitated you in this mistaken fear about your health." The reply was, "No, I got it off him!" Nearly two hours later he exclaimed in astonishment: "Why, that milk hasn't come up! Maybe I am cured!" "Of course you are cured," I answered; "there never was anything really the matter with your stomach, so you are cured as soon as you think you are."

Later Giovanni was inveigled into the house by the promise that he would have to eat nothing more than milk soup. All was smooth sailing after this. For my own part I feared for the permanency of the cure, for they were returning to the old environment. But more than three years have passed, and grateful letters still come telling of their continued health.

Another patient, a teacher of domestic science in a big Eastern university, had lived on skimmed milk and lime-water from Easter to Thanksgiving. Several attempts to enlarge the dietary by adding cream or white of egg had only served to increase the sense of discomfort. Finding nothing in the history of the case to warrant a diagnosis of organic disease of the stomach, I served her plate with the regular dinner, bidding her have no hesitancy even over the pork chops and potato chips. She gained nine pounds in weight the first week, and in two and a half months was forty pounds to the good.

When Re-education Failed. But there is one patient who has had to have his lesson repeated at intervals. This man laughingly calls himself a disgrace to his doctor because he is a "repeater." His story illustrates the power of an autosuggestion and the disastrous effect of attention to a physiological function. When Mr. T. came first to me he weighed only 120 pounds, although he is over six feet tall and of large frame. From the age of sixteen he had followed fads in eating and thought he had a weak stomach. I treated his "weak stomach" to everything there was in the market, including mince-pies, cabbage, cheese, and all the other so-called indigestibles. He gained 16-1/2 pounds the first week and 31 pounds in five weeks. One would think that the idea about the weak stomach would have died a natural death, but it did not. Again and again he came back to me like a living skeleton, the last time weighing only 105 pounds, and again and again he has gone back to his home in the Middle West plump and well. Twice while he was at home he underwent unnecessary operations, once for an ulcer that was not there and once for supposed chronic spasm of the pylorus. Needless to say, the operations did not help. You cannot cut out an idea with a knife. Neither can you wash it out with a stomach-pump; else would Mr. T. long ago have been cured! This particular idea of his seems to be proof against all my best efforts at re-education. Psycho-analysis is impracticable, partly because of the duration of the habit of repression, but the history, and certain symbolic symptoms, indicate the Freudian mechanisms at work. All I can do is to feed him up, bully him along, and keep him from starving to death. Just now he is doing very well at home, although he has moved to California so as not to be too far away from "the miracle-worker."

If Mr. T.'s case had been typical, I should long ago have lost my faith in psychotherapy. Keeping people from starving is worth while, but is less satisfactory than curing them of what ails them. The nervous patient who has a relapse is no credit to his doctor. It is only when the origin of his trouble is not removed that the bond of transference tends to become permanent. The neurotic who is well only while under the influence of his physician is still a neurotic. However, as most people's complexes are neither so deeply buried nor so obstinate as this, a simple explanation or a single demonstration is usually enough to loose the fettering hold of old misconceptions.

Common Ailments

"Gas on the Stomach." We all know people who suffer from "gas." Indeed, very few of us escape an occasional desire to belch after a hearty meal. But the person with nervous indigestion rolls out the "gas" with such force that the noise can sometimes be heard all over the house. He may keep this up for hours at a time, under the conviction that he is freeing himself from the products of fermenting food. He may exhibit a well-bloated stomach as proof of the disastrous effect of certain articles of diet. The gas and the bloating are supposed to be the sign and the seal of indigestion, a positive evidence that undigested food is fermenting in the stomach.

But what is fermentation? It is, necessarily, a question of the growth of bacteria and is a process which we may easily watch in our own kitchens. Bread rises when the yeast-cells have multiplied and acted on the starch of the flour, producing enough gas to raise the whole mass. Potatoes ferment because bacteria have multiplied within them. Canned fruit blows up because enough bacteria have developed inside to produce sufficient gas to blow open the can. Every housewife knows that it takes time for each of these processes. Bread has to stand several hours before it will rise; potatoes do not ferment under twelve hours, and canned fruit is not considered safe from the fermenting process under three days. Evidently there is some mistake when a person begins to belch forth "gas" within an hour or two after a meal. As a matter of fact, it is not gas at all but merely air that is swallowed with the food or that was present in the empty stomach.

