Suggestion will even make a cancer patient gain in weight, though one must be careful of that very fact because the apparent improvement may occasion delay until the case becomes inoperable.

Once the presence of these serious organic lesions of the stomach can be {255} excluded, the bringing of influence to bear on the patient's mind for the improvement of his digestion is indicated. It is true that there are certain reflex disturbances of the digestive tract consequent upon affections of other abdominal organs. Chronic lesions of the appendix may produce stomach symptoms as will also pathological conditions of the biliary tract. A floating kidney, various affections of the pelvic organs, especially in women, and of the urinary organs in men are sometimes said to produce seriously depressing effects upon the stomach. Where this occurs, the first indications undoubtedly are to put the patient into as good condition as possible before making any decision. Where a lesion of the stomach itself exists suggestions with regard to the increase of diet may do harm. They will not do harm in the reflex conditions, and so patients can be brought into better physical condition. As a consequence of this, their symptoms in other organs will often disappear. In case the symptoms do not disappear the patients are in better condition to stand and react from operative intervention.

Before concluding as to the character of the stomach symptoms we must make sure that other important organs are not affected. Most cases of tuberculosis begin with stomach symptoms, which often make their appearance before there is cough or any definite localizing symptom of the disease. Often there is only a disturbance of pulse, and perhaps a slightly increased range of temperature. If the patient has been exposed to tuberculosis, a careful investigation of the lungs should be made. Any disturbance of the liver or pancreas (especially cancer) will almost surely give rise to stomach symptoms. Latent cancer in any part of the body, however, will, by its depressing toxemia, produce loss of appet.i.te, consequent loss of weight, and a number of symptoms that are sure to be referred to the stomach. I have seen cancer of the prostate, without disturbing urination, produce such symptoms for months before it was recognized. I have seen cancer of the r.e.c.t.u.m in a comparatively young woman treated as piles, without an examination, the development of the piles being attributed to the gastro-intestinal symptoms which were consequent upon the presence of the cancer.

MENTAL INFLUENCE IN DYSPEPSIA AND INDIGESTION

It is often said that this teaching as to the effect of the mind on digestion and its eminent usefulness for the treatment of dyspeptic conditions, is due to the attention that has been attracted to this subject as a consequence of the prominence of Eddyism, New Thought, Mental Healing, and the like. There are absolutely no good grounds for any such a.s.sertion. Here in America, more than twenty-five years ago, before there was any question of the modern mental healing movements, our greatest medical clinician, Dr. Austin Flint, expressed himself very emphatically with regard to mental influence over digestion, and to solicitude of mind as one of the most frequent etiological factors in dyspepsia.

Dr. Flint was thoroughly scientific in his medical observations, was no seeker after notoriety, and he was reading his paper before the older physicians of the period, and all of those who took part in that first meeting of the New York Medical a.s.sociation strove to make their papers of scientific value. His words, then, must carry great weight:

{256}

Dyspepsia formerly prevailed chiefly among those who adopted, to a greater or less extent, the foregoing maxims [the finicky rules of dyspeptics which he deprecates and corrects as quoted later in this chapter]. It was comparatively rare among those who did not live in accordance with dietetic rules. The affection is much less prevalent now than heretofore, because these maxims are much less in vogue.

The dyspeptics of the present day are chiefly those who undertake to exemplify more or less of these maxims. It seems to me, therefore, a fair inference, that dyspepsia may result from an attempt to regulate diet by rules which have for their object the prevention of the affection which they actually produce. It is to be added that an important causative element involved in the practical adoption of these rules is the attention thereby given to digestion. It is by introspection and constant watchfulness of the functions of the stomach, that the mind exerts a direct influence in the causation of this affection.

Dietetic Rules of a Former Day.--In order to make definite just what were the views of the olden times which he deprecates, he stated them briefly and forcibly:

The views generally entertained, at the time to which I have referred, largely by physicians and almost universally by non-medical sanitarians, may be summed up in a few maxims as follows: Eat only at stated periods, twice or thrice daily, and never between meals, no matter how great may be the desire for food.

