WHY WORRY?
BY: GEORGE LINCOLN WALTON, M.D.
CONSULTING NEUROLOGIST TO THE MASSACHUSETTS GENERAL HOSPITAL
VII.
HYPOCHONDRIA
Il marche, dort, mange et boit comme tous les autres; mais cela n'empeche
pas qu'il soit fort malade.
--MOLIERE: Le Malade imaginaire.
 The victim of Hypochondria may present the picture of health, or may have some real ill regarding which he is unduly anxious. His consultation with a physician is likely to be preceded by letters explaining his exact condition, naming his various consultants and describing the various remedies he has taken. At the time of his visit notes are consulted, lest some detail be omitted. In his description anatomical terms abound; thus, he has pain in his lungs, heart, or kidney, not in his chest or back.
Demonstration by the physician of the soundness of these organs is met by argument, at which the hypochondriac is generally adept.
The suggestion that the Hypochondriac devotes undue attention to his own condition is met by him with indignant denial. Proposals that he should exercise, travel, engage in games, or otherwise occupy himself, fall on deaf ears, but he is always ready to try a new drug. If a medicine is found with whose ingredients the patient is not already familiar, its use is likely to produce a beneficial effect for a few days, after which the old complaint returns.
The case has come to my attention of a young man who, for fear of taking cold, remains in bed, with the windows of the room tightly closed and a fire constantly burning. He has allowed his hair to grow until it reaches his waist, he is covered with several blankets, wears underclothing under his nightshirt, and refuses to extend his wrist from under the bed-clothes to have his pulse taken.
Such faulty mental habits in minor degree are common. There are those who will not drink from a bottle without first inspecting its mouth for flakes of glass; some will not smoke a cigar which has been touched by another since leaving the factory; some will not shake hands if it can possibly be
avoided; another pads his clothing lest he injure himself in falling. Many decline to share the occupations and pleasures of others through fear of possible wet feet, drafts of air, exhaustion, or other calamity. Such tendencies, though falling short of Hypochondria, pave the way for it, and, in any event, gradually narrow the sphere of usefulness and pleasure.
No part of the body is exempt from the fears of the hypochondriac, but he is prone to centre his attention upon the obscure and inaccessible organs.
The anecdote is told of a physician who had a patient of this type...a robust woman who was never without a long list of ailments. The last time she sent for the doctor, he lost patience with her. As she was telling him how she was suffering from rheumatism, sore throat, nervous indigestion, heart-burn, pains in the back of the head, and what not, he interrupted her:
"Ah," he said in an admiring tone, "what splendid health you must have in order to be able to stand all these complaints!"
The phobias are so closely allied to that it will not be out of place to discuss them here. A phobia is an insistent and engrossing fear, without adequate cause as judged by ordinary standards. Familiar instances are fear of open places (agoraphobia), fear of closed places (claustrophobia), and fear of contamination (mysophobia).
The sufferer from agoraphobia cannot bring himself to cross alone an open field or square. The sufferer from claustrophobia will invent any excuse to avoid an elevator or the theatre. When a certain lady was asked if she disliked to go to the theatre or church, she answered, "Not at all, but of course I like to have one foot in the aisle; I suppose everyone does that."
The victim of mysophobia will wash the hands after touching any object, and will, so far as possible, avoid touching objects which he thinks may possibly convey infection. Some use tissue paper to turn the door-knob, some extract coins from the pocket-book with pincers. I have seen a lady in a public conveyance carefully open a piece of paper containing her fare, pour the money into the conductor's hand, carefully fold up the paper so that she should not touch the inside, and afterwards drop it from the tips of her fingers into a rubbish barrel.
 The case of a nurse who was dominated by fear of infection has come to my attention. If her handkerchief touched the table it was discarded. She became very adept at moving objects about with her elbows, was finally reduced to helplessness and had to be cared for by others.
Unreasoning fear of one or another mode of conveyance is not rare. It is said that Rossini found it impossible to travel by rail, and that the attempt of a friend to accustom him to it resulted in an attack of faintness (Lombroso).
The sufferer himself realizes, in such cases, that there is no reason in his fear--he knows he can undergo greater dangers with equanimity. Even doubting folly finds no answer to the question why should this danger be shunned and that accepted. The nearest approach to an answer is "I can't", which really means "I haven't".
