Part 2

One of our ablest medical scholars reports himself to me as having never been aware of any sensation in the head, by which he could tell that he had worked enough, up to a late period of his college career, when, having overtaxed his brain, he was restricted by his advisers to two or three hours of daily study. He thus learned to study hard, and ever since has been accustomed to execute all mental tasks at high pressure under intense strain and among the cares of a great practice. All his mind-work is, however, forced labor, and it always results in a distinct sense of cerebral fatigue,--a feeling of pressure, which is eased by clasping his hands over his head; and also there is desire to lie down and rest.

"I am not aware," writes a physician of distinction, "that, until a few years ago, I ever felt any sense of fatigue from brain-work which I could refer to the organ employed. The longer I worked the clearer and easier my mental processes seemed to be, until, during a time of great sorrow and anxiety, I pushed my thinking organs rather too hard. As a result, I began to have headache after every period of intellectual exertion. Then I lost power to sleep. Although I have partially recovered, I am now always warned when I have done enough, by lessening ease in my work, and by a sense of fulness and tension in the head." The indications of brain-tire, therefore, differ in different people, and are more and more apt to be referred to the thinking organ as it departs more and more from a condition of health. Surely a fuller record of the conditions under which men of note are using their mental machinery would be everyway worthy of attention.

Another reason why too prolonged use of the brain is so mischievous is seen in a peculiarity, which is of itself a proof of the auto-activity of the vital acts of the various organs concerned in intellection. We sternly concentrate attention on our task, whatever it be; we do this too long, or under circumstances which make labor difficult, such as during digestion or when weighted by anxiety. At last we stop and propose to find rest in bed. Not so, says the ill-used brain, now morbidly wide awake; and whether we will or not, the mind keeps turning over and over the work of the day, the business or legal problem, or mumbling, so to speak, some wearisome question in a fashion made useless by the denial of full attention. Or else the imagination soars away with the unrestful energy of a demon, conjuring up an endless procession of broken images and disconnected thoughts, so that sleep is utterly banished.

I have chosen here as examples men whose brains are engaged constantly in the higher forms of mental labor; but the difficulty of arresting at will the overtasked brain belongs more or less to every man who overuses this organ, and is the well-known initial symptom of numerous morbid states. I have instanced scholars and men of science chiefly, because they, more than others, are apt to study the conditions under which their thinking organs prosper or falter in their work, and because from them have we had the clearest accounts of this embarrassing condition of automatic activity of the cerebral organs. Few thinkers have failed, I fancy, to suffer in this way at some time, and with many the annoyance is only too common. I do not think the subject has received the attention it deserves, even from such thorough believers in unconscious cerebration as Maudsley. As this state of brain is fatal to sleep, and therefore to needful repose of brain, every sufferer has a remedy which he finds more or less available. This usually consists in some form of effort to throw the thoughts off the track upon which they are moving. Almost every literary biography has some instance of this difficulty, and some hint as to the sufferer's method of freeing his brain from the despotism of a ruling idea or a chain of thought.

Many years ago I heard Mr. Thackeray say that he was sometimes haunted, when his work was over, by the creatures he himself had summoned into being, and that it was a good corrective to turn over the pages of a dictionary. Sir Walter Scott is said to have been troubled in a similar way. A great lawyer, whom I questioned lately as to this matter, told me that his cure was a chapter or two of a novel, with a cold bath before going to bed; for, said he, quaintly, "You never take out of a cold bath the thoughts you take into it." It would be easy to multiply such examples.

Looking broadly at the question of the influence of excessive and prolonged use of the brain upon the health of the nervous system, we learn, first, that cases of cerebral exhaustion in people who live wisely are rare. Eat regularly and exercise freely, and there is scarce a limit to the work you may get out of the thinking organs. But if into the life of a man whose powers are fully taxed we bring the elements of great anxiety or worry, or excessive haste, the whole machinery begins at once to work, as it were, with a dangerous amount of friction. Add to this such constant fatigue of body as some forms of business bring about, and you have all the means needed to ruin the man's power of useful labor.

