CHAPTER VIII

SECONDARY PERSONALITY

So much attention has recently been directed to the subject of

secondary personality by the startling phenomena described in numerous

books and articles on the subject, that a certain class of "nervous"

patients have permitted themselves to be influenced by the

auto-suggestion, flattering the vanity, that they, too, have a

secondary personality. They even do not hesitate to hint that this

condition is responsible for many of the failures on {148} their part

to do what they ought to do, or at least what they think they would

like to do; but self-control and self-discipline require such constant

attention and effort that they fail. Even when these patients have not

quite reached the persuasion of a complete secondary personality, they

at least think that the subconscious (or their subliminal self) plays

a large role in their conduct. As a consequence, they assert, it is

more or less beyond their power to control themselves, and their

responsibility for certain acts is surely somewhat impaired. This is a

rather satisfying doctrine for those who do not feel quite equal to

the effort of conquering vicious or unfortunate tendencies. Those who

like to have some excuse for self-indulgence take refuge in this

supposedly scientific explanation to absolve them from blame, and from

the necessity of self-control. The drug habitue, the inebriate, the

victim of other habits, sometimes hug this flattering invention to

their souls, especially when they are of the class who delight in the

study of the abnormal. Reform becomes well-nigh impossible as long as

such an auto-suggestion of inherent weakness and lack of will-power is

at work.

The Other Self.--From the beginning of written history, man has always

been inclined to find some scapegoat for his failings. The story of

Adam blaming the first fault on the woman and the woman blaming it on

the serpent, is a lively symbol of what their descendants have been

doing ever since. The less personal the blame is, the better, and the

more it can be foisted over on some inevitable condition of human

nature, the more generally satisfying it is. A secondary personality

can scarcely resent being blamed for its acts by the primary

personality to which it is attached, and so the field of

auto-suggestion as to the blameless inevitability of certain acts is

likely to widen if it is given a quasi-scientific basis. Long ago St.

Paul spoke of the law in his members opposed to the higher authority,

and declared that the things he would do he did not, while what he

would not do he sometimes did. There is no doubt that there are two

natures in the curious personality of man. Everyone at times has the

uncanny feeling that there is something within almost apart from

himself, leading him in ways that he does not quite understand.

Usually the leading is away from what is considered best in us. But

those who have dwelt much on the better side of man and have tried to

climb above mere selfish aims, have realized that there is also a

power within them leading to higher paths. Indeed, some of the

greatest thoughts that men think, and the resolves that lift them up

to heroic heights, are apparently so far beyond ordinary human powers,

that the hero and the poet and even the more ordinary literary man, is

quite ready to proclaim inspiration as the source of his best

ideas--as if they were breathed into him from without and above.

Personal Responsibility.--For ordinary normal individuals, this

question of secondary personality has scant interest. Normal persons

go about their work realizing that what they want to do, they may do,

and what they do not want to do they can keep from doing, unless some

contrary _physical_ force intervenes. There are many metaphysical

arguments for free will, but none of them is so convincing as the

observation that every sane man, with regard to his own actions, has

the power to choose between two things that attract him. He may be

much drawn to one thing, yet choose another. He may allow himself to

be ruled by baser motives; he may sternly follow the {149} dictates of

reason, or he may do neither and hold himself inactive. In any case,

he realizes his power to choose. While this power may be impaired by

many external conditions, his consciousness of its actuality makes him

appreciate his responsibility. He realizes that punishment for wrong

done is not only a part of the law, but it is also a proper

vindication of that consciousness of free will which all men have, and

which does not deceive them. The question has been obscured by much

talk, but the reality is there, and the common-sense of mankind has

proclaimed its truth. All our laws are founded on it. Without it

punishment as meted out is an awful injustice and crime is a misnomer.

Hysterical Phenomena.--Most of the cases of secondary personality that

have been discussed at greatest length have been in persons who were

as desirous of attracting attention, and as pleased over being the

subject of special study as were the hysterical patients who used to

delight in investigation two generations ago. That most of the

phenomena of so-called dual personalities are mainly hysterical seems

now to be clear. In a few cases, where the patient has found that the

existence of a double personality was of special interest, a definite

tendency to the formation of further personalities has been noted.

Some triple personalities have been discussed and, in a few cases, a

group of personalities, even up to five or more, began to assert

themselves. This _reductio ad absurdum_, of the hypothesis of

supernumerary personality has revealed the real hysteric character of

the phenomena.

The whole story of secondary personality in recent years vividly

recalls commonplaces in the older medical literature that gathered

around the study of hysteria, and that afford a striking confirmation

of the conclusion as to the relation of the conditions ascribed to

hysteria. Physicians of a generation or two ago who found their

hysterical patients interesting, because of certain marvelous symptoms

which they presented, were usually astonished to learn that their

patients could, under suggestion, develop still further and more

surprising symptoms. Each new visit, especially when other physicians

were brought to see the patient, showed the existence of still further

symptoms and revealed new depths of interesting disease. Indeed, the

soil was found to be inexhaustible in its power to produce ever new

and interesting crops of symptoms.

When the real significance of hysteria as a mental condition in which

patients devoted themselves to the task of furnishing new symptoms for

the physician began to be realized, one of the most potent objections

against this explanation was that it would have been impossible for

the patients to have studied out their symptoms enough to furnish the

new material for study which physicians found so interesting. The

patients were supposed to be mentally incapable of fooling the

physicians. When, however, a person devotes entire attention to the

one subject of making phenomena in themselves appear interesting to

others, some very startling results are usually produced.

After having attracted the sensational attention so common with any

novel observation and having been exaggerated out of all proportion to

its due significance, the phenomenon is now settling down to its

proper place--a rather obscure neurotic phenomenon of memory in

hysteric individuals.

_Other Neurotic Symptoms_.--Janet's studies at the Salpetriere seem to

show that the alterations of memory which bring about what we call

{150} secondary personality (the forgetting of certain phases of

existence and the maintenance for a time of a small portion of

consciousness and memory quite apart from the rest) correspond with

alterations in the physical basis of memory, that is, in the

circulation to certain portions of the brain, and probably also in the

modes of association of brain cells. They occur, particularly, in

connection with certain phenomena of hystero-epilepsy so-called, or

with the deeper forms of epilepsy in which there are various

paresthesias, hyperesthesias and anesthesias as a consequence of a

disturbance of the circulation in the central nervous system; and

probably also of the connections made by neurons and the movements of

neuroglia cells in making and breaking these connections. These

alterations of memory are represented physically by such cases as

those in which patients so lose their consciousness of sensation that

they are unable to tell even where their feet are. As they themselves

say, "they have lost their legs." In these cases, patients are often

very deaf or have a limited auditory power, and their fields of vision

are extremely narrowed. In most of these cases, recovery of the

original personality takes place after hypnosis. This probably

represents a relaxation of that short-circuiting, within the nervous

system, which brought about the curious phenomenon studied as

secondary personality.

Dual Dispositions.--The studies of secondary personality that we have

had seem to show us persons under the influence of some strong

suggestion, in what is practically a hypnotic condition. There are

many similarities between the actions and the mentality of hypnotics

and of those in secondary-personality conditions. The individuals are,

for the moment, unable to recall what happened in other states. They

may be very different in disposition, gentle and tractable in one

state, but morose and difficult to get along with in another. Such

differences are, however, only exaggerations of the variations of

normal personality. There are times when, under the stress of

circumstances, even the mildest of men and women become querulous and

difficult. It is often noted that people are much more gentle and

careful in their relations with some people than with others. Men who

are known in their business relations to be quiet, easy to get along

with, are at times bears in their homes. This is a matter of the

exercise of inhibition for certain mental qualities, and this

inhibition is neglected for some places and persons. An American

humorist said not long since that a young girl passing a weekend at

the house of a friend, should remember that she is expected to be

unselfish, thoughtful for others, and ready to help her hostess to

make it pleasant for others, so that the party may be successful. He

adds that, of course, as soon as she returns home she should be

perfectly natural again.

At least in a limited sense, all of us have buried in us secondary

personalities that are due to a lack of control of ourselves, or

occasionally to a lack of such initiative as makes possible the best

that is in us. The secondary personality of some people, that side of

their characters that their friends see only rarely, is the best side

of them. Many people, under the demand of some great purpose, rise up

to be really heroic in quality, yet in the commonplace relations of

life they are quite ordinary. The secondary personality in either of

these cases is not something abnormal. It is due to a tapping of

deeper levels in personality than most people realize that they

possess. When taken in connection with hypnotism and the power of

suggestion over {151} susceptible individuals, these adumbrations of

the deeper problem of secondary personality as the psychologists have

discussed it, furnish the best data for its fuller explanation.

Excuses for actions founded on secondary personality must either rest

ultimately on insanity, or else on that lack of inhibition which

constitutes the source of so many of our actions that we regret.