The origin of this phobia is not always clear, but given the necessary inherent susceptibility of the individual, particular circumstances doubtless dictate the direction the phobia takes. A startling or traumatic personal experience, or even reading or hearing of such an experience may start the fear which the insistent thought finally molds into a fixed habit.
To the hypochondriac who concentrates his attention upon the digestive tract, this part of his body occupies the foreground of all his thoughts.
He exaggerates its delicacy of structure and the serious consequences of disturbing it even by an attack of indigestion. A patient to whom a certain
fruit was suggested said he could not eat it. Asked what the effect would be, he answered that he did not know, he had not eaten any for twenty years and dared not risk finding out.
Extreme antipathies to various foods are fostered among this class. A lady told me that she perfectly abominated cereals, that she could not stand
vegetables, that she could not bear anything in the shape of an apple, that she could not abide spinach, and that baked beans made her sick at the
stomach.
 The heart is perhaps the organ most often the object of solicitude on the
part of the Hypochondriac. When we realize that the pulse may vary in the healthy individual from 60 to over 100, according to circumstances, and
that mere excitement may send it to the latter figure, we may appreciate the feelings of one who counts his pulse at frequent intervals and is
alarmed if it varies from a given figure.
Insistent desire regarding the temperature is common not only among
hypochondriacs, but among others. I do not allude to the internal
temperature (though I have been surprised to learn how many people carry a
clinical thermometer and use it on themselves from time to time); I refer
to the temperature of the room or of the outside air. The wish to feel a
certain degree of warmth is so overpowering in some cases that neither work
nor play can be carried on unless the thermometer registers the desired
figure. A person with this tendency does not venture to mail a letter
without donning hat and overcoat; the mere thought of a cold bath causes
him to shudder.
Golf has cured many a victim of this obsession. It takes only a few games
to teach the most delicately constructed that he can remain for hours in
his shirt-sleeves on quite a cold day, and that the cold shower (preferably
preceded by a warm one) invigorates instead of depresses him. Further
experiment will convince him that he can wear thin underwear and low shoes
all winter. Such experiences may encourage him to risk a cold plunge in
the morning, followed by a brisk rub and a few simple exercises before dressing.
Morbid fears in themselves produce physical manifestations which add to the discomfort and alarm of the hypochondriac. I allude to the rush of blood
to the head, the chill, the mental confusion, and the palpitation. These symptoms are perfectly harmless, and denote only normal circulatory
changes. It is true that one cannot at will materially alter his circulation, but he can do so gradually by habit of thought. To convince
ourselves of this fact, we need only remember to what a degree blushing becomes modified by change of mental attitude. Similarly, the person who
has practiced mental and physical relaxation will find that the blood no longer rushes to his head upon hearing a criticism or remembering a
possible source of worry.
The automatic processes of the body are in general performed best when the
attention is directed elsewhere. After ordinary care is taken, too minute
attention to the digestive apparatus, for example, may retard rather than
aid it. Watching the digestion too closely is like pulling up seeds to see
if they are growing.
The more attention is paid to the sensations, the more they demand. Nor can
the degree of attention they deserve be measured by their own insistence.
If one tries the experiment of thinking intently of the end of his thumb,
and imagines it is going to sleep, the chances are ten to one that in five
minutes it will have all the sensations of going to sleep. If this is true
of the healthy-minded individual, how much more must it be so in the person
who allows his thoughts to dwell with anxious attention on such parts of
his body as may be the immediate seat of his fears. The next step is for
various sensations (boring, burning, prickling, stabbing, and the like)
to appear spontaneously, and, if attention is paid to them, rapidly to
increase in intensity.
It is probable that the mere pressure of part upon part in the body, even
the ordinary activity of its organs, would give rise to sensations if we
encouraged them. Given an anomalous sensation, or even a pain, for which
the physician finds no physical basis, and which, after a term of years,
has produced no further appreciable effect than to make one nervous, it is
always in place to ask one's self whether the sensation or the pain may not
be of this nature.