When the food enters the stomach it necessarily displaces air, which normally comes out automatically and noiselessly. But if, through fear or attention, a certain set of muscles contract, the pent-up air may come forth awkwardly and noisily or it may stay imprisoned until we take measures to let it out. A hearty laugh is as good as anything, but if that cannot be managed, we may have to resort to a cup of hot water which gives the stomach a slap and makes it let go. Two belches are enough to relieve the pressure. After that we merely go on swallowing air and letting it out again, a habit both awkward and useless.

If the emotion which ties the muscle-knot is very intense, and the stomach refuses to let go under ordinary measures, the pain may be severe. But a quantity of hot water or a dose of ipecac is sure to relieve the situation. If the person is able to give himself a good moral slap and relax his unruly muscles, he reaches the same end by a much pleasanter road.

Some people are fond of the popular remedy of hot water and soda. Their faith in its efficacy is likely to be increased by the good display of gas which is sure to follow. As any cook knows, soda and acid always fizz. The soda is broken up by the hydrochloric acid of the stomach and forms salt and carbon dioxid, a gas. However, as the avowed aim of the remedy is the relief of gas rather than its manufacture, and as the soda uses up the hydrochloric acid needed in digestion, the practice cannot be recommended as reasonable.

Gastritis. I once knew a woman who went to a big city to consult a fashionable doctor. When she returned she told with great satisfaction that the doctor had pronounced her case gastritis. "It must be true," she added, "because I have so much gas on my stomach!" The diagnosis of gastritis used to be very common. The ending itis means inflammation,—gastritis, enteritis, colitis, each meaning inflammation of the corresponding organ. An inflammation implies an irritant. There can be no kind of itis without the presence of something which irritates the membrane of the affected part. If we get unusual and irritating bacteria in some spoiled food, we are likely to have an acute inflammation until the offending bacteria are expelled. But an inflammation of this kind never lasts. People who have had ptomaine poisoning sometimes assert that they are afterwards susceptible to poisoning by the kind of food which first made them ill. Such a susceptibility is not so much a hold-over effect from the poison as a hold-over fear which tends to repeat the physical reaction whenever that food is eaten. I, myself, have had ptomaine poisoning from canned salmon, but I have never since had any trouble about eating salmon.

Sour Stomach. Sometimes when a person lies down an hour or so after a meal, some of the contents of his stomach comes up in his throat. Then if he be ignorant of physiology, he may be very much alarmed because his stomach is "sour." Not knowing that he would have far greater cause for alarm if his stomach were not sour, he may, if the idea is interesting to him, begin to restrict his diet, to take digestive tablets, and to develop a regular case of nervous dyspepsia. Sometimes when the specialists measure the amount of hydrochloric acid in the stomach, they do find too much or too little acid; but this merely means that an emotion has made the glands work overtime or has stopped their action for a little while. The functions of the body are so very, very old that there is little likelihood of permanent disturbance.

Biliousness. The stomach is not the only part of the body concerning which we lack proper confidence. Next to it the liver is the most maligned organ in the whole body. Although the liver is about as likely to be upset in its process of secreting bile as the ocean is likely to be lacking in salt, many an intelligent person labels every little disturbance "biliousness" and lays it at the door of his faithful, dependable liver.

As a matter of fact, the liver is liable to injury from virtually but three sources—alcohol, bacterial infection, and cancer—and even a liver hardened by alcohol goes on secreting bile as usual. The patient dies of dropsy but not of "liver complaint."

Some people act as if they thought bile were a poison. On the contrary, it is a very useful digestant; it aids in keeping down the number of harmful bacteria and helps to carry the food from intestines to blood. Every day the liver manufactures at least a pint of this important fluid. The body uses what it needs and stores the surplus for reserve in the gall-bladder. The flow is continuous and, despite all appearances to the contrary, there is no such thing as a torpid or an over-active liver.

It is true that after a "bilious" person has vomited for a few minutes he is likely to throw up a certain amount of bile, which is supposed to have been lying in his stomach and causing the nausea. In fact, however, this bile is merely a part of the usual supply stored away in the gall-bladder. By the very act of retching, the bile is forced out of the bile channels into the stomach and thence up into the mouth. Anybody can throw up bile at any time if he only tries hard enough.