I have been careful here to state that combined overwork of mind and body is doubly mischievous, because nothing is now more sure in hygienic science than that a proper alternation of physical and mental labor is best fitted to insure a lifetime of wholesome and vigorous intellectual exertion. This is probably due to several causes, but principally to the fact that during active exertion of the body the brain cannot be employed intensely, and therefore has secured to it a state of repose which even sleep is not always competent to supply. There is a Turkish proverb which occurs to me here, like most proverbs, more or less true: "Dreaming goes afoot, but who can think on horseback?" Perhaps, too, there is concerned a physiological law, which, though somewhat mysterious, I may again have to summon to my aid in the way of explanation. It is known as the law of Treviranus, its discoverer, and may thus be briefly stated: Each organ is to every other as an excreting organ. In other words, to insure perfect health, every tissue, bone, nerve, tendon, or muscle should take from the blood certain materials and return to it certain others. To do this every organ must or ought to have its period of activity and of rest, so as to keep the vital fluid in a proper state to nourish every other part. This process in perfect health is a system of mutual assurance, and is probably essential to a condition of entire vigor of both mind and body.

It has long been believed that maladies of the nervous system are increasing rapidly in the more crowded portions of the United States; but I am not aware that any one has studied the death-records to make sure of the accuracy of this opinion. There can be no doubt, I think, that the palsy of children becomes more frequent in cities just in proportion to their growth in population. I mention it here because, as it is a disease which does not kill but only cripples, it has no place in the mortuary tables. Neuralgia is another malady which has no record there, but is, I suspect, increasing at a rapid rate wherever our people are crowded together in towns. Perhaps no other form of sickness is so sure an indication of the development of the nervous temperament, or that condition in which there are both feebleness and irritability of the nervous system. But the most unquestionable proof of the increase of nervous disease is to be looked for in the death statistics of cities.

There, if anywhere, we shall find evidence of the fact, because there we find in exaggerated shapes all the evils I have been defining. The best mode of testing the matter is to take the statistics of some large city which has grown from a country town to a vast business hive within a very few years. Chicago fulfils these conditions precisely. In 1852 it numbered 49,407 souls. At the close of 1868 it had reached to 252,054. Within these years it has become the keenest and most wide-awake business centre in America. I owe to the kindness of Dr. J.H. Rauch, Sanitary Superintendent of Chicago, manuscript records, hitherto unpublished, of its deaths from nervous disease, as well as the statement of each year's total mortality; so that I have it in my power to show the increase of deaths from nerve disorders relatively to the annual loss of life from all causes. I possess similar details as to Philadelphia, which seem to admit of the same conclusions as those drawn from the figures I have used. But here the evil has increased more slowly. Let us see what story these figures will tell us for the Western city. Unluckily, they are rather dry tale-tellers.

The honest use of the mortuary statistics of a large town is no easy matter, and I must therefore ask that I may be supposed to have taken every possible precaution in order not to exaggerate the reality of a great evil. Certain diseases, such as apoplexy, palsy, epilepsy, St. Vitus's dance, and lockjaw or tetanus, we all agree to consider as nervous maladies; convulsions, and the vast number of cases known in the death-lists as dropsy of the brain, effusion on the brain, etc., are to be looked upon with more doubt. The former, as every doctor knows, are, in a vast proportion of instances, due to direct disease of the nerve-centres; or, if not to this, then to such a condition of irritability of these parts as makes them too ready to originate spasms in response to causes which disturb the extremities of the nerves, such as teething and the like. This tendency seems to be fostered by the air and habits of great towns, and by all the agencies which in these places depress the health of a community. The other class of diseases, as dropsy of the brain or effusion, probably includes a number of maladies, due some of them to scrofula, and to the predisposing causes of that disease; others, to the kind of influences which seem to favor convulsive disorders. Less surely than the former class can these be looked upon as true nervous diseases; so that in speaking of them I am careful to make separate mention of their increase, while thinking it right on the whole to include in the general summary of this growth of nerve disorders this partially doubtful class.

