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( Originally Published 1923 )

WHEN a person becomes very angry, one may observe how the veins of his head, especially the forehead, become distended. As these veins are closely connected with the blood-vessels in the inner cavities of the skull and with those of the brain, their distention indicates that on account of the emotion of anger, certain changes on the blood-vessels of the brain, viz., a congestion of these vessels, must have taken place.

That a marked congestion of these vessels can, indeed, arise, is best shown by the fact that there may occur sometimes in consequence of violent emotion, such as great anger, and the ensuing congestion, even a rupture of these vessels or apoplectic stroke. Of course such an occurrence is only possible, as a rule, if the walls of the blood-vessels are already diseased, as by arteriosclerosis, and their power of resistance against a great rise of the blood pressure in the blood-vessels diminished.

Such an apoplectic attack may not rarely be immediately fatal, although fortunately a fatal is-sue does not frequently occur. Many, after the first apoplectic stroke, recover after a time and remain alive for years sometimes even a good many years if they lead a regular life, observing all the rules of personal hygiene, and especially, when able to abstain from tobacco, alcohol, and the pleasures of a rich table.

Although, happily, apoplexy is not a daily occurrence in cases of great anger, taking place only when the arteriosclerotic changes in the blood-vessels are very considerable, generally after the disease has existed for some length of time, yet violent emotion,- such as anger, is apt to produce a great rise of blood pressure and influence very unfavorably the condition of the blood-vessels, promoting the arteriosclerotic process.

If this condition is already present, however, and especially if the vessels of the heart are themselves involved, life itself may be placed in jeopardy by anger in these cases. Indeed, it may bring on an attack of breastpang the dreaded angina pectoris which not rarely terminates in sudden death.

Apart from these harmful effects on the blood circulation, anger may also exert a very prejudicial action on the nervous system and promote the development of serious nervous and mental disturbances, especially in persons predisposed to such disorders by inheritance.

A particularly unfavorable action is exerted by it on the blood-vessels of the brain, and it may thus to a, marked degree favor the development of cerebral arteriosclerosis.

On the other hand, frequent outbursts of anger may be an indication of the existence of such a disturbance, and may often serve as a sign of it at its very beginning. Thus, I have frequently had occasion to observe that persons previously of a gentle disposition become strikingly irascible as soon as such a disorder becomes established in them. The irascibility which frequently appears in per-sons over fifty years of age, where it had not previously been present, may be taken as an indication of beginning sclerosis of the brain vessels. One of the most dreaded of nervous and mental diseases, progressive general paralysis, may, however, like-wise be manifested in this way in its earliest stage.

In persons between the ages of forty and fifty years one rather often notices frequent outbursts of temper either without motive or from quite trifling causes, even in persons who had the gentlest dispositions in earlier life and were not easily aroused to anger. If, in addition, there appears a condition of nervousness not previously present and not induced by outside factors, it is advisable to ascertain through a medical examination whether syphilitic infection has not been previously contracted and how the blood responds to the Wassermann reaction. It is in such incipient cases of this disease, which is constantly growing more common, that the best results from the treatment, otherwise hopeless and useless, may be obtained.

In fact, it may even be possible to prevent the complete development of the disease, with its destructive effect on the mind. In persons threatened with this frightful disorder all causes productive of an outburst of temper must be carefully avoided, since excitement of any kind may induce such outbursts.

In view of the close relationship existing between the nervous system and general nutrition, one may readily understand how anything which arouses temper exerts an extremely harmful effect on the economy. Anger, in common with a great variety of other forms of excitement, may, indeed, be the source of a disturbance of nutrition which is frequently dangerous to life, viz., diabetes. In my various contributions to medical literature on this disease I have described cases in which diabetes set in following some mental shock. Not infrequently a serious, incurable form of the disease is induced in such cases. In persons in whom diabetes already exists such a mental shock is followed by a marked increase of the sugar in the urine and the condition is aggravated. Not uncommonly the disease was observed to set in, as various writers have stated, after an outburst of anger because of marital unfaithfulness of the wife or husband, or following unsuccessful speculation, etc.

Another type of nutritive disorder, viz., gout, may likewise be made worse by emotional impressions.

Not uncommonly an acute attack of gout, in the form of podagra, comes on as a result of an out-burst of passion, nature thus afflicting with severe pain at night persons who are unable to control their tempers.

Pain still more severe than that of gout may be induced by anger in persons suffering from stone in the kidney. The pain experienced in such at-tacks is far more dreadful than that of any other disorder to which man is subject, with the exception of tabes.

Only slightly less painful attacks that may be induced by anger are those of gallstone disease, which often bears some relationship to stone in the kidney. Both of these disorders may occur in the same person; the attacks of gallstone colic may be, and indeed, rather frequently are, brought on by outbursts of anger. That the latter exerts some influence on the circulation of the bile may be assumed from the fact that there are persons who become jaundiced after a fit of temper; disease of the bile ducts commonly exists in such instances. It is to be strongly recommended, therefore, to persons suffering from gallstone disease or, more specifically, inflammation of the biliary passages, that they should shun, whenever possible, all causes that might induce an outburst of passion followed by gallstone colic. In a number of vocations, how-ever, this is difficult to avoid.

I have long been struck by the number of lawyers among the many hundreds of patients with gall-stones whom I have treated in Carlsbad during the last twenty-five years. Thus, disease of the biliary tract seems to be a common occurrence in members of this profession. Whence one might draw the conclusion that this honorable body of men busies itself solely with the defence of true justice; for in the opposite event it would be hard to under-stand how any "bile could be spilled" by them in the process!

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