One of the favorite habits of certain people is the taking of calomel and salts. After such a dose they view with satisfaction the green character of the stools and conclude that they have rid themselves of a great amount of harmful matter. As a matter of fact, the greater part of the coloring in the stools is from the calomel itself, changed in the intestines from one salt of mercury to another. Any excess bile is the result of the irritating action of the calomel on the intestinal wall, an irritation which makes the bowel hurry to cast out this foreign substance without waiting for the bile to be absorbed as usual.

A patient once told me that he had bought medicine from a street fakir and by his direction had followed it with a dose of salts. He saved the bowel movement, washed it in a sieve, and discovered a great number of "gall-stones," which the medicine had so effectively washed from his system. He was much astonished when I told him that his gall-stones were merely pieces of soap. He did not know that everybody manufactures soap in his body every day, and that by taking an extra quantity of oil in the shape of the fakir's medicine and an extra quantity of potash in the salts, he had merely augmented a normal physiological process. The supposed action of calomel belongs to the same class of phenomena, and has no slightest effect on the liver or on real gall-stones, which are the precipitate of bile-salts in the gall-bladder, and which cannot be reached by any medicine.

If the popular notions about biliousness are ill founded, what then causes the disturbances which undoubtedly do occur and which show themselves in attacks of nausea or sick headache? The answer can be given in a word of four letters; a coated tongue, a bilious attack and a sick headache are all the outcome of a mood. Stocks have gone down or the wife is cranky or the neighbors are hateful. Adrenalin and thyroid secretions are poured out as the result of emotion; digestion is stopped, circulation disturbed, and the whole apparatus thrown out of gear.

Sick-Headache. Sick-headache is primarily a circulatory disturbance; and although the disturbance may have been inaugurated by some chemical unbalance, the sum total of the force that makes a sick-headache is emotional. The emotion, of course, need not be conscious in order to be effective. If we picture the arteries all over the body as being supplied with, among other things, a wall of circular muscles, and then imagine messages of emotion being flashed to the nerves controlling this muscle wall, we may get an idea of what happens just before a sick-headache. Some parts of the arteries contract too much and other parts relax. The arteries to the head tighten up at the extremities and become loose lower down. The force of the blood-stream against the constricted portion can hardly fail to cause pain. The sick part of the headache is merely a sympathetic strike of the nerves which control circulation and stomach.

The moral of all this is plain. If a sick-headache is the result of an emotional spasm of the blood-vessels, the obvious cure is a change of the emotion. Some people manage it by going to a party or a picnic, others by ignoring the symptoms and keeping on with their work. A woman physician whom I know was in the midst of a violent headache when called out on an obstetrical case. She felt sorry for herself, but went on the case. In the strenuous work which followed, she quite forgot the headache, which disappeared as if by magic.

Sometimes it happens that a headache recurs periodically or at regular intervals. It is easy to see that in such cases the exciting cause is fear and expectation. At some time in the past, headaches have occurred at an interval of, say, fourteen days; as the next fourteenth day approaches the sufferer says to himself: "It is about time for another headache. I am afraid it will come to-morrow," and of course it comes. One man told me that if he ate Sunday-night supper he inevitably had a headache on Monday morning. We were about to sit down to a simple Sunday supper and he refused very positively to join us. I told him he could stay all night and that I would take care of him if the Monday sickness appeared. He accepted my challenge but was unable to produce a headache. In fact, he felt so unusually flourishing the next morning that he insisted on frying the bacon for my entire family. That was the end of the Monday headaches.

A Few Examples. As sick-headache has always been considered a rather stubborn difficulty, not amenable to most forms of treatment, it may be well to cite a few cases which were helped by educational methods. A patient came home from a walk one day and announced that he was going to bed. When questioned, be said: "I am tired and I have a sick-headache. Isn't it logical to go to bed?" To which I answered that it would be far more logical to put some food into his stomach and change the circulation than to lie in bed and think about his pain. This man was completely cured. I have had patients throw up one meal, and very rarely two, but I have never had to supply more than three meals at a time. The waste of food I consider amply justified by the benefit to the patient.