Never eat late in the evening or shortly before bedtime. In the choice of articles of diet, carefully select those which reason and personal experience have shown to be best digested; and never yield to the weakness of eating any article of food simply because it is acceptable to the palate. In order to avoid the temptation of overeating, let the articles of food be coa.r.s.e rather than attractive, and eschew all the devices of the cuisine. Always leave the table hungry. Study personal idiosyncrasies, and never indulge in kinds of food which, although wholesome for most persons, are injurious to a few who are peculiarly organized. With reference to this last maxim, bear in mind that "what is one man's meat is another man's poison." In order to secure, as effectually as possible, a proper restriction in the quant.i.ty of food, it was recommended by some physicians and to some extent practiced, that every article be carefully weighed at meal times, and that a certain quant.i.ty by weight be never exceeded. Vegetarianism or Grahamism was advocated and practiced by many. Total abstinence from drink was considered by a few as a good sanitary measure, compelling the body to derive the needed fluids exclusively from fruits, vegetables, and other solid articles of diet. Restriction in the amount of drink, as far as practicable with regard to the power of endurance, was very generally deemed important, so as not to dilute the gastric juice.

When to his question, "Do you regulate your diet," the patient answered promptly and often emphatically in the affirmative, Dr. Flint insisted always: "This is a good reason for your having dyspepsia; I never knew a dyspeptic get well who undertook to regulate his diet."

When the patient asks then, "How am I to be guided," the reply is, "Not by theoretical views of alimentation and indigestion, no matter how much they appear to be in accord with physiological and pathological doctrines, but by the appet.i.te, the palate and common sense." He then goes on to answer certain other objections that patients are wont to urge, and says:

But the patient will be likely to say, "Am I not to be guided by my own experience and avoid articles of food which I have found to disagree with my digestion?" The answer is, that personal experience in dietetics is extremely fallacious. An article of diet which may cause inconvenience of indigestion to-day may be followed by a sense of comfort and will be readily digested to-morrow. A variety of circ.u.mstances may render the digestion of any article of food taken at a {257} particular meal labored or imperfect. As a rule articles which agree with most persons do not disagree with any, except from casual or accidental circ.u.mstances, and from the expectation, in the mind of the patient, that they will disagree. Without denying that there are dietetic idiosyncrasies, they are vastly fewer than is generally supposed; and, in general, it is fair to regard supposed idiosyncrasies as purely fanciful. Patients not infrequently cherish supposed idiosyncrasies with gratification. The idea is gratifying to egotism, as evidence that Providence has distinguished them from the common herd by certain peculiarities of const.i.tution.

Dietetic Instructions.--Finally Dr. Flint has a series of instructions for those suffering from indigestion:

Do not adopt the rule of eating only at stated periods, twice or thrice daily. Be governed in this respect by appet.i.te; and eat whenever there is a desire for food. Eat in the evenings or at bedtime, if food be desired. _Insomnia is often attributable to hunger_ [italics ours]. In the choice of articles of diet, be distrustful of past personal experience, and consider it to be a trustworthy rule that those articles will be most likely to be digested without inconvenience which are most acceptable to the palate. As far as practicable, let the articles of diet be made acceptable by good cooking. As a rule, the better articles of food are cooked, the greater the comfort during digestion. Never leave the table with an unsatisfied appet.i.te. Be in no haste to suppose that you are separated from the rest of mankind by dietetic idiosyncrasies, and be distrustful of the dogma that another man's meat is a poison to you. Do not undertake to estimate the amount of food which you take. In this respect different persons differ very widely, and there is no fixed standard of quant.i.ty, which is not to be exceeded. Take animal and vegetable articles of diet in relative proportions as indicated by instinct. In the quant.i.ty of drink, follow nature's indication; namely, thirst. Experience shows abundantly that, with a view of comfortable digestion, there need be no restriction in the ingestion of liquids.

Removal of Solicitude as a Remedial Measure.--Many dyspeptics have no subject that they occupy themselves with more seriously than their digestion, and they thus divert blood needed for digestive purposes as well as nervous energy that would help in it from the stomach to the brain, in order to exercise surveillance over the process. As has been well said, "Probably much more than half of the indigestion is really above the neck." This does not mean that there are not cases that need definite stomachic treatment, or even that patients who have succeeded in functionally disturbing their digestion by thinking over much about it, will not need gastric remedies.

The explanation of the many fads and remedies that _cure_ indigestion, real or supposed, is exactly this tendency of the suggestive influence of such remedial measures to lessen the patient's solicitude about digestion. Any change in diet that carries with it the persuasion that for any reason digestion ought to be better, will, because of this, make digestion better. Any habit of taking warm or cold water before meals, or of chewing in a particular way, or of taking a particular kind of food different from what is usually taken--exclusively cereal, uncooked, largely fruit, vegetarian, etc.--will lift the concentration of attention on the digestive process, and so give the stomach a chance to do its work without interference from the brain.

