Psychotherapy Part 39

Prognosis.--The prognosis in cardiac neuroses is always worse in the patient's mind than it ought to be. If then the physician shows that he is uncertain as to the real significance of the affection, some hint of this uncertainty will be communicated to the patient with resultant unfavorable suggestion. The {323} more carefully neurotic heart affections have been studied, the better the prognosis becomes.

Morgagni in the olden time, Stokes and Corrigan in the early nineteenth century, Broadbent and MacKenzie in our time, have all emphasized the necessity for favorable prognosis. Even extreme irregularity is quite compatible with long life without any symptoms of serious circulatory disturbance. MacKenzie has, in his very careful studies of heart action, shown that extra systoles may cause marked irregularity in many forms without warranting unfavorable prognosis.

Arrhythmia may begin in comparatively early life, persist in spite of treatment, and yet continue up to old age. Sir William Osler tells of the case of the late Chancellor Ferrier of McGill University who died at the age of eighty-seven after having exhibited an extremely irregular heart action for the last fifty years of his life. He has seen several other patients who have had heart irregularity for many years without the slightest disturbance of their general health. His experience is not uncommon, and probably every physician who sees many cases of heart disease can recall a few of them. Ten years ago I saw a man past seventy suffering from distinctly irregular heart action, though he gave the history of having had cardiac irregularity for some years at least, and he is still alive, past eighty, and with his heart irregularity still present. I have a patient over seventy whom I know to have had irregular heart action for fifteen years, and he himself is sure that it has been present since he was about forty, at least.

It is cases of this kind, together with MacKenzie's recent studies of the subject, that must be before the physician's mind when he makes his prognosis for these patients. There must be no hesitancy about his declaration. Patients think that physicians are p.r.o.ne to deny the significance of heart trouble so as to avoid disturbing their patients. The slightest hesitation, then, will be surely looked upon as of ominous import.

The Intellectual Life and Cardiac Palpitation.--It is curious how many people who give themselves to intellectual work and live an almost exclusively indoor life have subjective symptoms relating to their hearts. Many of the English literary men and women of the last century had complaints of this kind. Sir Walter Scott described very vividly his sensations as if his heart did not have room to accomplish its functions, and said that he used to feel within his chest a fluttering as if there were a bird there beating its wings against a cage too small for it. Other literary people have told of this sense of overfullness in the chest, as if somehow there were not room for all the organs. This discomfort is mainly referred to the precordial region. In oversensitive, nervous people it may be described as painful, though a.n.a.lysis of what they mean by the word pain will show that they have only a persistent feeling of pressure which is uncomfortable and gives a sense of crowdedness in that region rather than any genuine ache. Where the feeling is much dwelt on, however, it may be exaggerated into pain, as, indeed, will any sensation, however trivial, if attention is concentrated on it. On the other hand, in practically all of these cases, just as soon as the mind is strongly diverted by any pleasant occupation, the sense of discomfort disappears not to reappear again until the patient has time to think about himself.

Heart Surveillance.--Prof. Oppenheim of Berlin has in his usual direct way expressed the power of the mind to influence the heart beat, and he does {324} not hesitate to say that certain nervous people who have been watching their hearts overmuch, and continually thinking about them, are capable of playing all sorts of tricks on themselves and sometimes even on their physicians, by this concentration of mind upon their heart and its action. Prof. Oppenheim in his "Letters to Nervous Patients," writing to a patient complaining of irregular heart action, says:

Whenever you succeed in controlling the action of your heart by means of introspection, there flows from your brain to your heart a current of innervation which disturbs the automatic movement of the organ. You now know what you have to thank for the irregularity in the action of your heart. I have frequently proved this to myself in your case: if I succeeded in feeling your pulse without your becoming aware of it, holding your attention by a conversation which interested you, the action of your heart was always absolutely regular. If, however, I tried it under your control, while your attention was anxiously directed to your heart, its action at once became irregular, and you experienced the very unpleasant sensation of palpitation.