There once came to me an elderly woman, the wife of a poor minister. She was suffering from attacks of nausea, which recurred every five to ten days with intense pain through the eyes, and with photo-phobia or fear of light. I found that she had by dint of heroic efforts raised a large and promising family on the salary of an itinerant minister—from four hundred to six hundred a year! All the time she had been feeling sorry for herself because her husband did not appreciate her. One day, after reading one of his letters which seemed to show an utter lack of appreciation of all that she was doing, she fell down in the field beside her plow, paralyzed. From that time on she had been more or less of an invalid, continually nursing her grudge and complaining that she ought not to have been made to bear so many children.

After I had heard this plaint over and over for about a week, I said: "Perhaps you ought not to have had that little daughter, the little ewe-lamb. Maybe she was one too many." "Oh, no," came the quick response. "I couldn't have spared her." Then I went down the line of the fine stalwart sons. Perhaps she could have spared John or Tom or Fred? Finally she saw the whole matter in a different light,—saw herself as a queen among women, the mother of such a family.

As to the husband, I tried to show her that she was not very clever to live with a man all those years without discovering that he was not likely to change. "You can't change him but you can change your reaction to him. If something keeps hurting your hand, you don't keep on being sore. You grow callous. Isn't it about time you grew a moral callous, too?"

I put her on the roof to sleep, on account of her fear of light. Only once did she start a headache, which I quickly nipped in the bud by making her get up and dress. She had come to stay "three months or four,—if I get along well." At the end of four weeks she left, an apparently well woman. The last I heard of her she was stumping the state for temperance, the oldest of an automobile party of speakers, and the sturdiest physically. With the emotional grievance, disappeared also the physical effects in stomach and head.

Miss S., a very brilliant woman, ambitious to make the most of her life, had been shelved for twenty-five years because of violent sick-headaches which made it impossible for her to undertake any kind of work. She had not been able to read a half-hour a day without bringing on a terrible headache. I insisted on her reading, and very soon she was so deep in psychological literature that I had difficulty in making her go to bed at all. After learning the cause of her headaches and gaining greater emotional control, she succeeded so well in freeing herself from the old habit, that she now leads the busiest kind of useful life with only an occasional headache, perhaps once in six months.

A certain minister suffered constantly from a dull pain in his head, besides having violent headaches every few days. He started in to have a bad spell the day after his arrival at my house. As I was going out of the door, he caught my sleeve. "Doctor," he said, "would it be bad manners to run away?" "Manners?" I answered. "They don't count, but morals, yes." He stayed—and that was his last bad headache. Both chronic and periodic pains disappeared for good.

One woman who had suffered from bad headaches for eighteen years lost them completely under a process of re-education. On the other hand, I have had patients who were not helped at all. The principles held good in their cases, but they were simply not able to lose the old habit of tightening up the body under emotion.

Hysterical Nausea. Sometimes nausea is merely the physical symbol of a subconscious moral disgust. We have already told the stories of "the woman with the nausea" (Chapter V) and of Mrs. Y. (Chapter VII). These cases are typical of many others. Their bodies were perfectly normal, and when, through psycho-analysis and re-education, they were helped to make over their childish attitudes toward the sex-life, the nausea disappeared.

Loss of Appetite. A nervous patient with a good appetite is "the exception that proves the rule." The neurotic is usually under weight and often complains that he feels satiated almost as soon as he begins to eat. Loss of appetite may, of course, mean that the body is busy combating toxins in the blood, but in a nervous person it usually means a symbolic loss of appetite for something in life, a struggle of the personality against something for which he has "no stomach." Psycho-analysis often reveals the source of the trouble, and a little bullying helps along the good work. By simply taking away a harmful means of expression, we may often force the subconscious mind to find a better language.

Summary

Since the stomach seems to be an organ which is much better fitted to care for food than to care for a depressing emotion or a false idea, it seems far more sensible to change our minds than to keep enlarging our list of eatables which are taboo.