People who are susceptible to hypnotism may remember absolutely

nothing of what occurs to them in the hypnotic condition, though they

will recall it without any difficulty if during hypnosis it is

suggested to them that they should remember it. This represents the

most prominent feature of secondary personality; the individuals who

are affected by it do not recall in one state of personality what

happens to them in the other. In the two states they are very

different in character. These differences have been much emphasized

with regard to a few cases that are especially abnormal and have not

attracted much attention in cases where the differences are slight.

Indeed, in a number of the cases where secondary personality asserted

itself, the differences in the character of the individual in the two

states were practically nil. The only difference was a lapse of memory

for certain important events. Considerations such as these help in the

understanding and psychotherapy of what are sometimes puzzling cases

of apparent dualism of disposition.

What we have to do with here are the suggestions of secondary

personality which neurotic patients have been inclined to make to

themselves as a consequence of the interest in the subject in recent

years. The investigations of Head and of Gordon Holmes have

undoubtedly shown, however, that there are true pathological

conditions associated with certain definite and very marked

manifestations of dualism of disposition consequent upon lesions in

the optic thalamus. These cases so far as can be judged at the present

time, at least, are quite rare and at most would account for duality

and not for the plurality of personality that has come to be discussed

by certain enthusiastic neurologists in recent years. The magnificent

work done on this shows how much may yet be accomplished in the

elucidation of nervous diseases by faithful study and investigation of

selected cases.

CHAPTER IX

HYPNOTISM

Hypnotism is popularly supposed to be a mysterious psychological

process by which susceptible subjects are brought under the influence

of a person possessing some marvelous power over others' minds and

wills. According to this supposition, during the periods in which the

subjects are under this influence, they either have some new source of

energy transferred to them from the operator's strong personality, or

else they share to some extent in the will power possessed by him. In

the midst of the sub-consciousness which characterizes the hypnotic

condition, then, they are in some way endowed with new strength, which

enables them to overcome obstacles to physical or mental health, some

of which seemed at least quite insurmountable under their normal

condition.

{152}

As a matter of fact, hypnotism is much simpler than this, consisting

merely of a state of mental absorption in which all distracting

thoughts are for the moment warded off, and only such thoughts as are

suggested by the hypnotist reach the consciousness of the patient. The

essence of hypnotism is the concentration of mind on one idea or only

a few ideas dictated by the hypnotist. This mental concentration

produces the effect of greater strength, whether apparent or real, to

carry out the purposes connected with those thoughts. It is usually

considered that hypnotism involves sleep, and in some cases it does.

This is often undesirable. True, therapeutic hypnosis leaves at least

certain senses of the subject open to perceive such things as are

presented by the hypnotist's suggestion though these senses may be,

and usually are, quite closed to all other perceptions. In a great

many cases, though there is a real hypnotic condition, a state

resembling true sleep does not occur. There is only a more or less

complete concentration of attention on the suggestions of the

operator, and a complete cessation of all spontaneous thought, or of

all suggestions that might come in ordinary ways from the subject's

own senses.

Effects of Hypnotism.--Most people have a very erroneous notion with

regard to the effects of hypnotism. Some expect that the hypnotic

sleep will work miracles. Nothing is more common in the experience of

one who is known to employ hypnotism, even occasionally, than to have

a patient who is addicted to some habit, alcoholic, drug, or sexual,

ask, "Do you hypnotize?" If an affirmative answer is given, the

patient proceeds to say that he has heard that one can be hypnotized,

and then all the tendency to fall back into the old habit is

immediately lost, and he has no further bother from it. This supposed

miraculous effect of hypnotism in supplanting the necessity for using

the human will has been cultivated very sedulously in the public mind

by quacks and charlatans of various kinds and even exploiters of

hypnotism who belong to the medical profession. But there is nothing

in it. Hypnotism will not change character unless it be for the worse,

since the habit of it sometimes leads to dependence on suggestion

rather than spontaneous motives. Hypnotism cannot be substituted for

weakness of will. The suggestions given in the hypnotic state are

practically no stronger than those given in the waking state, if the

patient would only equally concentrate his mind to receive them, and

would be as ready in response. It is the readiness of response which

comes in cumulative fashion, in the midst of the utter abstraction

from other thoughts, that characterizes the hypnotic condition.

This is, of course, quite a different valuation of hypnotism from the

very strong expressions, with regard to the power of hypnotists to

influence the human will, which have at various times been made. These

exaggerated claims have been no stronger than those often made for

remedies of various kinds that have been long since discredited. I

have heard a serious though young professor of psychology declare that

he was not sure whether he was justified in using all the power that

he possessed by hypnotism to influence men's wills to keep them from

indulging in liquor to excess, because after all men had a right to

their free will, even in a matter of this kind, and it would be wrong

to take it away from them. He added very philosophically that no human

being had the right to play the role of Providence in directing

others' actions even for good, unless they themselves were perfectly

satisfied. {153} If there was any such force in hypnotism as is thus

suggested, the reformation of the world, or still more its

deformation, at the hands of some of the strong-minded practicers of

hypnotism, would be a comparatively easy process. As a matter of fact,

however, the hypnotizer has, except as regards abnormally suggestible

people, only as much influence over the person hypnotized as the

subject permits, and the subject retains all his personality as an

individual with all his weaknesses. After he has been helped away from

his weaknesses by hypnotism, he is just as likely as ever to yield to

them again, unless, during the interval of conquest, he has succeeded

in bracing up his will to resist them.

FORMER METHODS OF HYPNOTIZATION

All the methods of hypnotizing, then, are directed to securing this

state of concentration of the patient's mind. The hypnotic state is

brought about in different ways by different operators, and even the

same operator must employ quite different methods to secure hypnotic

influence over different subjects. In the old times, mysterious passes

and strokings and rubbings of various kinds, and instruments that

flashed light, or that made special sounds, were employed. Among the

pioneers, each worker invented methods of his own. A review of these

will bring out the fact that none of them represents essentials, and

that they are only auxiliaries to secure concentration of the

patient's mind.

The methods of hypnotism practiced by those most noted in the history

of the art were very different from one another, but not more

different than are the methods in vogue to-day among individual

hypnotizers. Indeed, the practices of the past have come down as a

heritage to our own time. Stroking and touching, of which we have

hints in the oldest times in Egypt and Babylonia and Greece, have

always been prominent features. Valentine Greatrakes dreamt that he

heard a voice in his dream telling him that his right hand should be

dead and that stroking it with his left should cause it to recover its

power once more. After this had happened three times in succession he

began to apply this method to the ills of others. Greatrakes seems

really to have come in to replace the touching by the king for the

King's Evil at a time when there was no king in England, Pastor

Gassner, the next worker who attracted attention by hypnotic

procedures, used words of command after attracting the profound

attention of his patients. Father Hell employed the touch of magnets.

Mesmer used music to predispose the mind, but had many of the methods

of modern hypnotists.

Mesmer.--While Mesmer undoubtedly attracted attention to certain

phases of hypnotism that were to prove valuable, he was by no means

the first to do so, and what he did had such a tincture of

charlatanism it is no wonder that he was discredited. There was a

little truth, but there was a deal of mere pretense in his work. While

he undoubtedly obtained results, he did so mainly because of certain

mentally impressive methods that he employed in connection with

whatever of hypnotism he used. Binet and Fere, who have given us some

details of his work, describe his methods in such a way as to make it

clear that they smacked largely of quackery:

{154}

Mesmer, wearing a coat of lilac silk, walked up and down amid his

agitated throng, accompanied by Dezlon and his associates, whom he

chose for their youth and comeliness. Mesmer carried a long iron

wand with which he touched the bodies of the patients and especially

the diseased parts. Often laying aside the wand, he magnetized the

patients with his eyes, fixing his gaze on theirs, or applying his

hand to the hypochondriac region and to the abdomen. This

application was often applied for hours, and at other times the

master made use of passes. He began by placing himself "en rapport"

with his subject. Seated opposite to him, foot against foot, knee

against knee, Mesmer laid his fingers upon the hypochondriac region

and moved them to and fro, lightly touching the ribs. Magnetism,

with strong electric currents, was substituted for these

manipulations when more energetic results were to be produced. The

master, raising his fingers in a pyramidal form, passed his hands

all over the patient's body, beginning with the head, and going

downward over the shoulders to the feet. He then returned to the

head, both back and front, then the belly and the back, and renewed

the process again and again until the magnetized person was

saturated with the healing fluid and transported with pain or

pleasure, both sensations being equally salutary. Young women were

so much gratified by the crisis that they wished to be thrown into

it anew. They followed Mesmer through the halls and confessed that

it was impossible not to be warmly attached to the person of the

magnetizer.