Du Bois has quoted some striking testimony in this matter from Baras, who wrote on the "Gastralgias and Nervous Affections of the Stomach and the Intestines" as early as 1820. Baras had himself been a sufferer from {258} gastric discomfort, fullness after eating, eructations of gas, constipation, and general depression. He consulted most of the distinguished medical pract.i.tioners of his time. With one exception they were convinced that he was a sufferer from chronic gastro-enteritis. They added more and more to his concern about his stomach, and furnished him with numerous sources of autosuggestion. In spite of all that they did for him, his condition grew worse and worse, he lost in weight, and was sure that his case was hopeless. He was cured in a single day. His daughter was attacked with consumption, and "in the moment my attention," says Baras, "was centered entirely upon my child, I thought no more of myself, and I was cured."

Brain Workers and Indigestion.--Perhaps the best proof of how necessary it is that people should not continue to occupy their intellect seriously during the time when digestion is going on, is to be found in the frequency with which complaints of indigestion occur in literary folk. The complaints are heard most from literary folk because they are more likely to tell their stories. They have their work, and thoughts of it, always with them. So there is a constant call for nervous and mental activity and for much blood in the brain tissues. This subtracts from the nervous energy necessary for digestion, and makes it impossible to conduct it with that perfection which comes naturally to people who banish all other thoughts and keep their minds free for the pleasures of the table and social intercourse at meal time.

Nervous indigestion is so common among literary folk, teachers and scientific workers, that various causes have been suggested for it.

Dr. George Gould, in his "Biographic Clinics," calls attention to it and suggests that the cause is probably the need of properly fitted spectacles. In our own time, when we are much more careful in the matter of eyegla.s.ses, and when most writers and professors wear scientifically adapted gla.s.ses, the complaints still continue. The reason is evidently something a.s.sociated with the almost continuous work that they do. Such people, too, are much more self-conscious than others. They think more about their digestion and what they eat. They often think that they differ from other people and have special idiosyncrasies for food. These thoughts are sure to culminate in nervous indigestion.

Food Faddists.--Literary folk and people who live the intellectual life are very p.r.o.ne to take up with fads of various kinds and find surcease from their sorrows in all sorts of out of the way dietaries, modes of eating, food limitations and specializations. They const.i.tute a majority of the food faddists. Some of them--sure that they should not eat meat--are strenuous vegetarians. Others confine themselves entirely to food the life of which has not been completely destroyed by cooking. They are fruit faddists, nut faddists, milk-product faddists, and the like. Some of them try to persuade the world that it eats too much; others that it eats too frequently. Some of them take but a single real meal a day and have apologies for the other meals.

All want to lead people to their particular mode of life, as if all the world had been wrong until they came to set it right. Some want the rest of the world to chew seventy-times-seven before they swallow and to adopt other exaggerations of attention to eating that are quite contrary to instinct, the most precious guide that we have in the matter of food choice and food consumption.

These intellectuals are always improved by their fads, no matter what they {259} may be. The reason is apparent. Their original digestive disturbance was due to over-occupation with intellectual work. Then they began to worry about their digestion and feared that nearly everything they ate would disagree with them. This fear and solicitude still further interfered with digestion. Next they acquired the new fad. They became persuaded that they could eat certain things in certain ways. They no longer disturb their digestion by anxiety about it, but, on the contrary, help it by favorable suggestion. Now under the new regime everything will surely go on well. Besides, they usually learn the lesson of not doing intellectual work close to their meals, and of s.p.a.cing their work better. They learn to do a daily stint of work and no more. One of the fads that goes with most food fashions is abundant outdoor air. This always does good. Between the favorable mental influence, the lessened work, especially just after meals, and the increased outdoor air they get better and then they attribute it all to their special fad about food. The _"cure"_ is due to psychotherapy and common sense, and not in any way to the special fad.

Worry.--Worry of any kind will have the same effect as the over-attention of the literary man or teacher to his work. Anyone who brings his business home with him is likely to suffer and, unless he has a superabundant supply of energy, will impair his digestive function as a consequence of attempting to do business after dinner, perhaps also stealing some of it in before and during breakfast.