And since most indigestion is in very truth nothing more nor less than an emotional disturbance, worked up by fear, anger, discontent, worry, ignorance, suggestion, attention to bodily functions which are meant to be ignored, love of notice and the conversion of moral distress into physical distress, the best diet list which can be furnished to Mr. Everyman in search of health must read something like this:

MENU

Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday

A Calm Spirit Plenty of Good Cheer A Varied Diet Commonsense Good Cooking Judicious Neglect of Symptoms Forgetfulness of the Digestive Process A Little Accurate Knowledge A Determination to BE LIKE FOLKS

CHAPTER XI

In which we relearn an old trick

THE BUGABOO OF CONSTIPATION

Popular Superstitions

In line with the taboos connected with the taking of food are the ceremonials attendant upon its elimination. Taking anxious thought about functions well established by nature is a feature of conversion-hysteria, the displacement of emotional desire from its psychic realm into symbolic physical expression. Whatever other symptoms nervous people may manifest, they are almost sure to be troubled with chronic constipation. It is true that there are many constipated people who do not seem to be nervous and who resent being classed among the neurotics. Everybody knows that the occasional individual who has difficulty in swallowing his food is nervous and that the, trouble lies not in the muscles of his throat but in the ideas of his mind. But very few people seem to realize that the more common individual who makes hard work of that other simple process—elimination of his intestinal waste matter—is suffering from the same kind of disturbance and giving way to a nervous trick. When all the facts are in, the constipated person will have hard work to clear himself of at least one count on the charge of nerves.

An Oft-told Tale. Sooner or later, then, the neurotic, whether he calls himself a neurotic or not, is very likely to begin worrying over his diet or his sedentary occupation. He imagines himself the victim of autointoxication, afflicted with paralysis of the colon or dearth of intestinal secretions. He leaves off eating white bread, berries, cheese, chocolate, and many another innocent food, and insists on a diet of bran-biscuit, flaxseed breakfast-foods, prunes, spinach, cream, and olive-oil with doses of mineral oil between meals. In all probability, he begins a course of massage or he starts to take extra long walks and to exercise night and morning, pulling his knees up to his chin and touching his fingers to his toes. When all these measures fail, he gives in to the morning enema or the nightly pill, in imminent danger of succumbing to a life-long habit.

The Truth About Constipation

What the Colon Is For. It is well, then to have a fair understanding of the structure and purpose of our intestinal machinery. Contrary to general opinion, the intestines are not a dumping-ground but a digestive organ. After the food is partly digested in the stomach, it passes through a twenty-two foot tube (the small intestine) into a five-foot tube (the large intestine or colon) where digestion is completed, the nutriment is absorbed, and the waste matter is passed on and out through the rectum. As the food passes along the colon, pushed slowly ahead by the peristaltic wave, or rhythmic muscular contractions of the intestinal wall, it is seized upon by the four hundred varieties of friendly bacteria which inhabit the intestines of every healthy person, and is changed into a form which the body can assimilate. Digestion in the stomach and small intestine is carried on by means of certain digestive juices, but in the large intestine it is the bacteria which do the work. Without them we could not live.

Around the colon is a thick network of little blood vessels, all of which lead straight to the liver, the storehouse of the body. After the food is fully digested, it is passed through the thin intestinal wall into these tiny vessels and carried away to liver and muscles for storage or for immediate use.

This process of absorption is carried on throughout the whole length of the colon. Not until the very end of the intestine is reached is all the nutrition abstracted. The bowel-content can properly be called waste matter only after it has reached the rectum or pouch at the lower end of the colon. Even then, this waste matter is not poison, but merely indigestible material which the body cannot handle.

Food, not Poison. The colon is not a cesspool but a digestive and assimilating organ. Its content is not poison but food. Active elimination is important not so much because delay causes autointoxication or poisoning as because too large a mass is hard to manage and irritates the intestinal wall. The problem is not so much one of toxicology as of simple mechanics. If Nature had put within the body five feet of tubing which could easily become a cesspool and a breeder of poison, it is not at all likely that she would have laid alongside an elaborate system of blood vessels leading not out to the kidneys but into the storehouse of the liver; and if civilized man's changed manner of living had so upset Nature's plans as easily to transform his internal machinery into a chronic source of danger, we may be sure that he would long ago have gone the way of the unfit and succumbed to his own poisons.