Irritable Heart of Athletes.--A curiously interesting form of heart neuroses has appealed to me very much because I have suffered somewhat from it myself and owing to circ.u.mstances I think I have seen a larger number of patients suffering from it than usually come to a single individual. I refer to the tendency to irritability of the heart which is so marked in men who have been athletes when they were younger, and have taken a large amount of exercise during the years between fifteen and twenty-five. If these men later settle down to a sedentary life they almost inevitably suffer from a marked sense of discomfort in the precordial region because of palpitation, and are apparently much more liable than other people to have an intermittent pulse. Just what these symptoms are due to is not always easy to discover, and in different individuals there seem to be different accessory causes at work. I have seen it particularly in professional men who while at college have been on the teams and have played such hard games as handball, hockey on the ice, and the like. I do not refer only to those who have played an occasional game, but who every day of the college year have had some severe muscular exercise.

Whether this irregularity of heart action has not at least been predisposed to by over-exertion remains to be determined. Strenuous athletics produce curious heart symptoms. Missed heart beats and irregular heart action and even leakages at the valves are not unusual even in the best of hearts after severe exertion. A careful examination of the hearts of those who took part in a Marathon run at Harvard some years ago showed that immediately after the race many of them were irregular and some of them had leakages at the mitral valve which lasted from one to twenty-four hours. These were probably due to irregularity in the action of the papillary muscles as a consequence of the fatigue. I had occasion to examine the hearts of some theatrical dancers a few years ago, immediately after they came off the stage. One of them is one of the most successful of modern dancers and is able to occupy the better part of an hour in the severest kind of exertion before an audience. Her heart was not only very rapid immediately after she left the stage, but there were missed beats and a distinct disturbance at the mitral valve. It was hard to determine absolutely, but the sounds at all the valves were impure and there {325} seemed to be imperfect closure or irregularity of action. In another case there was a regular missed beat at every sixth or seventh pulsation. This seemed to be due to an abortive systole. Usually within an hour regularity of heart action is restored and the valve sounds become normal. At times when the patient is run down for any reason, the cardiac disturbance may persist for many hours, or even until after long hours of sleep.

The patients I have mentioned seem to have developed their muscles to a noteworthy degree and have enlarged and strengthened their hearts by this exercise. Later on their occupation in life prevents them from taking any severe exercise, or at least furnishes no opportunity for it, and they often settle down to existence that, beyond a short, quiet walk perhaps once a day, affords no exercise at all. Under these circ.u.mstances the muscular development that they secured as young men and which kept them in such magnificent health during their adolescent years seems to prove a positive detriment to good health, or at least to good feeling. The muscular system seems to crave to be kept up.

Occasionally I have been sure that the intermittent heart action so often seen in these cases was due to the fact that the appet.i.te, or as I should rather put it, the habit of eating, which they formed while they were accustomed to taking vigorous exercise, remains with them during their sedentary life and as a consequence they overeat, particularly of proteid food materials. The large consumption of these materials gives rise to the presence of substances in the blood which make all the muscles more irritable than usual, and this seems to add particularly to the irritability of the heart.

_Dietetic Regulation_.--For many of these people a regulation of diet seems to be the best possible remedy. They must be made to eat less substantially, since they do not need the same amount of proteid material to make up for muscle waste, now that there is no longer the old use of muscles. Some of them become very heavy. These, however, are mainly individuals who, besides eating abundantly of proteids, also consume carbohydrates in large quant.i.ties. In these there is a distinct disturbance of digestion and a tendency to dilatation of the stomach with gas which interferes with the heart action and brings on the intermittent pulse so often seen in them. In a certain number, however, there are no accessory symptoms of indigestion, but the heart symptoms are most prominent.

_Exercise_.--For these people the only real relief is afforded by a certain amount of exercise every day. They become ever so much more comfortable just as soon as their physician insists that they shall have an hour's walk at least every morning and every afternoon and that this walk shall be brisk and always have some definite purpose in it, so that there is no mere sauntering or delaying on the way. Most business men to whom this prescription of an hour's walk is given will reply that it is impossible. Most clergymen will say that their duties are such that they cannot arrange their hours for this purpose. As a rule, it is not difficult to show the business man, however, that if instead of riding to his business, he should walk every day, and this will probably only take twenty minutes to a half-hour longer than if he goes by trolley or even by automobile, this walk will provide him with a full hour of brisk exercise in the open air. The walk back from business will provide the other hour, whenever golf or some other diversion cannot be provided instead. In most cities men live from three to five miles away from their {326} business, and it is not too much to ask them to take this walk. The muscular clergyman must be made to understand that there shall be no trolley cars for his ordinary clerical calls, or at least that none are to be taken unless he has had his full two hours of brisk walk.