Taking the years 1852 to 1868, inclusive, it will be found that the population of Chicago has increased 5.1 times and the deaths from all causes 3.7 times; while the nerve deaths, including the doubtful class labelled in the reports as dropsy of the brain and convulsions, have risen to 20.4 times what they were in 1852. Thus in 1852, '53, and '55, leaving out the cholera year '54, the deaths from nerve disorders were respectively to the whole population as 1 in 1149, 1 in 953, and 1 in 941; whilst in 1866, '67, and '68, they were 1 in 505, 1 in 415.7, and 1 in 287.8. Still omitting 1854, the average proportion of neural deaths to the total mortality was, in the five years beginning with 1852, 1 in 26.1. In the five latter years studied--that is, from 1864 to 1868, inclusive--the proportion was 1 nerve death to every 9.9 of all deaths.

I have alluded above to a class of deaths included in my tables, but containing, no doubt, instances of mortality due to other causes than disease of the nerve-organs. Thus many which are stated to have been owing to convulsions ought to be placed to the credit of tubercular disease of the brain or to heart maladies; but even in the practice of medicine the distinction as to cause cannot always be made; and as a large proportion of this loss of life is really owing to brain affections, I have thought best to include the whole class in my statement.

A glance at the individual diseases which are indubitably nervous is more instructive and less perplexing. For example, taking the extreme years, the recent increase in apoplexy is remarkable, even when we remember that it is a malady of middle and later life, and that Chicago, a new city, is therefore entitled to a yearly increasing quantity of this form of death. In 1868 the number was 8.6 times greater than in 1852. Convulsions as a death cause had in 1868 risen to 22 times as many as in the year 1852. Epilepsy, one of the most marked of all nervous maladies, is more free from the difficulties which belong to the last-mentioned class. In 1852 and '53 there were but two deaths from this disease; in the next four years there were none. From 1858 to '64, inclusive, there were in all 6 epileptic deaths: then we have in the following years, 5, 3, 11; and in 1868 the number had increased to 17. Passing over palsy, which, like apoplexy, increases in 1868,--8.6 times as compared with 1852; and 26 times as compared with the four years following 1852,--we come to lockjaw, an unmistakable nerve malady. Six years out of the first eleven give us no death from this painful disease; the others, up to 1864, offer each one only, and the last-mentioned year has but two. Then the number rises to 3 each year, to 5 in 1867, and to 12 in 1868. At first sight, this record of mortality from lockjaw would seem to be conclusive, yet it is perhaps, of all the maladies mentioned, the most deceptive as a means of determining the growth of neural diseases. To make this clear to the general reader, he need only be told that tetanus is nearly always caused by mechanical injuries, and that the natural increase of these in a place like Chicago may account for a large part of the increase. Yet, taking the record as a whole, and viewing it only with a calm desire to get at the truth, it is not possible to avoid seeing that the growth of nerve maladies has been inordinate.

The industry and energy which have built this great city on a morass, and made it a vast centre of insatiate commerce, are now at work to undermine the nervous systems of its restless and eager people, with what result I have here tried to point out, chiefly because it is an illustration in the most concentrated form of causes which are at work elsewhere throughout the land.

The facts I have given establish the disproportionate increase in one great city of those diseases which are largely produced by the strain on the nervous system resulting from the toils and competitions of a community growing rapidly and stimulated to its utmost capacity. Probably the same rule would be found to apply to other large towns, but I have not had time to study the statistics of any of them fully; and, for reasons already given, Chicago may be taken as a typical illustration.

It were interesting to-day to question the later statistics of this great business-centre; to see if the answers would weaken or reinforce the conclusions drawn in 1871. I have seen it anew of late with its population of 700,000 souls. It is a place to-day to excite wonder, and pity, and fear. All the tides of its life move with bustling swiftness. Nowhere else are the streets more full, and nowhere else are the faces so expressive of preoccupation, of anxiety, of excitement. It is making money fast and accumulating a physiological debt of which that bitter creditor, the future, will one day demand payment.

If I have made myself understood, we are now prepared to apply some of our knowledge to the solution of certain awkward questions which force themselves daily upon the attention of every thoughtful and observant physician, and have thus opened a way to the discussion of the causes which, as I believe, are deeply affecting the mental and physical health of working Americans. Some of these are due to the climatic conditions under which all work must be done in this country, some are out-growths of our modes of labor, and some go back to social habitudes and defective methods of early educational training.