De Puysegur and His Successors.--De Puysegur has some definite

instructions for hypnotizers, whom he called magnetizers. It is

instructive even now to read these, for they emphasize the most

important element in all hypnotism, the confidence of the operator in

his own power, for this, communicated to the subject, produces the

beneficial results:

You are to consider yourself as a magnet; your arms, and

particularly your hands, being its poles; and when you touch a

patient by laying one of your hands on his back, and the other in

direct opposition upon his stomach, you are to imagine that the

magnetic fluid has a tendency to circulate from one hand to the

other through the body of the patient. You may vary this position by

placing one hand on the head and the other on the stomach, still

with the same intention, the same desire of doing good. The

circulation from one hand to the other will continue, the head and

stomach being the parts of the body where the greatest number of

nerves converge; these are, therefore, the two centres to which your

action ought to be mostly directed. Friction is quite unnecessary;

it is sufficient to touch with great attention.

Some of these methods continued to be employed by the successors of

Mesmer and De Puysegur, the sense of touch being the principal

adjuvant, though Mesmer employed also the sense of hearing. Braid

seems to have been the first to realize that the sense of sight could

be used effectively, or perhaps that the tiring of the muscle sense

might well serve as a point for the concentration of attention. He

used the flash of a light from some bright object or tired the eye

muscles by having the patient look upward at some object brought near

so as to require convergence of vision. His methods were imitated by

most of the hypnotizers of the nineteenth century. Liebault and

Bernheim, at Nancy, employed them regularly, and they were used in the

investigations at the Salpetriere. It was found, however, that after a

patient had been once hypnotized, all that was needed was a word of

command or a definite suggestion, and the hypnotic state recurred.

Further experience showed also that the original hypnotic phenomena

might, in most cases, be secured very simply by word-suggestion to the

patient, though some individuals required persistent efforts in the

application of several methods {155} to secure the concentration of

mind on a single idea or set of ideas that is the essence of

hypnotism.

By most serious hypnotists, especially those who use hypnotism for

therapeutic purposes, all the rubbings and manipulations are now

either completely eliminated, or are used only under special

circumstances. The important element of the operator's influence

consists in obtaining the complete confidence of the subject in the

operator's power to control his intelligence for the time being;

getting the subject to resign himself completely, with absolute

assurance that his trust will be for his good, and can by no means

result in harm. Without this attitude of mind on the part of the

subject, anything like real hypnotism is impossible. Even with this,

only a slight degree of the hypnotic condition may be secured in

certain people, but the majority have a distinct susceptibility to it.

PRESENT DAY METHODS OF HYPNOTIZATION

Though various methods of producing the hypnotic sleep are in use, the

rule is now that, in the course of a hypnotizer's experience, less and

less external auxiliaries of any kind are needed, and more and more

dependence is placed on the bringing about of mental _rapport_ between

the active and passive agencies in hypnotism by persuasion and

command. If the hypnotic sleep has once been obtained, usually all

that is necessary is a few gentle words, and then the command to

sleep. It is at the initial attempts to hypnotize a particular person

somewhat refractory to the condition that auxiliaries are needed. In

these cases it is often well to tire the eyes of the patient. This is

done by directing them to the fingers of the operator held well above

the patient's head. After a minute or two of effort the distinct

fatigue which occurs may induce forgetfulness of everything else and

cause absorption in the single idea of attending only to the

hypnotizer's suggestions. This constitutes the beginning of hypnotism.

Occasionally the flash of a bright object, or a revolving mirror, may

be used, but these are only adjuncts and may be dispensed with

entirely if the operator has the patience and the time to give to the

subject.

Accessories.--Some operators use a mirror on which a ray of light is

cast for the purpose of concentrating the attention and bringing about

tiredness of the eye muscles. In so far as it has a more universal

application, sight is certainly the best sense to act upon. Other

senses may be appealed to, as I suggest later. Instead of a mirror, a

polished match-box or pencil-case may be used, but as a rule the less

artificiality enters into it and the simpler the procedure, the

better. One of the inconveniences of using the flash of a bright

object is that occasionally patients who are very susceptible may,

after they have had a number of hypnotic experiences, be thrown into a

hypnotic condition by the flash of a light in the street, or by the

reflection of light from a mirror in their own homes. These conditions

of facile auto-hypnotism constitute one of the serious dangers of the

practice on susceptible subjects. Whatever good may be accomplished by

hypnotism will probably be reached during the first half dozen

seances. To proceed with the treatment beyond this, if it is employed

at regular and short intervals, is almost sure to result in harm

rather than good.

{156}

Sensations.--Besides sight, sounds have sometimes been used for the

purpose of inducing hypnotism. The ticks of a watch, for instance,

placed at a little distance and listened to very intently, have been

known to assist in securing the hypnotic state. Sometimes the sound of

a gong, or an imitation of a cathedral chime, have been used in the

same way. Soft music has also been used by operators with decided

advantage. It is necessary that the sounds should be of a kind that do

not disturb, but only attract attention to one sensation, and then, as

concentration on this is secured, the hypnotic condition results.

Practically any other sensation may be used in the same way. Touch is

often employed. Mesmer stroked his patients gently, and others have

used the same process with advantage. Some of the French workers in

hypnotism have claimed that there were special portions of the body

the stroking of which was likely to produce this favorable effect.

They have called these regions zones hypnogenes--areas that give rise

to hypnotic conditions. Strokings of the forehead, of the cheeks, of

the hands, are favorite locations for these auxiliary touches. In

this, as with regard to sound, the main thing is to concentrate

attention on some one sensation without producing disturbing thoughts.

Stroking.--Stroking seems to affect many people and to easily induce a

sort of hypnoidal condition. It is done very naturally to a child when

one wants to console or encourage or admonish slightly but kindly. In

older people it is a familiar gesture among those who think much of

one another, and represents a very natural tendency. Even in the midst

of physical discomfort its effect is quite soothing, and it is evident

that something resembling hypnotism is at work. Evidently, what really

happens is a concentration of attention on the sensation thus

produced, which concentration prevents distracting thoughts from

making themselves felt and permits the words of the one who does the

stroking to produce a deeper effect on the mind than would ordinarily

be possible. This seems to be nature's method of making suggestion

more effective. It has been adopted, quite spontaneously, by many of

the pioneers in hypnotism as the result of their observations upon its

efficacy. Lloyd Tuckey calls attention to an illustration of this

practice, which makes clear its effectiveness and at the same time

shows how naturally it suggests itself as a mode of using mental

influence. He says:

Among the medical men who have come to watch some of my cases was a

gentleman who seemed much struck at seeing the method I adopted with

a rather refractory subject. I held his hand and stroked his

forehead while at the same time suggesting the symptoms of sleep.

The gentleman told me afterward the reason why he was so interested.

It appears that he had a few months previously been in attendance on

a very severe and protracted case of delirium tremens. The patient

could get no sleep, and the doctor was afraid of death from

exhaustion. On the third evening he resolved to make a strong effort

to produce sleep, and, if necessary, to sit up all night with the

patient. He told the man that he would not leave him until he slept,

and sitting down by the bedside, he took his hand in one of his own,

and with the other gently stroked the forehead. At the same time he

talked quietly and reassuringly to him. In less than half an hour he

was rewarded by seeing the restlessness entirely cease and the man

drop off into a quiet sleep. That sleep, the doctor told me, lasted

fourteen hours, and the patient awoke out of it weak, but cured.

Manipulation about the head has in many persons a most soporific

effect, and several persons have told me that they always become

drowsy under their barber's hands.

{157}

Drugs.--A number of drugs and related substances have been used as

aids to hypnosis, but in nearly all of these cases it is doubtful

whether it is true hypnotism that results and whether the suggestions

in these states have much therapeutic value. One of the drugs most

frequently administered by hypnotists is _cannabis indica_, which has

long been used in the East for a similar purpose. After this,

chloroform is most popular. Schrenck-Notzing even ventured to employ

alcohol as an aid in hypnosis, and claims that he has succeeded at

times in making intoxication pass into the true hypnotic condition.

Bernheim and many others of the French school have used chloral and

morphine. These substances are, however, liable to great abuse.

Whenever they have to be employed it means that the patient is but

little susceptible to hypnotic influence. These aids are employed only

because hypnotists do not want to confess that a very considerable

portion of humanity is not directly susceptible to the hypnotic

influence.

Serious harm may be done by the employment of these drugs. A

physician, who hoped that he would be able to overcome a drug

addiction that had been the bane of his existence for a long while,

went to a well-known hypnotist physician with the idea that perhaps

the miracle of hypnotism would be worked in his case. He was one of

these flighty mortals whom it is extremely difficult to have fix their

minds upon any one idea for a definite time. As it was impossible to

bring him into anything like a hypnotic condition by ordinary means, a

large dose of chloral was administered. He already had an idea that

his heart had been affected by his previous drug-taking habit, but the

chloral was administered to him before he realized what it was. When

he came out of the sleep it induced, he was in an agony of solicitude

and anxiety lest his heart should have been further hurt by the

chloral. He went back for no more doses of that kind of hypnotism.