There is always the fear in the patient's mind that exercise, by calling for heart exertion, is almost sure to make the condition worse. This fear of itself further hampers heart action. When exercise is first increased in those who have been living sedentary lives the heart action for a time is brought more and more into the sphere of consciousness and any irregularity that is present is likely to be emphasized. A little persistence, however, soon shows that what the heart actually was craving was the opportunity to expend some of its energy and it was this pent-up force that was disturbing its action.

There is often the fear in physicians' minds lest the advising of exercise should really do harm to the patient. They fear the presence of perhaps a fatty condition, or of some obscure muscular condition, or of some other heart lesion not easy to detect, yet likely to produce serious symptoms. Stokes, who probably knew fatty heart disease better than anyone else in the nineteenth century, outlined his views of the therapy of it as follows:

In the present state of our knowledge the adoption of the following principles in the management of a case of incipient fatty heart disease seems justifiable:

We must train the patient gradually but steadily to the giving up of all luxurious habits. He must adopt early hours, and pursue a system of graduated muscular exercises; and it will often happen that, after perseverance in this system, the patient will be enabled to take an amount of exercise with pleasure and advantage, which at first was totally impossible, owing to the difficulty of breathing which followed exertion. This treatment by muscular exercise is obviously more proper in younger persons than in those advanced in life. The symptoms of debility of the heart are often removable by a regulated course of gymnastics or by pedestrian exercise, even in mountainous countries, such as Switzerland or the Highlands of Scotland or Ireland. We may often observe in such persons the occurrence of what is commonly known as "getting the second wind,"

that is to say, during the first period of the day, the patient suffers from dyspnea and palpitation to an extreme degree, but by persevering, without over-exertion, or after a short rest, he can finish his day's work and even ascend high mountains with facility.

In those advanced in life, however, as has been remarked, the frequent complications with atheromatous disease of the aorta, and affections of the liver and lungs must make us more cautious in recommending the course now specified.

Perhaps the most important therapeutic suggestion which Sir William Broadbent has to make with regard to the cardiac conditions that have come to occupy much of the patient's attention is of a negative character. He says that "patients suffering from these functional derangements of the heart usually make them a pretext for avoiding exercise and often for taking stimulants or drugs, whereas exercise and fresh air are what they need. The best way to prevent the expenditure of superfluous energy on the part of the heart in the form of palpitation is to give it a fair amount of legitimate physiological work to do." Personally I have found that most of the cardiac tonics seem to do harm, in the sense of increasing the subjective symptoms, except in cases where the patient is run down in general health because of failure to take sufficient food, when strychnin seems to be of avail and in the shape of nux vomica acts as an appetizer as well as a heart tonic. Sir William Broadbent has warned particularly with regard to the use of alcohol in these cases. {327} Most patients find that for the moment palpitation is lessened by alcoholic stimulation.

They pay for it afterwards, however, by an increased sense of discomfort that sometimes lasts for 24 hours or more. As Sir William Broadbent declared, "To relieve one attack of palpitation or fainting by alcohol is to invite another, while the terrible danger of dropping into alcoholism is incurred."

Lest it should be thought that even Broadbent is a little old-fas.h.i.+oned and not quite to be trusted in the light of our present-day knowledge, and above all lest it might be feared that these older men made a better prognosis or emphasized the value of exercise more than is compatible with our recent discoveries in the physiology and pathology of the heart, it seems well to give MacKenzie's opinion of these cases in full. This is all the more important because, as I have said, the influence of German teaching has led to the formation of rather different opinions in America, especially among our younger physicians. Prof. Martius in this country in his lecture for the Harvey Society gave quite a serious prognosis for practically all heart irregularity. He almost went so far as to lay it down as a rule of diagnosis that whenever a heart beats irregularly there is something the matter with the heart muscle or good reason to suspect a myocardial lesion of some kind. MacKenzie's view is very different to this and he warns particularly against permitting the influence of an unfavorable att.i.tude of mind on the part of these patients. He says:

The most serious thing about these cases is that the consciousness of having an irregularity sometimes makes a patient introspective and depressed. He keeps feeling his pulse, and communicates his doleful tale whenever he find a sympathetic ear.

