Psychotherapy Part 30

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 circ.u.mstances (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 const.i.tutional, 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 ill.u.s.tration of how much a difference in the mental att.i.tude 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 quant.i.ties.

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 princ.i.p.al 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.

{248}

Since this doctrine of Metchnikoff's has come to be popularly known, fewer patients have insisted that they could not take milk in such quant.i.ties 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 att.i.tude 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 att.i.tude 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 att.i.tude toward a particular article of food bringing about a corresponding difference as regards not only the appet.i.te for it, but also its digestibility. Many persons, who used to have no appet.i.te for breakfast, now find that after eating a crisp piece or two of bacon, they develop an appet.i.te 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 circ.u.mstance. 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.

{250}

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 cla.s.ses 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 att.i.tude 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 circ.u.mstances. 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 quant.i.ty, 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 appet.i.te.

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 appet.i.te and of digestive power. Hence, a vicious circle of change is inst.i.tuted, 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 b.u.t.ter. The harm done by the remark may, therefore, even be serious, for these foods should const.i.tute 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 a.s.sociated 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 prostat.i.tis, 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 rea.s.suring.

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 a.s.sociated 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.

{254}

_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 ill.u.s.trates this. If the laboratory cat is fed some dainty that it likes, mixed with bis.m.u.th 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, pa.s.sed 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 a.s.sure 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 att.i.tude will often be of great service to the patient.