The use of drugs seems to be a confession of failure to secure true

hypnotism, so that it is doubtful whether their employment is

justified. Suggestions received while in the more or less comatose

state induced by drugs, instead of having a strengthening effect on

the patient's will, rather tend to produce the idea of the

impossibility of effectively using his own will, or even exercising

his will when helped, as he supposes, by the will of the operator. The

real value of hypnotism consists in the concentration of mind upon a

particular idea without any distractions, which enables the subject to

make firm resolutions and then to have his mind help his body as much

as possible by directing his energy to the accomplishment of one end.

When drugs are employed, they have a diffusive rather than a

concentrating influence, so that the real purpose of hypnotism is

entirely missed.

PRACTICE OF HYPNOTISM

In the ordinary practice of hypnotism now, the patient is placed

sitting on a comfortable chair and the operator on one side facing

prepares the mind of the subject by proper assurances. The patient

must be brought into a thoroughly assured and comfortable state of

mind and must be quite ready to submit to hypnotism. Then in most

people, if the finger is held rather close to the patient and well

above the line of sight, requiring special effort {158} on the part of

the superior recti muscles as well as of the power of convergence, a

tired feeling will come over the subject with a tendency of the lids

to droop. When this happens the subject is asked to allow the lids to

drop and to quietly concentrate the attention on the idea of sleep so

as to permit the drowsy feeling gradually to increase. On a first

seance this may take ten minutes, subsequently much less time will be

needed, and, as a rule, in five minutes the subject is quite

predisposed to sleep. In more difficult cases a much longer time may

be needed, and repeated efforts may have to be made. Great patience is

required. The operator soon learns to adjust himself to certain

peculiarities of individuals in predisposing them to the hypnotic

condition.

Hypnotism Simple, Natural, Not Mysterious.--The most important thing

to know about hypnotism is the fact that any one who wishes can

hypnotize. There may be need for favoring circumstances, but there is

no need for any special faculty in the operator. If he has confidence

in himself so as to take up the question of hypnotizing seriously, if

the subjects are reasonably susceptible and if they are persuaded that

they may be hypnotized, or even if they are not, so long as they take

the operator seriously a hypnotic state will result. Nothing is more

surprising to the operator himself, the first time he succeeds, than

his success. This at once gives him renewed confidence, and future

hypnosis becomes a comparatively simple matter. To have this idea

widely diffused would do much good, since it would at once strip the

charlatans, who abuse hypnotism, of most of the mystery that surrounds

them. The general diffusion of such knowledge would also do good in

another way. It would expose the supposed wonderful power that some

people are presumed to possess. Hypnotism works no wonders; it is a

mere natural manifestation not unlike sleep, and probably not a whit

more mysterious.

Stages.--A number of divisions of the hypnotic state have been

suggested, but probably the simple division into three stages is the

best for ordinary teaching purposes, and helps to the understanding

both of the conditions themselves and of many things that are written

about hypnotism.

The first stage consists of a subdued, dreamy condition, in which the

patient is not asleep and yet not thoroughly awake to all that is

going on around him. He has his mind so concentrated on certain

thoughts that he is preoccupied, and suggestions are much more

efficient than under ordinary circumstances. This is really only a

state of intense attention to the suggestions that are being made,

with the banishment of all distracting thoughts. It is rather

difficult for any one to keep from being distracted, and whenever this

is accomplished, the ideas that then enter the mind penetrate more

deeply and, above all, seem to affect the will more forcibly than when

they are merely superficially considered. This first stage of

hypnotism would not be considered hypnotic by most people who

associate the idea of sleep with hypnotism.

In recent years it has been found that most of the good that is

accomplished, especially for nervous people, by hypnotic suggestion,

can be attained almost, if not quite as well, in this first stage, and

without the hypnotic trance. The first stage is much less liable to

the dangers of hypnotism in many ways, and it represents one of the

most interesting phases of psychotherapy.

{159}

The second stage of hypnotism is the hypnotic sleep. The patient loses

consciousness of his surroundings, though his senses are still open to

suggestion from the operator. Practically all that happens in the room

apart from what is brought to the subject through the operator's

direction remains unnoticed. If the sleep is very deep, even the

suggestions of the operator do not penetrate after a time, so it may

be quite difficult to awaken the subject. It may be even some hours

before the person hypnotized will come out of the lethargy which has

been induced in these cases. Under these circumstances, this second

stage partakes somewhat of the nature of the deeper trance condition

that characterizes the third stage.

The third stage of hypnotism consists of a profound trance-like

condition in which there is catalepsy--that is, firm contracture of

muscles all over the body--and as the extensors are stronger than the

flexors, this contracture takes place in the extended position. The

cataleptic condition is really a nervous spasmodic seizure rather than

a true stage of hypnotism. It is probably always harmful for the

patient to have it induced. Its occurrence as one manifestation of

hysteria, apart from hypnotism, shows its real character. It is with

this stage of hypnotism that professional hypnotists, who give

exhibitions, make their demonstrations--that is, of course, when their

demonstrations are really hypnotic and are not merely, as is often the

case, performances by actors trained for the purpose. Catalepsy is

entirely pathological; experiment with it then is eminently

undesirable, and certainly should not be undertaken except under the

most careful precautions and by a physician. One of its dangers was

very clearly pointed out by the death of a young man, who in a

cataleptic condition was subjected to certain strains upon his thorax

which brought about the rupture of an aortic aneurism. Catalepsy never

permits of suggestion in such a way as to be helpful to the patient.

It always leads to further functional deterioration of the nervous

system, and yet it has unfortunately come to mean for many people the

most essential characteristic of hypnotism. Its production is supposed

to represent the acme of skill in the hypnotist. Nothing could

possibly be less true nor be more likely to do harm.

Susceptibility.--As to the number of people who are susceptible to

hypnotism, there are great differences of opinion. Liebault declared

that practically every one is susceptible in the hands of a patient

operator. In a carefully made series of cases his failures were less

than three per cent. Van Rentergehem and Van Eeden, in a series of

over 1,000 persons, failed only with fifty-eight, or little more than

five per cent. Schrenk-Notzing's statistics, collected from many

countries, seem to show that only about six per cent. were

uninfluenced. Bernheim, at Nancy, was not nearly so successful as

Liebault, his master, and his failures amounted to twenty-five per

cent. at the beginning and at least twenty per cent. later. I remember

that when I was at the Saltpetriere fifteen years ago, they were

inclined to discount the enthusiasm of the Nancy school with regard to

the value and significance of hypnotism. They insisted that probably

not more than one out of two of the persons presenting themselves at a

nervous clinic could be hypnotized to the extent that is ordinarily

associated with the word--could be brought beyond the drowsy stage.

There are other workers in the subject who have insisted that not more

than one out of three ordinary individuals can be so {160} deeply

hypnotized as to exhibit the ordinary symptoms. These symptoms consist

of complete neglect of surroundings and absolute absorption in the

suggestions of the operator.

Some people can be hypnotized to the extent of being thrown into sleep

and yet walk and talk under the absolute control of the operator.

These are so-called somnambules, the class of persons who are

exhibited by professional hypnotizers who want to attract popular

attention, and, indeed, the class usually exhibited by physicians

before medical societies, and even by professors before their classes.

This extreme susceptibility is, however, quite rare. Even the most

ardent advocates of hypnotism and of the susceptibility of humanity to

it do not claim that more than one in ten of average individuals can

be influenced to this degree. There are milder degrees of hypnotism

than this, until we reach a state in which all the patients feel is a

certain dreamy sense of well-being and a heaviness of the eyes, with a

readiness to respond to suggestions. Most people who think of the

somnambulistic stage as representing hypnotism would not consider

these latter to have been at all subjected to the hypnotic state.

_Repeated Efforts_.--As to this question of susceptibility, much

depends on how often the operator has tried to hypnotize the

particular subject, for susceptibility develops with repeated trials,

not only where there is a manifest impression at first, but also where

there is not. It is not uncommon to find that a patient who cannot be

brought at all under the influence of hypnotism in the first or second

or third trial, will, at the fifth or sixth trial, yield to the

suggestion to go into a hypnotic sleep. A dozen unsuccessful efforts

may be followed by the development of a very satisfactory hypnosis.

Those who have practiced hypnotism much tell of having tried a score

or even two score of times before finally bringing on a hypnotic

condition. Dr. J. Milne Bramwell, one of the English authorities on

hypnotism, tells the story [Footnote 20] of having tried sixty or more

times to hypnotize patients before finally succeeding. It is this

persistence that enables successful hypnotic operators to accomplish

results where less confident physicians fail. It is also the frequency

of trial that makes all the difference in the statistics as to the

susceptibility of patients to hypnotism in the hands of different

individuals. There must be the confidence of the patient in the

physician's power to hypnotize, but, above all, there must be the

physician's own confidence in his power to bring on the hypnotic sleep

so that he tries and tries again, even to seventy times.

[Footnote 20: "Hypnotism. Its History, Practice and Theory," by J. M.

Bramwell, 2nd edn. London, The De la More Press, 1906.]