Possible Invasions. It is true that the intestinal tract, like the rest of the body, is open to attack by harmful bacteria. But in a great majority of cases, these enemy bacteria are either quickly destroyed by the beneficent microbes within or are immediately cast out as unfit. Any germs irritating to the intestinal wall cause the mucous membrane to produce an unusual flow of mucus which washes away the offending bacteria in what we call a diarrhea. [52]

Sometimes the wrong kind of bacteria do persist, causing anemia, rheumatism, sciatica, or neuritis. When these disorders are not the result of infection from teeth, tonsils, or other sources of poison, but are really caused by intestinal bacteria, I have found that a diet of buttermilk (lactic acid bacteria), with turnip-tops or spinach to supply the necessary mineral salts, often succeeds in planting the right bacteria and driving out the disturbing ones. These disorders are invasions from without, like tuberculosis or malaria, and are as likely to attack the person with easy bowel movements as the one with the most chronic constipation.

Autointoxication. A good deal of the talk about autointoxication is just talk. It sounds well and affords an easy explanation for all sorts of ills, but in a large majority of cases the diagnosis can hardly be substantiated. Uninformed writers of newspaper articles on the care of the body, or purveyors of purgatives or apparatus for internal baths are fond of dilating on the "foulness of the colon" as a leading cause of disease. As a rule, they advise either a strict diet, some kind of cathartic, or an elaborate process of washing out the colon to clear the body of its terrible accumulation of poisons.

Cathartics and Enemas. He who makes a practice of flushing out his intestinal tract with high enemas and internal baths is like a person who eats a good dinner and then proceeds to wash out his stomach. In the mistaken idea that he is making himself clean, he is washing what was never intended to be washed and robbing the body of the nutrition which it needs. And the man who persists in the pill habit is making a worse mistake, adding insult to injury and forcing the mucous membrane to toughen itself against such malicious attacks.

Cathartics and Operations. Even in emergencies, the use of purgatives as a routine measure is happily decreasing year by year. For many years I have deplored the use of purgatives before and after operations. That other practitioners are coming to the same conclusion is witnessed by a number of papers recently read in medical societies condemning purgation at the time of operation.

Among the most favorably received papers of the California Medical Societies have been one by Emmet L. Rixford, surgeon of the Stanford University Medical College, read before the Southern California Medical Society at Los Angeles December 8, 1916, and one by W.D. Alvarez at the California Medical Society, Del Monte, 1918,—both condemning the use of purgatives as a routine measure before operations. An article entitled the "Use and Abuse of Cathartics" in the "Journal of the American Medical Association" admirably summarizes the disadvantages of purgation at such a time. [53]

Four years ago I was called to a near-by city to see a former patient who two days before had had a minor operation,—removal of a cyst of the breast. She was dazed, almost in a state of surgical shock and very near collapse. I found that she had been put through the usual course of purgation before operation and starvation afterward, and I diagnosed her condition as a state bordering on acidosis, or lowering of the alkaline salts of the body. I ordered food at once. She rallied and recovered.

A few months later this same woman had to undergo a much more serious operation for multiple fibroids of the uterus and removal of the appendix. This time I advised the surgeon against the use of any purgative, and he took my remarks so seriously that he did not even allow an enema to be given. This time the patient showed no signs of exhaustion and had very few gas pains. I firmly believe that the day will soon come when a patient under operation, or a patient after childbirth, will no longer be depleted by a weakening and dehydrating cathartic and by a period of starvation, at a time when he needs all the energy he can summon.

Cathartics and Childbirth. The article referred to in the "Journal of the American Medical Association" cites the experiences of Dr. R. McPherson of the Lying-in Hospital of New York, "who showed that the routine purgation after confinement is not only useless but harmful. Of 322 women who were not purged, only three had fever (and one of them a mammary abscess); most of them had normal bowel movements and those who did not were given an enema every third day. Of 322 women who were delivered by the same technique and the same operators but were purged in the usual routine manner, twenty-eight had some fever." This experience of one physician is corroborated by that of others who find that the more we tamper with the natural functions in time of stress the harder do we make the recuperative process. There are certainly times when catharsis is necessary but "one thing is certain, the day for routine purgation is past." [54] Even in emergencies we need to know why we administer cathartics and in chronic cases we may be sure that they are always a mistake.