PREVENTION AND CORRECTION

The important rule with regard to the mental att.i.tude of the patient toward uncomfortable feelings due to digestion must be, first to correct all other possible sources of the trouble, and only after these have been proved not to be factors in the case, should there be any question of modification of diet. This is just the opposite rule from that which obtains, and by which patients begin to meddle with their diet at the slightest symptom, or supposed symptom, of indigestion. My custom is to tell patients at once that there is probably something else besides their diet at fault. It is not that they eat too much, nor too great a variety, but that perhaps they eat too rapidly. Without reducing their diet, and above all without eliminating supposedly indigestible things from it, there should be formed a habit of eating more slowly. This will usually result in the reduction of the quant.i.ty eaten, but the variety of food should be the same, and the patient should not be permitted to limit his diet to a few supposedly bland, unirritating materials. In that event, constipation will a.s.sert itself, particularly if there is limitation of the amount of fluid taken.

Longevity of Dyspeptics.--There is one consolation that may be given to nervous dyspeptics, though in the midst of their worst symptoms they may not be sure whether it is a genuine consolation or not. It has been noted that many of those who live to extreme age tell the story of having suffered from nervous dyspepsia in middle-life. Their solicitude about themselves makes them safe against over-indulgences of many kinds in food or drink that might prove hurtful to them. Much of their discomfort is indeed due to the fact that they do not eat quite enough. If they succeed in avoiding the {260} pitfalls of the infectious diseases, and especially tuberculosis during their earlier years, and most of them are likely to because of the great care they take of themselves, they often live to old age. Certainly of two men, one of whom eats very heartily and the other very sparingly, the latter is much the more likely to attain old age. There are those who declare that the valetudinarian life, "half dead and alive," which even Plato satirized nearly 2,500 years ago, ever renews the question as to whether life is worth living or not. It is particularly dyspeptics who seriously discuss this question--yet with all their complaints, they actually do live longer lives.

Pharmaceutic Remedies.--This insistence on the importance of mind in the treatment of indigestion does not imply that tonic remedies, and especially such substances as strychnin, which stimulate appet.i.te and add tone to the muscles of the stomach, should not be used when duly indicated. They are always helpful. Alone, these remedies give but temporary relief and after a short time the system becomes accustomed to them. If prescribed in connection with changes in the patient's habits, and especially such as divert his attention from his digestive tract, and from wrong persuasions as to food taking, the good they accomplish will be lasting. Nervous people usually have an increase of acidity. They are liable to overdo everything, and even the stomach overdoes its acid forming function. For this, alkaline remedies such as rhubarb and soda will do good. But, just as with strychnin, the benefit is but temporary unless the patient's habits and att.i.tude of mind are modified so as to eliminate their solicitude as a constantly disturbing factor.

Circ.u.mstantial Suggestions.--There are many changes of habits that are of great value in the treatment of nervous and allied forms of indigestion. These changes often make a great difference in the general health of the patient and thus help to improve digestion.

Besides their influence as alteratives, they are valuable from the mental influence which they exercise. It requires a definite exertion of will many times, perhaps, each day to bring about the omission or performance of certain actions, and this act of the will is accompanied by the repeated suggestion that this will cause improvement in the digestion. Many of the cures effected by special diet. Habits of exercise, health resort regimes and the like, owe their efficacy to this accompanying repeated suggestion of acts for the formation of new habits or the breaking of old ones.

Physiological Measures.--There are, of course, certain details with regard to digestion in which the patient's mental att.i.tude needs to be changed by instruction rather than persuasion, by knowledge of physiology rather than by psychology. In the taking of food itself, chewing is, of course, the most important consideration after its good preparation by the cook. If patients are told to chew their food carefully, however, without further directions than this, it will usually be found that they begin to chew their meat a great deal and their vegetables scarcely more than before. It is, however, vegetables that must be chewed particularly. The meat-eating animals bolt their food. They have only cutting and tearing teeth. Their instinct is correct, for the saliva has nothing to do with the digestion of meat, and therefore no chewing is necessary. On the other hand, the vegetable-eating, and especially the grain-eating animals, chew carefully. Most of them are ruminants, that is, after a preliminary thorough chewing of their food, they swallow it, and then {261} afterwards at their leisure bring it up once more into the mouth and chew it again.

_Mastication and the Stomach_.--If food is not chewed well, and occurs in large ma.s.ses in the stomach, not only is it not dissolved easily, but the work of pa.s.sing it out to the intestine is delayed. The reflex which brings about the opening of the stomach and the ejection of food into the intestine is best brought about by the liquefaction of the stomach contents. During the mixing process all the food, as far as possible, becomes fluid and then is pa.s.sed on. Large pieces of any kind are delayed, however, hamper the emptying of the stomach and interfere with stomach motility. The stomach is only a thin-walled membranous viscus which finds difficulty in dealing with food in lumps. It is different from the stomach of the hen, which, having no teeth, swallows grains of all kinds without chewing, but also by instinct swallows small stones which, in its thick-walled, muscular gizzard, are used for grinding up the food.