ANIMAL HYPNOTISM

The hypnotization of animals shows that only a very low grade

intelligence is needed for the production of this state. The famous

experiment of Father Kircher with the hen, which any one may repeat at

any time, is a good illustration. The fascination exerted upon birds

by snakes is another familiar example. The bird is paralyzed with

terror at the sight of the snake, and so cannot escape from its enemy,

fairly glueing its eyes on the terrifying object, and thus loses power

to control its wings. Stories of snake {161} fascination are usually

told as if the eye of the snake attracted the bird, who thereupon

proceeded to approach the snake. These are, however, doubtful stories.

The paralysis of motion seems to be the main effect. The rabbit is

affected in nearly the same way. There is a tremor of horror in

anticipation, and then the animal stands perfectly quiet, though

ordinarily he would be quite able to escape, while its enemy

approaches. The underlying mechanism is evidently a concentration of

attention, which completely precludes the possibility of the exertion

of any spontaneous energy except that involved in the one act of

watching the awful object.

DANGERS OF HYPNOTISM

There are many and various opinions of the dangers of hypnotism. Some

of those who have given it a fair trial have insisted on its dangers.

Some of those who have had very large experience have declared

emphatically that there is no danger at all. Occasionally it has

seemed that such a declaration must be considered as having been

dictated by such intensity of interest as sometimes leads men to

overlook the darker side of things with which they are much occupied.

Certain moral aspects of hypnotism are at least dubious, and, it must

be admitted, present opportunities for abuse. There are certain

dangers connected with its effect upon nervous patients, and

especially with its influence upon character, that have become more

and more clear in recent years. Dr. John K. Mitchell, in his "Self

Help for Nervous Women," a series of familiar talks on economy in

nervous expenditure, [Footnote 21] has dwelt on certain of these

dangers of hypnotism for nervous patients in a passage that deserves

to be recalled. As a representative of a school of thought that is

worthy of special regard from American physicians his expressions must

carry weight:

[Footnote 21: Philadelphia, Lippincott, 1909.]

The greatest danger of all is the use of hypnotism in any form or

degree, a two-edged sword, capable indeed of usefulness, but more

capable of harm. After years of study, beginning with too easy an

approval of it, hypnotism, whether called by that name or by the

unsuitable one of suggestion, has been laid aside by the medical

profession as a means too dangerous for ordinary use, involving

great risk of deterioration of character in the subject if often

repeated, and putting a terribly tempting tool in the hands of the

user, fascinating in the ease with which it can produce superficial

and temporary good results and equally capable of being used for

harmful ones.

A susceptible person, once hypnotized, is more and more easily

thrown into the hypnotic state until even the slightest hint

suffices to bring about the condition. It is not necessary for the

hypnotization to go so far as deep sleep; this more advanced stage

is indeed seldom required, and to say that persons are not

hypnotized because they are not put into a sleep or a trance shows

ignorance of the subject.

I am not asserting that very slight degrees of the hypnotic

condition are as dangerous as the deeper, but I do say that all

degrees of it are dangerous to the integrity and healthy action of

the subject's nervous system. The danger of harm increases with

every repetition of the hypnotization.

In suggestible, that is, over-susceptible, individuals, who are

almost universally neurotic persons, to fix the eyes on a small

point, especially a bright one, sometimes even to fix the mind on

the one idea of going into the hypnotic state (mild or deep), is

enough without further intervention from any one to put them into

that state.

{162}

In an article on the "Danger and Uses of Hypnotism" Prof. Forel, of

Zurich, twenty years ago, while frankly admitting that hypnotism is by

no means a panacea for all nervous affections and unfortunate habits,

found it to be an extremely valuable help in the treatment of many

forms of functional nervous disease. He suggests that some of its many

dangers are due to the fact that hypnotism is practiced by men who are

too distrustful of it, and this distrust, unconsciously communicated

to the patients, produces an unfortunate effect. On the other hand,

fear and distrust on the part of the subjects seriously disturbs the

process of hypnotization, interferes with its effect and sometimes

leads to unfortunate results.

In some cases it seems that the state of dependence on some one else,

at least by suggestion, that had been created during the hypnotic

experience, resulted in a diminution of will power and caused a less

hopeful state on the patient's part than before. I found personally

that suggestion in the waking state might in most cases be used quite

as efficiently as hypnosis itself, and that when improvement came

under these circumstances, the patient always felt more confidence in

himself and less in the operator. Anything that restores

self-confidence and gives patients the feeling that they can conquer

inclinations, tendencies, even habits, if they only will, merely by

firmly resolving to do so, is the best possible mental influence for

them. The hypnotic relief is always easier, but nothing that is easy

is likely to be of lasting value. The enduring effect of gradual cure

by suggestion means much more than the hypnotic miracle that these

patients are so prone to crave.

At present there is a very general feeling among those who have had

considerable experience with hypnotism, that in spite of the claims of

certain votaries for it, there is no justification for its frequent or

habitual use. It has a definite place in diagnosis, in certain

difficult cases, and at the beginning of the treatment of certain

forms of the psycho-neuroses. When repeated frequently it is not

therapeutic, but is likely to produce serious results in a certain

lack of self-control and tendencies to auto-hypnotization with

deterioration of character. There is very seldom need of a repetition

of deep hypnosis, and, as a rule, all the diagnostic benefit can be

secured in one or two seances. Its continued use only illustrates the

tendency noted at all times, in the history of medicine, for the

unthinking or unprofessional to persist in the application of supposed

remedial measures after they have been shown to be useless or even

harmful. The subject well deserves further study, but investigations

should be carefully made by men who realize the dangers, and who are

not likely to be tempted to exploit patients and curious psychological

phenomena for the sake of sensational reputation. The use of hypnotism

for exhibition purposes, by men who are not physicians, is an unmixed

evil, producing entirely wrong impressions on the public, and doing

untold evil to the subjects employed.

{163}

SECTION III

_THE INDIVIDUAL PATIENT_

CHAPTER I

PSYCHOTHERAPY AND THE INDIVIDUAL PATIENT

The most important element in Psychotherapy is the individual patient.

Old Dr. Parry of Bath said a century ago, "It is much more important

to know what sort of a patient has a disease, than what sort of a

disease a patient has." Mental influence is not of the slightest avail

against pneumonia or typhoid fever, nor constipation nor rheumatism as

such; mental influence may be, and often is, of the greatest possible

help to the patient suffering from any of these diseases.

We recognize frankly now that for most diseases we can do nothing to

counteract the disease directly or to cure it specifically. The idea

of specifics in medicine has to a large extent disappeared. Two or

three of them possibly we have, but even with regard to these, there

are certain doubts as to the essential modes of their activity. We

have learned, however, to help the patient to overcome disease. We

know how to conserve his forces, to increase his vital reaction, to

maintain his nutrition without disturbing his general condition, and

to secure elimination in such a way as to prevent nature from being

interfered with in her curative purposes. To this, psychotherapy would

enable us to add such encouragement of the patient as would tap new

sources of energy in him according to the law of reserve energy, and

would prevent discouragement and the inhibition of favorable nerve

impulses that so often follow. The outcome of any disease depends on

two factors. One is the condition of the patient at the time the

infection was acquired, the other is the virulence of the infection.

We can do nothing to modify this latter element, once the disease

manifests itself. We can, however, do much to enable the patient to

throw off the disease and, above all, by securing a favorable attitude

of mind, we can enable him to use his forces to the best advantage.

Anyone who has noted the difference between the patient's state just

before and just after his physician has called, though absolutely no

physical remedy has been employed, is able to realize very well how

much psychotherapy is able to accomplish. One who did not know, would

be sure to assume that some potent remedy had been administered--and

there has been. This potent remedy is psychotherapy. Whether the

personal magnetism necessary to produce therapeutic effects of this

kind can be learned or not depends on the individuality of the

physician. Undoubtedly, however, everyone can add to whatever of

personal influence he has by definitely recognizing its place, by

{164} making every effort to employ it, and then by regular systematic

effort in securing as much personal information as possible with

regard to the patient. This personal relationship of physician and

patient makes instruction easier and suggestion more effective.

The securing of personal information is of the utmost importance in

determining the affections that psychotherapy will relieve, because

very often details of life and habits are discovered that can be so

modified by instruction as to bring about a disappearance of

unfavorable physical influences. It is indeed surprising to find how

many unreasonable things people do from habit, from unfortunate

persuasion, or from lack of knowledge. In many of the minor chronic

ailments that are the source of so much mental discomfort to patients,

the physician finds that a change in the patients' habits, not

necessarily of marked degree, may make all the difference between

cheerful health and rather despondent low-spirited feeling. Now that

epidemic disease has become rarer, a physician's practice, especially

among the better classes, is much more taken up with these minor

ailments than with the typical classical diseases.

The ordinary history of their ailments, as patients commonly present

them, especially when there are neurotic elements, is likely to be

meager in what is objective, but consists mostly of the subjective.