Medical instructors are continually consulted by students who fear that
they have the diseases they are studying. The knowledge that pneumonia
produces pain in a certain spot leads to a concentration of attention
upon that region which causes any sensation there to give alarm. The mere
knowledge of the location of the appendix transforms the most harmless
sensations in that region into symptoms of serious menace. The sensible
student learns to quiet these fears, but the victim of "hypos" returns
again and again for examination, and perhaps finally reaches the point of
imparting, instead of obtaining, information, like the patient in a recent
anecdote from the "Youth's Companion":
It seems that a man who was constantly changing physicians at last called in a young doctor who was just beginning his practice.
"I lose my breath when I climb a hill or a steep flight of stairs," said the patient. "If I hurry, I often get a sharp pain in my side. Those are the symptoms of a serious heart trouble."
"Not necessarily, sir," began the physician, but he was interrupted.
"I beg your pardon!" said the patient irritably. "It isn't for a young physician like you to disagree with an old and experienced invalid like me, sir!"
There is no absolute standard for the proper degree of solicitude regarding
one's health, but if the habitual invalid possess a physique which would
not preclude the average normal individual from being out and about, even
at the expense of a pain, a stomach ache, or a cold, there is probably a
hypochondriacal element in the case. It is a question of adjustment of
effect to cause.
The term "imaginary" is too loosely applied to the sensations of the
hypochondriac. This designation is unjustified, and only irritates the
sufferer, rouses his antagonism, and undermines his confidence in the
judgment of his adviser. He knows that the sensations are there. To call
them imaginary is like telling one who inspects an insect through
a microscope that the claws do not look enormous; they _do_ look
enormous--through the microscope--but this does not make them so. The
worrier must learn to realize that he is looking at his sensations, as he
does everything else, "through a microscope".
 If a person living near a waterfall ignores the sound, he soon ceases to
notice it, but if he listens for it, it increases, and becomes finally
unbearable. Common sense teaches him to concentrate his attention
elsewhere; similarly, it demands that the victim of "hypos" disregard his
various sensations and devote his attention to outside affairs, unless the
sensations are accompanied by obvious physical signs. Instead of running
to the doctor, let him "do" something - ride horseback, play golf, anything
requiring exercise out of doors. Let him devote his entire energy to the
exercise, and thus substitute the healthy sensations of fatigue and hunger
for the exaggerated pains and the anomalous sensations which are fostered
by self-study. Let him remember moreover, that nature will stand an
enormous amount of outside abuse, but resents being kept under close
surveillance.
In practicing the neglect of the sensations, one should not allow his mind
to dwell on the possibility that he is overlooking something serious, but
rather on the danger of his becoming "hipped," a prey to his own doubts and
fears, and unable to accomplish anything in life beyond catering to his own morbid fancies.
Turning now to the bibliographic study of Hypochondria, an interesting and
characteristic contrast is offered between [Thomas Henry] Huxley , who called himself
a hypochondriac, but apparently was not, and [Thomas] Carlyle, who resented the
imputation, though it apparently had some justification in fact.
With regard to [Thomas Henry] Huxley,--the only basis for the diagnosis hypochondria in a given case, is undoubted evidence, by letter or conversation, that the
question of health is given undue prominence. I have looked carefully through the volume of Huxley's letters (published by his son), without
definitely establishing this diagnosis. The state of his health and the question of his personal comfort received comparatively little attention.
Whatever suffering Huxley endured he seems to have accepted in a philosophical and happy spirit, thus:
"It is a bore to be converted into a troublesome invalid even for a few weeks, but I comfort myself with my usual reflection on the chances of
life, 'Lucky it is no worse.' Any impatience would have been checked by what I heard about ... this morning ... that he has sunk into hopeless
idiocy. A man in the prime of life!"
With regard to Carlyle,--it is true, as claimed by Gould (_Biographic
Clinics_, 1903) that he showed every evidence of eyestrain with resulting
symptoms, particularly headache. This does not, however, preclude his
having had hypochondria also, and in view of the violent and reiterated
complaints running through his letters it seems quite credible that
Froude's estimate of his condition was not far wrong. Surely, unless
Carlyle was merely trying his pen without intending to be taken seriously,
he devoted to the question of health a degree of attention which may be
fairly adjudged undue.
The first letter I quote (from those cited by Gould in fortifying his
position) is of special interest as presenting in rather lurid terms
Carlyle's ideal of health. After reading this letter one cannot help
suspecting that the discomforts so vividly described in his other letters
were compared by him with this ideal rather than with those of the average
individual.