_Exercise_.--The taking of exercise is an important habit that needs to be changed in the case of dyspeptics. Many of those who live a sedentary life, and are much occupied with intellectual or business matters, are almost sure to take little or no exercise. If earlier in life they were accustomed to take much, the lack of it leads to serious disturbances of nutrition. They have formed certain habits as to the amount of food they eat, and these continue, so that they consume more heat-making material than they can use. In the process of dissipating it, there is likely to be much nervous energy wasted, usually to the discomfort of the patient. This is likely to be eventually reflected back to the stomach, with disturbance of appet.i.te and digestion.

We now know that the motor function of the stomach is much more important than its secretory function. Its main purpose is to mix the food and pa.s.s it on in small quant.i.ties, at intervals, to the intestines. When patients have a sense of uncomfortable fullness in the gastric region after a hearty meal, or of discomfort after the taking of food, especially if much liquid is taken with it, they are p.r.o.ne to attribute these feelings to imperfect secretion not completing digestion as it should, and permitting fermentation with a production of gas and consequent stomach distention. The real reason for their discomfort is not secretory, but motor. It is due to a delay in pa.s.sing on the food and to stomach distention because the gastric muscle is not in good tone.

People who have been used to taking exercises have their muscular system in good tonic condition. This includes the involuntary muscles, as well as the voluntary, and if they are neglecting air and exercise, the whole muscular system becomes flabby. Hence the uncomfortable sense of distention, because the stomach walls do not contract readily for the expulsion of food. A second important factor is also present--the muscles of the abdomen. Ordinarily they support the abdominal organs without any sense of effort. If by lack of exercise they have diminished in tone, however, when a hearty meal is eaten, the abdominal muscles have to support this additional weight since the stomach itself sags, and the consequence is a feeling of pressure on the left side of the abdomen about the level of the umbilicus. To relieve this feeling the tendency of the patient is almost always to lessen the amount eaten. If he is not distinctly overweight this will do harm rather than good. Instead he {262} needs to take sufficient exercise to tone abdominal muscles and reflexly also tone even involuntary muscles, and with them the gastric muscularis.

_Air_.--Almost more important than exercise is an abundance of fresh air, and without this muscles soon fail to respond to voluntary or involuntary impulses. If people do not spend two or three hours in the air every day, they are likely to develop an over-sensitive condition in which all nervous sensations are exaggerated. The reason men and women differ so markedly in their reaction to pains, aches and discomforts, is mainly that their habits of being out in the air differ correspondingly. Men are out much and, as a rule, stand discomfort better. Women are out little and are more sensitive to pains and aches. The more a man is out, the less is he likely to notice discomforts and aches that he would otherwise complain about.

_Sleep_.--Another important factor is the amount of sleep. Over and over again I have found that patients who were beginning to complain of discomfort, which they a.s.sociated with the word indigestion, were taking too little sleep, and as soon as I persuaded them to add an hour or more to their sleep their gastric symptoms began to improve.

It is easy in our large cities to acquire the habit of shortening the hours of rest. This is sometimes done so gradually that the individual scarcely realizes how much he has cut into his sleeping period. Some people who have to get up at seven or half-past seven in the morning go to bed about twelve, but really do not get settled for sleep until nearly one o'clock. Sometimes people read interesting books just before going to bed, or while in bed, and it is nearly two o'clock when they get to sleep.

Many people have the habit of reading themselves to sleep. This may be an excellent way to get rid of bothersome thoughts, provided the reading selected is not of too absorbing a character, and provided also as soon as sleepiness comes its call is heeded. Some write letters late at night. Writing always keeps one awake, though reading may be helpful for sleep. If this abbreviation of sleep becomes habitual, the first organs in the body to set up an objection is the digestive tract. It is one of the hardest worked systems in the body, having to dispose of its quantum of food three times every day, and if the organism does not receive due rest, the digestive tract suffers first. People who get insufficient sleep often have no appet.i.te in the morning, and suffer from uncomfortable feelings in the gastric region.

What they are too p.r.o.ne to do is to meddle with their diet, and this practice always does harm.

CHAPTER IV

APPEt.i.tE