Such patients have much to say of their sensations, their feelings,

their dreads, their surmises, their conclusions as to their particular

condition, and especially the hereditary elements in it, but

comparatively little of the objective realities of their ills and of

their environment. What the physician needs to know about them is

their habits of life, their daily routine of existence, just as

minutely as it is possible to obtain the information. There is just

one way to get the latter details, and that is to inquire particularly

with regard to actual happenings. In chronic conditions of many kinds,

it is so helpful that it will always be worth the physician's while to

get at these details, especially in supposedly puzzling cases for

which various forms of treatment have been already tried.

In spite of every precaution in this matter, the physician sometimes

finds, after a series of consultations, that some point which when

brought to light he considers to be of great importance, has been

thought so trivial by the patient that it was never mentioned, in

spite of the most careful questioning. In all medical practice the

rule is that mistakes of diagnosis are much more due to neglect in

eliciting necessary information than either to lack of expertness in

diagnosis, or lack of knowledge of the significance of symptoms.

In the affections that can be relieved by psychotherapeutics, the most

important element for diagnosis, besides a minute knowledge of the

patient's habits, is just as detailed information as possible with

regard to his ways and modes of thought as to his ills. Practically

every motive, as well as every action of the day, must be scrutinized,

and often it will be found that little things mean much for the

individual. "Trifles make perfection, but perfection is no trifle," as

said by Michelangelo, might well be changed for the physician to,

"Trifles make all the difference between health and discomfort, though

health is no trifle."

{165}

CHAPTER II

THE MORNING HOURS

In getting the history of patients for diagnostic purposes the safest

way is to begin with the getting up in the morning and then to follow

out the various actions of the day. The hour and mode of rising should

be inquired into. Practically all nervous people, and nearly all those

beyond middle life, feel less fit in the morning hours than at any

other time in the day. Apparently as a consequence of their will

having been allowed to lose its hold during sleep, it does not secure

thorough command over the organism for some time. Nervous people, as a

rule, wake up with a tired feeling, a dread of the day, wondering

whether life is worth living. They dread--for it is a real dread--to

get up and tackle the daily round of life once more.

If they have nothing very definite to do, then slight tired feelings

or discomfort, even of very minor degree, may lead them to think that

they cannot get up. Any yielding in this matter is almost sure to do

harm. When there are no objective signs, that is, when there is no

fever recognizable by the thermometer and there has been no diarrhea

or any physical weakness, nervous patients should get up promptly at a

particular hour every morning, because, as a rule, within a half hour

after getting up they feel better, and by the time they are washed and

have had their breakfast, life has grown not only quite possible but

even plausible, and the day's work does not seem such a nightmare as

it was at first. It is not advisable to tell people all this as soon

as they confess their habit of dawdling in the morning, for they must

be gradually brought to discipline themselves. The detail emphasizes

the necessity of knowing how they get up as well as when.

Mode of Awaking.--It is often valuable to know how patients awake.

Sometimes it will be found that they are anxious and solicitous to be

at work at a particular hour, or to catch a train at a particular

time, and that as a consequence their sleep is disturbed in the early

morning hours. At best it may be fitful and when they awake they fear

to go to sleep again lest they oversleep. An alarm clock will

sometimes remedy this state of affairs. Better still is an arrangement

by which someone, who can be depended on, will wake them at a

particular time. Occasionally patients cannot content themselves in

spite of the assurance that they will be waked. They dread that the

alarm clock may not go off, or that the awakener may make a mistake,

and so they go to bed with a dominant idea, which is more or less

constantly present in their mind during all their sleeping hours,

disturbing sleep and preventing complete rest. It may be necessary to

insist on a change of occupation for such persons, or a change of

residence that will do away with the necessity for early rising. When

this is done, many a neurotic condition that has before proved

intractable will disappear.

Amount of Sleep.--It is of cardinal importance to know how long

patients sleep. In our large cities most people have too little sleep.

A comparison of the hours when they get to bed with those when they

get up will often show that at least three or four nights in the week

some patients who are complaining of nervous symptoms, especially

nervous indigestion, are {166} sleeping less than seven hours. There

are but few men, and still fewer women, who will retain their health

under such conditions. Some men have been able to do it, but they are

comparatively rare. King Alfred's rule of dividing the day into three

eight-hour periods--one for sleep, one for work, and the third for

bodily necessities and recreation, still remains the best for human

nature. Whenever people try to live the strenuous life and get along

on less than eight hours of sleep, they are almost sure, sooner or

later, to render themselves uncomfortable, to make themselves liable

to all sorts of neurotic symptoms and, above all, to detract from

their efficiency for whatever work they are engaged in. Whether they

sleep or not, they should be in bed for nearly eight hours.

Bathing.--_Morning Bath_.--In our larger cities at least, many of the

inhabitants begin the day with a bath. In this matter one finds all

sorts of harmful fads that need to be corrected. Many men take a cold

bath, and unless they are particularly strong and vigorous, this is

rather an exhausting experience for the beginning of the day, when the

last nutrition the body absorbed is twelve hours before. On the other

hand, large, athletic men who manufacture a great deal of heat, their

muscles--the heat-making organs--being well developed, will be

benefited by having a cold bath because of the abstraction of heat

that it involves. It is not, however, infrequent to find that the man

for whom it will be good is not taking it, while the thin, neurotic

individual, already exhausting more of his vitality by worry and

dieting and in various fads with regard to his health than is good for

him, is regularly taking his cold plunge or douche. Unless especially

asked about it, few men give particulars in this matter, yet they are

extremely important.

Women, on the other hand, are likely to take hot baths more frequently

than is good for them. Especially when they have maids to assist in

dressing and undressing, it is not unusual to find that women take

two, and sometimes even three, hot baths in a day. They take them in

the early morning when they first get up, and in the evening before

dressing for dinner. I have known cases where some took a third hot

bath before going to bed and sometimes even put in a fourth before

luncheon in case they had had any exercise in the morning

hours--tennis, or horseback riding, or the like--that made them

perspire. These are details which the physician will learn only if he

asks particularly about them. Until he has actually had the experience

of finding that they play an important role in some ailment he is

almost sure not to think of it. It is probable that even two hot baths

a day are too many. I have known women to begin at once to get better

of neurotic symptoms that before had proved quite intractable, when

their hot baths were limited or when they were changed for a single

warm bath with a cold rub after it in the morning, or sometimes just

before dinner.

Bathing is more liable to abuse than is usually thought to be

possible. While the habits of modern life call for it often, and many

people are quite sure that they would not be healthy without it, the

people who live longest, and who have had the best health far beyond

three score years and ten, have usually not been noted for bathing

proclivities. The human body is composed of nearly seven-eighths

water, and so our cells are constantly bathed in it, but the making of

the whole organism a marine animal once more, as seems to be the

definite tendency of some people, is not nearly so hygienic as {167}

it is often thought to be. Enough bathing for thorough cleanliness,

but not for luxury, must be the rule for people who have active work

and want to retain their health.

_Bathing Fads_.--While such mistakes are usually made only by the

wealthy and leisure classes, the physician will sometimes be surprised

to find that women who have no maids for personal service are

indulging themselves in these over-frequent bathing practices. They

have heard that it softens the skin and renews youth, or they have

heard that the Japanese take hot baths and are revivified when they

are very fatigued, and so they go to great lengths in bathing. Often

this is the main reason for the relaxation of muscle tissue and the

sense of prostration that has come over them. Neurotic people are

constantly going to extremes. Even delicate women will sometimes be

found to take very cold baths which are surely doing them harm. Over

frequent washings of hands and face are sometimes responsible for skin

lesions, especially if the soap used is one of the varieties so

scented that the manufacturer is enabled to conceal the impurities in

its ingredients. Some women easily run into what is really a

misophobia, an exaggerated morbid fear of dirt, and need to be

restrained from washing themselves over frequently. Many a chapped

hand would be saved by avoiding unnecessary washings, and especially

in warm water just before one goes out, for it leaves the skin without

its proper oily protection.

Clothing.--Then comes the question of clothing. It is curious how

irrationally many people clothe themselves. People complain of cold

hands and feet when they are wearing thin cotton undergarments, and

who need only to have these changed for wool for their feelings to be

at once improved. In the meantime they have been persuaded that they

have a defective circulation. The usual excuse for not wearing wool is

that it produces hyperemia of the skin with itchy discomfort, but

this, as a rule, is only passing and is due to unaccustomedness. The

coarser wools should not be worn by the sensitive. A thin cotton

garment may, if absolutely necessary, be worn next the skin. There is

too little variety in the underclothing that people wear. Some change

from light to heavy weight and only that, but there should be a medium

weight worn, and occasionally, when there is a spell of mild weather

in the winter time, even during the season when heavy weight is

usually worn, medium weight should be substituted for comfort's sake.