As the process which gives rise to it in elderly people is the same as that which produces the tortuous temporal arteries, no more significance should be attached to the one symptom than to the other. I have followed cases for many years, and watched them pa.s.s through seasons of sickness and of stress, and have seen no reason to attach any serious import to this symptom. In rare instances the heart, from being occasionally irregular, has after many years become continuously irregular for short or long periods, and in a few the permanent establishment of the nodal rhythm has been the means of hastening the end. But this is infrequent, and in cases of cardio-sclerosis has only happened in advanced life, and the patient should on no account be frightened by being warned of the possible occurrence of this unlikely contingency. In younger and neurotic people I have never seen it lead to any bad results. It may appear in serious affections of the heart, as in febrile complaints, but it does not of itself add to the gravity of the condition, though I am not sure that when due to an acute infection of the heart, as in pneumonia and rheumatic fever, it may not be a sign of invasion of the myocardium by the diseased process.

If the patient is aware of the irregularity, he should be a.s.sured that there is no cause for alarm. It is useless to attempt to treat the irregularity itself. If in other respects the patient is well, then there is no need of any special treatment. If the patient be suffering from conditions which seem to promote irregularity, such as worry, fatigue, dyspepsia, the treatment should be devoted to the removal of the predisposing cause. In people with temporary high blood pressure, who show extra systoles, I find plenty of healthy exercise in the open air specially beneficial, though until they get trained, the extra systoles may at times become more frequent by the exertion.

This last remark of MacKenzie's is particularly important, for at the beginning of an attempt to relieve the symptoms by insisting on more {328} exercise, the patient is almost sure to be disturbed by this symptom of which he will often be conscious, and it takes a good deal of experience on the part of the physician to rea.s.sure him that because of the increased subjective symptoms at the beginning of the treatment by increased exertion, he may not be doing harm rather than good. As a rule, however, it is not long before the good results of the exercise treatment of these cases begin to make themselves felt and the patient is rea.s.sured. Regulated exercise of body and occupation of mind are the two important factors even in the treatment of organic heart disease. They are extremely important even in the cases with alarming heart symptoms that occur in the very old, once the acute symptoms have subsided. In all the functional heart affections exercise is the most important therapeutic resource we have. It would seem that in the course of muscular exercise some heart tonic was manufactured, which in all but the cases of absolutely failing hearts is the best possible therapeutic resource for the stimulation and steadying of the heart action. Such an internal secretion would not be surprising in the light of all that we have learned of the physiological nexus of organs in recent years.

Many so-called cures for heart disease probably depend for their good effect much more on the graduated exercise that goes with them than on many of the other remedial measures, though it is these latter that are usually vaunted most highly. We all now recognize how little value there is in the Nauheim bath treatment for heart disease away from Nauheim itself. The reason is because the resisted movements of the early part of the cure and, above all, the graduated exercise of walking up the hills around Nauheim, which are such important parts of the treatment there, cannot be so well given with the baths at a distance.

CHAPTER IV

CARDIAC PALPITATION AND GASTRO-INTESTINAL DISTURBANCE

Morgagni, whom Virchow greeted as the Father of Modern Pathology, made a careful study of the pulse and especially of its irregularities. He had learned from the most careful pathological studies that marked intermission and even more decided irregularity of the heart may be present in life, though there may be absolutely no organic affection of the heart itself, either of the valves or of the muscle, discoverable at autopsy. In his opinion the most frequent cause for such irregularity is flatulency and disturbance of digestion generally. He went still farther, however, and seems to have understood very well that constipation was often one of the most important links in the chain of causes leading up to such heart disturbance, itself either a cause or an effect of other digestive symptoms. This idea deserves to be borne in mind when there is question of the significance of heart symptoms. What Morgagni thus determined by precise studies in pathological anatomy had been clinically observed by many of the distinguished old-time pract.i.tioners of medicine, who knew the fatal tendencies of organic heart symptoms, yet recognized that many cardiac cases a.s.sociated with gastric symptoms did not have an unfavorable prognosis.

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In spite of the recognition of these conditions by old-time medical investigators, there has always been a tendency to fear that heart symptoms in these cases might be due to a cardiac affection. This has invariably been true for patients themselves to whom the heart disturbance became conscious, but has often made physicians hesitate as to the diagnosis and rendered their prognosis more unfavorable than is justified by actual knowledge.