In studying this subject, it will not answer to look only at the causes of sickness and weakness which affect the male sex. If the mothers of a people are sickly and weak, the sad inheritance falls upon their offspring, and this is why I must deal first, however briefly, with the health of our girls, because it is here, as the doctor well knows, that the trouble begins. Ask any physician of your acquaintance to sum up thoughtfully the young girls he knows, and to tell you how many in each score are fit to be healthy wives and mothers, or in fact to be wives and mothers at all. I have been asked this question myself very often, and I have heard it asked of others. The answers I am not going to give, chiefly because I should not be believed--a disagreeable position, in which I shall not deliberately place myself. Perhaps I ought to add that the replies I have heard given by others were appalling.

Next, I ask you to note carefully the expression and figures of the young girls whom you may chance to meet in your walks, or whom you may observe at a concert or in the ball-room. You will see many very charming faces, the like of which the world cannot match--figures somewhat too spare of flesh, and, especially south of Rhode Island, a marvellous littleness of hand and foot. But look further, and especially among New England young girls: you will be struck with a certain hardness of line in form and feature which should not be seen between thirteen and eighteen, at least; and if you have an eye which rejoices in the tints of health, you will too often miss them on the cheeks we are now so daringly criticising. I do not want to do more than is needed of this ungracious talk: suffice it to say that multitudes of our young girls are merely pretty to look at, or not that; that their destiny is the shawl and the sofa, neuralgia, weak backs, and the varied forms of hysteria,--that domestic demon which has produced untold discomfort in many a household, and, I am almost ready to say, as much unhappiness as the husband's dram. My phrase may seem outrageously strong, but only the doctor knows what one of these self-made invalids can do to make a household wretched. Mrs. Gradgrind is, in fiction, the only successful portrait of this type of misery, of the woman who wears out and destroys generations of nursing relatives, and who, as Wendell Holmes has said, is like a vampire, sucking slowly the blood of every healthy, helpful creature within reach of her demands.

If any reader doubts my statement as to the physical failure of our city-bred women to fulfil all the natural functions of mothers, let him contrast the power of the recently imported Irish or Germans to nurse their babies a full term or longer, with that of the native women even of our mechanic classes. It is difficult to get at full statistics as to those a higher social degree, but I suspect that not over one-half are competent to nurse their children a full year without themselves suffering gravely. I ought to add that our women, unlike ladies abroad, are usually anxious to nurse their own children, and merely cannot. The numerous artificial infant foods now for sale singularly prove the truth of this latter statement. Many physicians, with whom I have talked of this matter, believe that I do not overstate the evil; others think that two-thirds may be found reliable as nurses; while the rural doctors, who have replied to my queries, state that only from one-tenth to three-tenths of farmers' wives are unequal to this natural demand. There is indeed little doubt that the mass of our women possess that peculiar nervous organization which is associated with great excitability, and, unfortunately, with less physical vigor than is to be found, for example, in the sturdy English dames at whom Hawthorne sneered so bitterly. And what are the causes to which these peculiarities are to be laid? There are many who will say that late hours, styles of dress, prolonged dancing, etc., are to blame; while really, with rare exceptions, the newer fashions have been more healthy than those they superseded, people are better clad and better warmed than ever, and, save in rare cases, late hours and overexertion in the dance are utterly incapable of alone explaining the mischief. I am far more inclined to believe that climatic peculiarities have formed the groundwork of the evil, and enabled every injurious agency to produce an effect which would not in some other countries be so severe. I am quite persuaded, indeed, that the development of a nervous temperament is one of the many race-changes which are also giving us facial, vocal, and other peculiarities derived from none of our ancestral stocks. If, as I believe, this change of temperament in a people coming largely from the phlegmatic races is to be seen most remarkably in the more nervous sex, it will not surprise us that it should be fostered by many causes which are fully within our own control. Given such a tendency, disease will find in it a ready prey, want of exercise will fatally increase it, and all the follies of fashion will aid in the work of ruin.

While a part of the mischief lies with climatic conditions which are utterly mysterious, the obstacles to physical exercise, arising from extremes of temperature, constitute at least one obvious cause of ill health among women in our country. The great heat of summer, and the slush and ice of winter, interfere with women who wish to take exercise, but whose arrangements to go out-of-doors involve wonderful changes of dress and an amount of preparation appalling to the masculine creature.