It is even more common to find that neurotic individuals, who fear to

catch cold, wear too much clothing, especially around the chest. Very

often they alternate from this during the day to next to nothing in

the evening, and by so doing subject themselves to special risks of

internal congestions. When the skin is covered with too much clothing

it loses the habit of reacting, and the warmth and the irritation of

wool keep up an artificial hyperemia which gradually lowers the tone

of the peripheral vessels. Many people wear "chest protectors," as is

evident from the prominent display of these abominations in the

drug-store windows. By leaving certain portions of the chest

unprotected while other parts are kept over-warm, these add greatly to

the risk of such disturbances of circulatory equilibrium as predispose

to the infections grouped under the term "taking cold." It is not

heavy clothing that keeps people warm so much as the layers of

non-conducting air between the skin and the outer air. It is better,

therefore, to wear three thin {168} garments than two heavy ones

because of the additional layers of air that are thus confined. A

paper vest, if one is driving in the wind, will probably protect

better than the heaviest woolen garment worn. The wearing of chamois

garments is not, as a rule, advisable because chamois does not permit

free access of air and it hampers transpiration.

Before Breakfast.--After dressing comes breakfast, with regard to

which it may be advisable to ask many questions. It is well to begin

with a query as to whether liquids are taken before breakfast. Many

people have taken to the fad of drinking a large quantity of warm

water, sometimes as much as a pint, before breakfast. Surely this

never does any good and, in most cases, just as surely does harm.

Plain water will not dissolve mucus that may have collected in the

stomach, and warm water merely dilates that organ, relaxes its fibers,

and renders the whole gastric digestive system atonic. If cold water

can be borne, it will often be found that a glass of cold water the

first thing in the morning stimulates peristalsis, and serves to

lessen the necessity for laxatives. Many people complain that cold

water is too much of a shock. Usually, if they are reminded that when

we want to warm our hands we rub them vigorously with cold water and

that the reaction after this gives a healthy glow, the effect of the

supposed shock, which was merely an unfavorable suggestion, will

disappear. Sometimes delicate people cannot drink cold water. If there

is any reason to suspect an accumulation of mucus in the stomach, a

small bouillon cup of _very hot water_, just as hot as it can be

borne, in which a pinch of salt and a pinch of bi-carbonate of soda

have been dissolved will prove an excellent aperitive for the day.

This is physiological and appropriately chemical, as well as naturally

stimulating. Mucus does not dissolve in ordinary water but dissolves

readily in an alkaline salt solution, and this is just what is thus

recommended. This drink is quite grateful to the palate. Indeed, it

tastes very much like clear soup, and, if the eyes are closed, cannot,

as a rule, be distinguished from some of the bouillon commonly served.

I have known this cup of hot water to stimulate an appetite when drug

tonics had failed.

It is better to take the glass of cold water from fifteen to twenty

minutes before the morning meal--say immediately on rising. If,

instead, the small cup of hot water is chosen, it should come

immediately before eating, and will usually prove an appetizer.

Breakfast.--The exact details of the amount of breakfast taken and how

it is eaten should be known. Nervous people eat little breakfast. When

ordered to eat, they find it difficult at first, but the habit is

easily formed, and then they want their breakfast like anyone else. It

is surprising how often physicians will find that nervous persons, who

are under weight, are not taking enough breakfast. They will

ordinarily say that they are eating breakfast about as other people do

and will, perhaps, mention eggs and rolls, but it will be found that

their ordinary breakfast consists of a roll and piece of toast and

coffee, and only occasionally do they have any of the other things

mentioned.

Breakfast is ordinarily the meal which those who work are likely to

eat too hurriedly. Those who are neurotically inclined are especially

victims of the habit. They lie abed until there is only a few minutes

left to get the train so as to reach their place of occupation in

time, and thus their breakfast is {169} skimped. Their oatmeal or

other soft cereal is fairly shovelled in, coffee is gulped, toast is

unchewed, the coffee softening it; if they have creamed potatoes they

are swallowed in such large pieces that, as every physician knows, if

for some reason they vomit they are surprised, beyond all measure, at

the large portions they have been able to pass down into their

stomachs. A breakfast thus eaten makes a bad beginning for a nervous

man's day, and the more that is so eaten the worse for the victim.

With a habit like this, it will be utterly impossible by means of

drugs or directions as to diet to relieve the discomfort of neurotic

indigestion, or to keep the patient from suffering that stomach

discomfort so often complained of in the morning.

Working Women.--Working women are even more prone than are men to take

a hurried breakfast, and having, as a rule, less appetite than men,

their meal is likely to be deficient. It is not unusual to find that a

young woman who is under weight and who needs three meals a day, is

taking so little for the first meal that even she hesitates to regard

it as a meal. Very often her last previous meal has been taken before

seven o'clock the night before, so that she goes out ill prepared for

her day's work. Much more than men, women are annoyed in the morning

by our transportation systems, and by worry as to whether they will

get to the office on time. Suggestions as to the modification of this

unfortunate routine, the taking of an earlier train, the using of a

quiet local instead of a crowded express, a short walk at least before

taking the train, will often help in producing a marked change in the

general health.

Home Keeping Women.--For those who really have homes, the morning

duties are usually sufficient to rouse their activities and make them

begin the day well. For those who live in apartment-hotels, however,

and for those who have the luxury of many servants, the morning hours

are often a serious problem. Madame does not get up, or if she does,

it is only to lie around in dressing gown for most of the morning.

Breakfast is easily neglected or may be eaten hurriedly because the

head of the house is rushing to business. The lack of an incentive

requiring them to rise, and get outside for a time every morning, is

probably at the root of more feminine symptoms among leisure class

patients than anything else. As we grow older all of us are likely to

note the lowered physiological cycle of the morning hours, so that

unless there is some sharp reason to compel action, we are rather

prone to persuade ourselves that it is better to lie abed, or at least

to loll around. This leads to a concentration of attention on self and

on one's feelings that easily gives rise to neurotic conditions.

Interest in life.--In my special clientele I have often found that

going to church in the early morning hours was an excellent remedy for

many of these patients. It gives them a definite reason for rising

promptly, the service provides motives to rouse them to activity, they

are likely to think during it of how they shall make their life a

little bit more livable for others as the result of their trying to be

better, and so the apathy that is so fruitful of ill feeling is shaken

off. This can only serve for those who have faith in the service. For

others, the old-fashioned going out to market, or the making of

appointments at morning hours that will tempt them to regular activity

early in the day, is of special significance. It is always ominous for

health when a woman can look forward to a whole long day without any

particular duties {170} in it until the late afternoon or evening

hours. This has become so frequently the case for the women of our

large cities, particularly those who live in apartment hotels, it is

no wonder that neuroses and psychoneuroses of various kinds have grown

in frequency. The best prophylaxis for them is occupation of mind. The

cure for them is the securing of many interests and such diversion of

mind as will prevent concentration of attention on self.

Mail Before Breakfast.--Many people receive their most important mail

in the early morning, and personal mail, in cities especially, is

likely to be placed beside the breakfast plate. Not infrequently,

letters contain serious matters that are likely to disturb people, and

occasionally even important business finds its way to the side of the

plate at breakfast time. Authors often find their rejected manuscripts

sent back in the morning's mail. Occasionally bad news of other kinds

comes in this way, and, as a rule, it is the very worst time for its

reception. The human system--it cannot be too often repeated--is at

its lowest physiological term in the morning, the temperature is lower

than during the rest of the day, all the nervous vitality is below the

normal. Half an hour after breakfast the reception of bad news, or the

coming of important matters requiring decision, would not make so much

difference. Hence, the necessity for knowing whether the mail is

ordinarily read in the early morning, in order to know something about

people, and about the consumption and digestion of their breakfast.

Company at Breakfast.--Pleasant company during meals is an important

factor that makes for good digestion. At the other meals there is much

more likelihood of having such pleasant company, while the morning

meal is often a solitary, and quite as often as not, a rather glum

quarter of an hour, preoccupied with the business cares of the day. As

may be readily understood from our discussion of this problem of

mental preoccupation during digestion, this may seriously hamper

digestive processes. Often men take refuge in their paper. The

thoughts aroused by reading the modern newspaper are not the

pleasantest in the world and consist, very often, of the following out

of details of hideous crimes and scandals. When, as is sometimes the

case, these scandals concern relatives, friends or acquaintances in

whom we are interested, and with regard to whom we feel poignantly

because of the publicity involved, nearly the same effect is produced

as when bad news is received in letters, or when business worries are

thus brought to the breakfast table.

The best conditions for the eating of breakfast are those in which it

becomes like the other meals, a family matter. When father, mother and

children eat their breakfast together, nearly always family interests

and especially the enlivening effect of the joyousness with which

children face a new day is the best possible tonic for a business man

in whom a solitary breakfast starts a day of digestive disturbance.

Sociability and sufficient time must be insisted on, whether at home

or in a boarding house, at breakfast as well as the other meals, and

it will often be surprising to find how much difference this makes

both as regards the quantity eaten and the digestion of the food.