Gastro Cardiac Arrhythmia.--What may be called the gastro-intestinal cardiac neuroses usually run a typical course. As a rule, with young folks, the beginning of cardiac unrest is found in some stomachic symptoms. The distention of the stomach with gas is said to be a mechanical reason for interference with the heart action. Whether this is really gas that has formed within the stomach, or whether it is to a great extent, at least, gas which has been diffused from the vessels of the stomach walls in a disordered viscus, or in some cases at least, air which has been swallowed because of certain gaspy habits of neurotic individuals, is hard to determine. In many cases the absence of all odor of decomposition, or of any disagreeable taste, makes for serious doubt whether the substance is really due to fermentation.

Certainly the changes that take place in food in the stomach during the course of an hour or two of digestion are not sufficient to account for the volume of gas that exerts pressure upon the gastric walls and is eructated in large mouthfuls. Fermentative processes are slow gas producers, as anyone with experience in the chemical laboratory knows.

_Mechanical Cardiac Interference_.--Every physician has seen the young man who is sure that he has heart trouble when he is really suffering from indigestion. Many of the feelings of discomfort accompanied by palpitation and irregularity are really phenomena connected rather with the stomach than the heart itself. The reason for this is not always clear. In many cases there seems to be a mechanical interference with the heart's action. This is due to the presence of gas in the stomach pressing against the diaphragm. In many cases the distention of the stomach by a heavy meal, especially if the heart has been rendered sensitive by the taking of stimulants, will have the same effect. This is particularly noticeable if the patients lie down shortly after the meal, when there is distinct discomfort in the cardiac region and noticeable irregularity of the pulse.

The most frequent phenomenon is a missed beat, or often simply a sense of discomfort in connection with the heart action that makes its beating very noticeable. This palpitation, as it is called, is usually entirely subjective. There is nothing abnormal in the sensation produced on the hand when the heart is palpated, nothing the most delicate finger can detect in the apex beat and nothing uniform in the change in the heart sounds produced in these cases. There is usually a somewhat over-excited action of the heart, but this is not characteristically revealed by either palpation or auscultation. The rhythm is interfered with, but the arrythmia affects only an occasional beat, usually rather regularly s.p.a.ced, and does not interfere with the heart's rate nor with its action in any way. This represents the most familiar form of cardiac neurosis and may, of course, be due to such substances as tobacco, or coffee, or tea, where these are taken in excess. Excess is always a matter of individual idiosyncrasy.

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_Cardiac Reflexes_.--It is thought by some that this heart irregularity and palpitation is a reflex action due to irritation of the gastric terminal filaments of the vagus nerve reflected back along this nerve and affecting the heart. The doctrine of reflexes is not as popular, however, as it was, but there can be no doubt of the fact that the vagus nerve has terminal filaments in all the large organs, yet is so extremely important to the heart that it has a definite physiological meaning and doubtless is meant to act in such a way as to stimulate the heart when these important organs are overloaded or are laboring in their functions, and, on the other hand, to depress it or at least to inhibit it somewhat, whenever there is a tendency to send too much blood to these parts. In any case, whether the positive factor in the production of the heart trouble be mechanical, as it surely often is, or whether it be reflex and due to the action upon the vagus, it must not be forgotten that in all cases where heart symptoms occur with considerable intervals of absolute freedom from them and with large subjective elements in the case, the relation of the stomach or the digestive organs in general to the heart may serve as their best explanation.

_Gastric Dilatation_.--In dilatation of the stomach there is likely to be an a.s.sociated tendency to a cardiac neurosis. Unfortunately, enough of these cases have not been followed up so as to be sure what the outcome is and whether there may not really have been some affection of the myocardium with a premature breakdown of the heart. As a consequence of the excessive irritation of the terminal filaments of the vagus nerve in the stomach wall, or because of the mechanical interference with the heart's action as a consequence of the dilated stomach pulling upon the esophagus and probably somewhat interfering with the action of the diaphragm, an irregularity of the heart action is established and a sense of discomfort in the precordia develops that is often very marked. These patients sometimes suffer from pseudo-angina and still more frequently from cardiac irregularity.