"An Old Trick." Before we make a practice of interfering with Nature's processes, it is well to remember how old and stable those processes are. As long as there has been the taking in of food, there has been also the casting out of waste matter. The sea-anemone closes in on the little mollusk that floats against its waving petals, assimilates what it can and rejects the rest. In the long line from sea-anemone to man, this automatic process of elimination has gone on without a hitch, adapting itself with perfect success to the changing habits of the varying types of life. So old a process is not easily upset. And, be it noted, in the human body this automatic, involuntary process still goes on with very little trouble until it reaches a point in the body where man, the thinking animal, tries to control it by conscious thought.

A Question of Evacuation. Much of the misconception about constipation arises from the mistaken idea that this is a disorder of the whole intestine or at least of the whole colon. As a matter of fact, the trouble is almost wholly in the rectum. There is no trouble with the general traffic movement, but only with the unloading at the terminus. In my experience, the patient reports that he feels the fecal mass in the lower part of the rectum, but that he is unable to expel it. Examination by finger or by X-ray reveals a mass in the rectal pouch. If there is a piling up of freight further back on the line, it is only because the unloading process has been delayed at the terminus.

So long as the bowel-content is in the region of automatic control, there is very little likelihood of trouble. An occasional case of organic trouble—appendicitis, lead-colic, mechanical obstruction, new growths or spinal-cord disease—may cause a real blockade, but in ninety-nine cases out of every hundred there is little trouble so long as the involuntary muscles, working automatically under the direction of the subconscious mind, are in control. By slow or rapid stages, on time or behind time, the bowel-content reaches the upper part of the rectum and passes through a little valve into the lower pouch. Here is where the trouble begins.

Meddlesome Interference. In the natural state the little human, like the other animals, empties his bowel whenever the fecal mass enters the lower portion of the rectum. The presence of the mass in the rectum constitutes a call to stool which is responded to as unthinkingly as is the desire for air in the taking of a breath. But the tiny child soon has to learn to control some of his natural functions. At the lower end of the rectum there is a purse-string muscle called the Sphincter-ani, an involuntary muscle which may with training be brought partly under voluntary control. Under the demands of civilization, the baby learns to tighten up this muscle until the proper time for evacuation. Then, if he be normal, he lets go, the muscles higher up contract and the bowel empties itself automatically, as it always did before civilization began.

There is, however, a possibility of trouble whenever the conscious mind tries to assume control of functions which are meant to be automatic. Under certain conditions necessary control becomes meddlesome interference. If the child for one reason or another takes too much interest in the function of elimination; if he likes too much the sense-gratification from stimulation of the rectal nerves and learns to increase this gratification by holding back the fecal mass; if he gets the idea that the function is "not nice" and takes the interest that one naturally feels in subjects that are taboo; or if he catches from his elders the suggestion that the bowel movement is a highly important process and that something disastrous is likely to happen unless it is successfully performed every day; then his very interest in the matter tends to interfere with automatic regulation, and to cause trouble.

Just as people often find it hard to let go the bladder muscle and urinate when in a hurry or under observation, and just as an apprehensive woman in childbirth tightens up the purse-string muscle of the womb, so the little child, or the grown up who catches the suggestion of difficulty in the bowel movement, loses the trick of letting go. Instead of merely exercising control by temporarily inhibiting the function, he tries to carry through the process itself by voluntary control—and fails. Constipation is a perfect example of the power of suggestion, and of the troublesome effect of a fear-idea in the realm of automatic functions.

Food and Constipation

Since the waste matter from all foods finally reaches the rectum, and since constipation is merely a difficulty in the forces of expulsion, it is hard to see how any normal food in the quantities usually eaten could have the slightest effect on the problem. When we remember that it takes food from twelve to twenty-four hours to reach the rectum, and that it has during all that time been subjected to the action of the powerful chemicals of the digestive tract, it is hard to imagine a piece of cheese, of whatever variety, strong enough to stop the contraction of the muscles of the upper rectum or to tie the sphincter-muscle into a knot. It would be difficult to find a food which could pass without effect through twenty-seven feet of intestinal tubing only to become suddenly effective on the wall of the rectum. If the wrong kind of food is the cause of constipation, why does the rectum prove to be the most refractory portion of the tube? On what principle could a piece of chocolate inhibit the call to stool or contract the sphincter muscle? On the other hand, even if it should be conceded that constipation were the result of lack of lubricating secretions in the colon, how could two tablespoonfuls of mineral oil be a sufficient lubricant after being mixed with liquid and solid food through many feet of the intestinal tract?