"In the midst of your zeal and ardor,... remember the care of health.... It
would have been a very great thing for me if I had been able to consider
that health is a thing to be attended to continually, that you are to
regard that as the very highest of all temporal things for you. There is no
kind of achievement you could make in the world that is equal to perfect
health. What to it are nuggets and millions'? The French financier said
'Why is there no sleep to be sold!' Sleep was not in the market at any
quotation.... I find that you could not get any better definition of what
'holy' really is than 'healthy.' Completely healthy; mens sana in corpore
sano. A man all lucid, and in equilibrium. His intellect a clear mirror
geometrically plane, brilliantly sensitive to all objects and impressions
made on it and imaging all things in their correct proportions; not twisted
up into convex or concave, and distorting everything so that he cannot see
the truth of the matter, without endless groping and manipulation: healthy,
clear, and free and discerning truly all around him."
The following extracts illustrate his attitude toward his physical shortcomings, whatever they may have been.
"A prey to nameless struggles and miseries, which have yet a kind of horror in them to my thoughts, three weeks without any kind of sleep, from impossibility to be free from noise."
"I sleep irregularly here, and feel a little, very little, more than my
usual share of torture every day. What the cause is would puzzle me
to explain. I take exercise sufficient daily; I attend with rigorous
minuteness to the quality of my food; I take all the precautions that I
can, yet still the disease abates not."
"Ill-health, the most terrific of all miseries."
"Grown sicker and sicker.... I want health, health, health! On this subject
I am becoming quite furious.... If I do not soon recover, I am miserable
forever and ever. They talk of the benefit of health from a moral point of
view. I declare solemnly, without exaggeration, that I impute nine-tenths
of my present wretchedness, and rather more than nine-tenths of all my
faults, to this infernal disorder in the stomach."
"Bilious, too, in these smothering windless days."
"Broke down in the park; "konnte nichts mehr", being sick and weak beyond measure."
"Many days of suffering, of darkness, of despondency.... Ill-health has much to do with it."
"Occasionally sharp pain (something cutting hard, grasping me around the heart).... Something from time to time tying me tight as it were, all around the region of the heart, and strange dreams haunting me."
"There is a shivering precipitancy in me, which makes _emotion_ of any kind
a thing to be shunned. It is my nerves, my nerves.... Such a nervous system
as I have.... Thomas feeling in his breast for comfort and finding bilious
fever.... All palpitating, fluttered with sleeplessness and drug-taking,
etc.... Weary and worn with dull blockheadism, chagrin (next to no sleep
the night before)."
"A head "full of air"; you know that wretched physical feeling; I had been
concerned with drugs, had awakened at five, etc. It is absolute martyrdom."
"A huge nightmare of indigestion, insomnia, and fits of black impatience
with myself and others, - self chiefly.... I am heartily sick of my
dyspeptic bewilderment and imprisonment."
"Alas! Alas! I ought to be wrapped in cotton wool, and laid in a locked
drawer at present. I can stand nothing. I am really ashamed of the figure I
cut."
Froude's statements regarding Carlyle's condition are as follows:
"... The simple natural life, the 'wholesome air, the daily rides or
drives, the poor food,... had restored completely the functions of a
stomach never so far wrong as he had imagined... Afterwards he was always
impatient, moody, irritable, violent. These humours were in his nature, and
he could no more be separated from them than his body could leap off its
shadow.... He looked back to it as the happiest and wholesomest home that
he had ever known. He could do fully twice as much work there, he said, as
he could ever do afterwards in London."
"... If his liver occasionally troubled him, livers trouble most of us as
we advance in life, and his actual constitution was a great deal stronger
than that of ordinary men.... Why could not Carlyle, with fame and honor
and troops of friends, and the gates of a great career flung open before
him, and a great intellect and a conscience untroubled by a single act
which he need regret, bear and forget too? Why indeed! The only answer is
that Carlyle was Carlyle."
These observations carry weight as representing the impartial and judicial
estimate of a careful observer desiring only accurately to picture Carlyle
as he was. The only logical conclusion, it seems to me, was that Carlyle,
in addition to ocular defect with its legitimate consequences, was weighed
down by worry over the failure to realize his own exaggerated ideal of
health, that he devoted an undue degree of attention to this subject
and was unduly anxious about it--in other words, that he had decided
hypochondriacal tendencies.
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