This cardiac irregularity is sometimes quite marked, and yet in 24 hours, as a consequence of the emptying of the stomach, will disappear, so that only slight intermittency remains, which eventually subsides. I have known a heart affected thus to be p.r.o.nounced absolutely without any lesion when examined by a competent heart specialist within a month after it had been so irregular as to be quite alarming to both patient and physician.

_Upward Distention_.--There is sometimes a tendency for the stomach to distend upward rather than to dilate downward and toward the left.

Perhaps this is due to the fact that in certain individuals the gastric ligaments are much stronger and more unyielding than they are in others. One thing is sure--that there are great individual differences in these cases. In some that are without any demonstrable gastric dilatation, except that gastric tympany extends higher than usual, there is marked interference with the heart action. The physician needs to see these cases when they are so irregular that there would seem to be absolutely no doubt of the existence of a myocardial lesion and then to examine them some months afterwards when the stomach had been restored to good conditions, before he is able to realize how much interference with heart action is consonant with complete return in a comparatively short time to the normal, at least so far as heart function goes. This is a very different opinion from that held by many heart specialists and {331} especially certain German authorities, who insist that any irregularity of the heart must be considered as probably representing a muscular lesion; but the evidence of careful observers may be adduced in support of it, and it is an opinion that very much rea.s.sures the patients.

Old-time Clinicians--Morgagni, Lancisi.--In this subject it has always seemed to me wise to recur to the opinions of some of the old-time clinicians who noted symptoms very carefully and studied out particularly the connection of symptoms with prognosis.

_Morgagni_.--Morgagni, for instance, whose clinical remarks are always precious, said:

Now that mention is made of the intermission of the pulse which approaches more nearly to the nature of an asphyxia than even its slenderness or weakness (for what else is the intermission of the pulse but a very short asphyxia, or what is an asphyxia but an intermission which lasts very long?) the causes of this disorder in the pulse are not to be pa.s.sed over without examination in this place, as the greater part of physicians are very greatly terrified thereby, often with good reason, yet frequently without any; as when there is some cause of it in the stomach or intestines, which may even vanish away of itself, or be easily removed by the physician.

For in what manner a palpitation of the heart may sometimes be brought on by flatus distending these parts, and again carried off by the dissipation of such flatus, I have already said; and in the same manner, or one not very dissimilar, it is also evident, that an intermission of the pulse has sometimes generated, and gone off of itself, in many whom I have known. At another time, in these very same viscera, there is a matter which produces the same effect, by irritating their nerves, with which you know how easily the nerves of the heart consent. And this matter is sometimes of such a nature that it may readily be prevented from harboring itself there. Thus I remember, when I attended to the cure of a young girl who had a fever, and an intermission of the pulse was added to the other symptoms contrary to my expectations, I was not at all deterred from giving such a medicine as I had before determined upon, that the stomach and intestines might be well cleansed; and even that I gave it so much the more boldly; and that on the same day after these parts had been deterged, the pulse returned to its former standard.

But you will read even in the _Sepulchretum_ that Ballonius had not only seen this disorder of the pulse, but also that of a languid and small stroke, removed in the same manner. "According to the degrees to which the purging was carried," says he, "the pulse was restored." And, indeed, there is an intermission of the pulse, that is of a far longer continuance as that with which Lancisi says he had been troubled "for the s.p.a.ce of six years"; yet if this intermission should be, as it was in him, "from a consent with the hypochondria," it may be entirely and perfectly taken away, by perfectly restoring those parts.

_Lancisi_.--Lancisi was another distinguished clinical observer who made special studies in neurotic heart disturbance. These studies are all the more interesting because he himself was a sufferer from this affection for many years. He was inclined to think that his heart intermittency was due to disturbance in his digestive organs and especially those lying in the upper part of the abdomen. He attributes it himself to sympathy with these and said that it came _ex hypochondriorum consensu_, as it were a reflex from his hypochondriac regions. As Lancisi lived to a pretty good age in spite of noting this symptom in early middle life, the significance of it will be well understood. It would be perfectly possible to gather a series of such cases from among the distinguished physicians of history, and as for our contemporaries and colleagues, at least one out of four of them will tell you that at some time he has suffered from an affection of this kind and has been much worried {332} about it, yet has recovered without incident and without any serious development.