An Adaptable Apparatus. The lining of the intestines has plenty of secretions to take care of its function. It is as well adapted to the vicissitudes of life as are the other parts of the body. The muscular coat is no more liable to paralysis or spasm than are the voluntary muscles. As the skin adapts itself to all waters and all weathers, and as the lungs adjust themselves to varying air-pressures, so the intestinal wall makes ready adaptation to any common-sense demands, adjusting itself with ease to an athletic or a sedentary life, and to the normal variations of diet. What man has eaten throughout the centuries man may eat to-day. If you will but believe it, your intestines will make no more objection to white bread, blackberries, and cheese, along with all other ordinary articles of food, than the skin makes to varying kinds of water. Naturally, the suggested idea that a food will constipate tends to carry itself out to fulfilment and to prevent the call to stool from rising to the level of consciousness; but the real force lies not in the food but in the suggestion.

The Bran Fad. It is when we try to improve on the normal human diet that we really insult the body. He who leaves off eating nourishing white bread and takes to bran muffins is simply cheating his body. Bran has a small food value, but the human body is not made to extract it. Not only does bran fail to give us any nourishment itself, but it lessens the power of the intestines to care for other food. [55] The fad for bran is based on the well-known fact that we need a certain quantity of bulk in order to stimulate the intestinal wall to normal peristalsis. We do need bulk, but not more than we naturally get from a normal and varied diet including a reasonable amount of fruit and vegetables.

It is true that the suggestion of the efficacy of bran, dates, spinach, or any other food is frequently quite sufficient to give relief, temporarily, just as massage, manipulation of the vertebrae, the surgeon's knife, or mineral oil may be enough to carry the conviction of power to a suggestible individual. But who wants to take his suggestions in such inconvenient forms as these?

Change of Water. Another popular superstition centers around drinking-waters. There are people who cannot move from one town to another, much less take an extensive trip, without a fit of constipation—or a box of pills. If they only knew it, there is no water on earth which could make a person constipated. A new water, full of unusual minerals, might hasten the bowel movement, but on what possible principle could it retard it? Constipation has nothing to do with food or with water, but solicitous care about either can hardly fail to create the trouble which it tries to avoid.

The Cure

Taking off the Brakes. Since constipation is wholly due to the acceptance of a false suggestion, the only logical cure must be release from the power of that suggestion. "He is able as soon as he thinks he is able"; not that thought gives the power, but that the right thought releases the inhibition of the mistaken thought. As soon as the brakes are taken off, the internal machinery is quite able to make the wheels go round. The bowel will empty itself if we let it. The function of elimination is not a new trick learned with difficulty by the aged, but a trick as old and as elemental as life itself. Like balancing on a bicycle, it may not be done by any voluntary muscular effort, but it just does itself when one learns how.

Once the sense of power comes, once the mind forgets to be doubtful or afraid, then the old automatic habit invariably reasserts itself. Meddlesome interference may throw the mechanism out of gear, but fortunately it cannot strip the gears. Constipation is an inhibition or restraint of function, but is never a loss of function. No one is too old, no one is too fixed in the bad habit to relearn the old trick. I have had a good many patients with chronic constipation, but I have never had one who failed to learn. Real conviction speedily brings success, and in many cases success seems to outrun conviction. So efficient is Nature if she has only half a chance!

Some People Who Learned. Unless you are over ninety-two, do not despair. One old lady of that age, a sort of patient by proxy, was able to cure herself without even one consultation. Her daughter had been a patient of mine and had been cured of the constipation with which she had been busy for many years. The mother, who believed her own bowel paralyzed, had been in the habit of lying on the bed and taking a copious enema every second day of her life. When, however, she heard of her daughter's cure, the bright old woman gave up her enemas and let her bowels do their own functioning. She stayed cured until her death at ninety-five.