The time taken for the more serious instruction of girls extends to the age of nineteen, and rarely over this. During some of these years they are undergoing such organic development as renders them remarkably sensitive. At seventeen I presume that healthy girls are as well able to study, with proper precautions, as men; but before this time overuse, or even a very steady use, of the brain is in many dangerous to health and to every probability of future womanly usefulness.

In most of our schools the hours are too many, for both girls and boys. From nine until two is, with us, the common school-time in private seminaries. The usual recess is twenty minutes or half an hour, and it is not as a rule filled by enforced exercise. In certain schools--would it were common!--ten minutes' recess is given after every hour; and in the Blind Asylum of Philadelphia this time is taken up by light gymnastics, which are obligatory. To these hours we must add the time spent in study out of school. This, for some reason, nearly always exceeds the time stated by teachers to be necessary; and most girls of our common schools and normal schools between the ages of thirteen and seventeen thus expend two or three hours. Does any physician believe that it is good for a growing girl to be so occupied seven or eight hours a day? or that it is right for her to use her brains as long a time as the mechanic employs his muscles? But this is only a part of the evil. The multiplicity of studies, the number of teachers,--each eager to get the most he can out of his pupil, the severer drill of our day, and the greater intensity of application demanded, produce effects on the growing brain which, in a vast number of cases, can be only disastrous.

My remarks apply of course chiefly to public school life. I am glad to say that of late in all of our best school States more thought is now being given to this subject, but we have much to do before an evil which is partly a school difficulty and partly a home difficulty shall have been fully provided against.

Careful reading of our Pennsylvania reports and of those of Massachusetts convinces me that while in the country schools overwork is rare, in those of the cities it is more common, and that the system of pushing,--of competitive examinations,--of ranking, etc., is in a measure responsible for that worry which adds a dangerous element to work.

The following remarks as to the influence of home life in Massachusetts are not out of place here, and will be reinforced by what is to be said farther on by a competent authority as to Philadelphia:

"The danger of overwork, I believe, exists mainly, if not wholly, in graded schools, where large numbers are taught together, where there is greater competition than in ungraded schools, and where the work of each pupil cannot be so easily adjusted to his capacity and needs. And what are the facts in these schools? I am prepared to agree with a recent London School Board Report so far as to say that in some of our graded schools there are pupils who are overworked. The number in any school is, I believe, small who are stimulated beyond their strength, and the schools are few in which such extreme stimulation is encouraged. When, with a large class of children whose minds are naturally quick and active, the teacher resorts to the daily marking of recitations, to the giving of extra credits for extra work done, to ranking, and to holding up the danger of non-promotion before the pupils; and when, added to those extra inducements to work, there are given by committees and superintendents examinations for promotion at regular intervals, it would be very strange if there were not some pupils so weak and so susceptible as to be encouraged to work beyond their strength. There is another occasion of overwork which I have found in a few schools, and that is the spending of nearly all of the school time in recitation and putting off study to extra time at home. When, in a school of forty or more, pupils belong to the same class, and are not separated into divisions for recitation and study, there is a temptation to spend the greater part of the time in recitation which few teachers can resist; and if tasks are given, they have to be learned out of school or not at all. Pupils of grammar schools are known to feel obliged to study two or three hours daily from this cause at a time when they should be sleeping, or exercising in the open air. Frequently, however, it is not so much overwork as overworry that most affects the health of the child,--that worry which may not always be traced to any fault of system or teacher, but which, it must be admitted, is too often induced by encouraging wrong motives to study.

"In making up the verdict we must not forget that others besides the teacher may be responsible for overwork and overworry. The parents and pupils themselves are quite as often to blame as are the teachers. An unwillingness on the part of pupils to review work imperfectly done, and a desire on the part of parents to have their children get into a higher class, or to graduate, frequently cause pupils to cram for examinations and to work unduly at a time when the body is least able to bear the extra strain. Again, children are frequently required to take extra lessons in music or some other study at home, thus depriving them of needed exercise and recreation, or exhausting nervous energy which is needed for their regular school work.