Morbid Habits.--In matters of diet, it is important to ask for

details, for it is surprising what unexpected things may be discovered

after weeks of treatment. That was illustrated for me once by a case

of persistent acne in a young girl, which all the ordinary remedies

failed to cure. I felt sure that {171} I had given her such explicit

directions with regard to diet that I knew exactly what she was taking

and that nothing could be hoped for from any change. As a last resort,

I asked once more with regard to all that she ate and only then

discovered that before breakfast every day she ate a baked banana. It

had been recommended to her by a friend as a sure cure for

constipation, she had formed the habit of taking it as a medicine, and

so had not spoken of it. Baked bananas agree with many people well,

but just as soon as this was eliminated from her diet her acne began

to improve and before long had disappeared almost entirely. The taking

of large amounts of warm water, already spoken of, is another of these

morbid habits. Then many people take a glass of salt water, or

laxative water, and some have curious habits with regard to the eating

to excess of salt on cereal or on fruit, or sometimes they eat too

great a variety of fruit. All this should be known, but often will not

be ascertained unless particularly inquired about.

CHAPTER III

THE DAY'S WORK

Probably even more important than details with regard to the early

hours of the day, is detailed information as to the day's work, the

kind and character of the occupation and the length of time spent at

it, the interruptions that may occur, the habits with regard to

luncheon, and, above all, the state of mind in which the occupation is

pursued. The physician will only learn these details when he sets

before himself a definite schedule of what he wants to know, and then

proceeds to secure information with regard to it. With this sufficient

can be learned in a short time to ascertain the source of the

affection or the symptoms complained of. In some cases it is, however,

only when the whole day's occupation is reviewed that proper

suggestions can be made.

Getting to Work.--Many a man, especially if he has been accustomed to

much exercise in younger years, craves muscular exercise, feels much

better whenever he has the opportunity to take it, yet rides down to

business every morning and back every evening. On his vacation in the

summer time, he gets up early for the sake of a morning walk, but he

scarcely has time to take his breakfast and ride to business at other

times, though the main reason for his better feeling during his

vacation is his exercise. There is usually the story of crowded cars

in the busy hours, often with annoying thoughts pestering him that he

may not be in time and with a constant call on nervous energy while he

stands up in the train, jolted, pushed, crowded, or unable to read his

paper with satisfaction, even if he has a seat. The discomfort

experienced during a ride in crowded cars to business is about as bad

a way to begin a day for a nervous person as could be imagined.

As a rule, it will take more than half an hour to get to business in

this way. If an extra twenty minutes were taken, it would be possible

to walk the distance. On at least two out of every three days in the

year this would give a magnificent opportunity for exercise of the

best kind, for fresh air, {172} for diversion of mind, for the route

could be frequently changed, and, during the spring and fall, if there

are parks on the way, these would provide occasion for pleasant

thoughts to replace the annoyances which too intimate contact with

over-strenuous humanity in overcrowded cars is likely to occasion.

This seems almost too trivial for a doctor to talk about, but it is on

the care of trivialities that good health often depends. It is easy to

assume that this amounts to little for health but tempt a dissatisfied

patient, whose digestion and sleep are disturbed, to do it, especially

in the spring and in the fall, and see what a difference it makes in

all his physical functions. If he is not used to walking, he will have

to begin by walking only a mile or two, but after a time he will do

his four-mile walk in about an hour, with no waste of business time,

and with a renewal of energy that will seem little short of marvelous.

Details of the Day's Work.--If patients are to be benefited through

mental influence it is extremely important that details as to

occupation be completely secured. This must include, especially in

cases where there are objective but obscure symptoms, minute

information that may seem trivial, and yet which often proves to be of

great importance. In recent years there has been profound study of the

dangers of trades and occupations. Anyone who wants to treat nervous

patients, must know much about these occupations, for otherwise

symptoms may be ascribed to old infections, to obscure rheumatic

conditions, to intestinal auto-intoxication, or to nervous weakness or

exhaustion, when they are really the result of occupation-conditions.

The various poisons must be carefully looked for, or affections will

be wrongly treated. I have had a series of cases of lead poisoning

[Footnote 22] under most unexpected conditions which have taught me

much as to the possibilities of obscure plumbism. Lead poisoning from

new lead pipes--with no one else in the household suffering from it,

lead poisoning from frequent drinking of carbonated waters, the

bottles of which had the old-fashioned lead stoppers, lead poisoning

from the painting of a flat by a settlement worker who could not get a

painter to do it, show how carefully such things must be looked for.

[Footnote 22: "Curiosities of Lead Poisoning,"

_International Clinics_, Eighth Series, Vol. II.]

_Dust and Respiratory Affections_.--Mechanical conditions connected

with trades are especially important. Workers in dusty trades are

almost sure to suffer severely from bronchitis at times, and to have

the affection oftener than others, to have it "hang on longer," as

they say, and eventually to have tuberculosis develop. There are some

of the polishing trades in the metal industries in which it is

impossible to maintain the ordinary death benefit fund that workmen

have in other trades, because the men die so frequently and at such an

early age from consumption that the drain on the treasury makes it

impossible to maintain the fund. Practically all of the dusty

occupations have this same tendency. This is true often in occupations

where dust is sometimes not supposed to be much of a factor. Railroad

trainmen suffer more frequently from colds than do those in other

trades because of the dust to which they are exposed, and a trainman

with incipient consumption will be greatly benefited by getting out of

the dust during the summer months. Sweepers in large buildings,

janitors and janitresses have colds that are often untractable because

of the dust in their occupations. It is to be hoped that {173} the new

vacuum cleaning system now becoming so popular will obviate these

dangers, though like all improvements, it will probably bring its own

dangers with it.

_Lack of Light_.--People who work at occupations that keep them from

the light are likely to suffer from lung symptoms and to have quite

intractable colds which will not clear up until they get more

sunlight. Workers in theaters and like places who do their sweeping

where sunlight does not penetrate, are in more danger than others from

respiratory disease. Those who work in gloomy lower stories,

especially in narrow but busy and dusty streets, suffer the same way.

Attendants at moving picture shows who work much in the dark where the

frequently changing crowd brings in dust which cannot be well removed,

and in quarters where the sun does not penetrate, are almost sure to

have persistent repeated respiratory troubles.

_Habitual Movements_.--After the question of dust comes the mode of

the occupation. Many occupations demand certain habitual and repeated

movements. When people come complaining of pains in muscles in and

around joints, or of achy conditions in the limbs, it is important to

know every detail of their occupation movements, if the physician is

to appreciate just what pathological causes are at work. It is not

enough, for instance, to know that a man is a clerk, or a bookkeeper,

but it should be asked whether he stands much at his occupation, or

walks considerably, or whether he sits practically all the day. If he

stands much, we can expect that he will have various painful

conditions in his feet and legs, unless he takes care to change his

position frequently, to wear the most comfortable shoes obtainable

and, above all, to provide against any yielding of the arch of the

foot. Often it will be found that people who complain of discomfort in

the feet stand much on a cold, and sometimes damp and draughty floor,

and this needs to be corrected or their symptoms, often carelessly

called rheumatic, will not disappear. If he sits down always during

his occupation, he will need exercise and air or he will suffer from

many vague discomforts, over sensitiveness and irritability of nerves,

as well as from physical conditions.

Most patients prefer to think that they are suffering from some

constitutional condition, rather than from a merely local

manifestation due to their occupations. Those who have to stand much

can often make such arrangements as will permit their sitting down

from time to time. They may, if they are standing at a desk, have a

high stool; they may during their hour of lunch sit down restfully, or

even to recline for a time, so as to restore the circulation in the

legs. For many people who suffer from the achy discomfort connected

with varicose veins in the leg, a rest of half an hour in the middle

of the day with the feet a little higher than the head, will do more

than anything else to make them comfortable. This same thing is true

for people with flat-foot, and there are many occupations with regard

to which advice of this kind will be appreciated. The well known

tendency of many men to sit with their feet higher than their head is

not a mere caprice, but is due to the fact that this is an extremely

restful posture and thoroughly hygienic for those who have been

standing much.

Unfortunately, it is not so easy to secure such relief for working

women, but occasionally the advice to lie down during the middle of

the day on the couches of the retiring rooms may be the best medical

prescription that can {174} be given. This will carry young women over

trying periods of the month when everything seems to be going wrong.

In women particularly, if there are complaints of the pains in the

lower limbs, footwear must be investigated. When the heels are too

high those who have to stand much are thrown forward and there is a

strain of the muscles of the thighs and on the muscles of the back.

Many young women suffer from backache supposed to be due to internal

conditions usually of gynecological character, when it is only due to

high heels or a combination of high heels and constipation. On the

other hand, heels that are too low are not comfortable and women's

shoes, in spite of the outcry against them, have been better adapted

than men's to prevent them from developing flat foot. Fewer women than

men suffer from this affection. Shoes that are too loose are almost as

bad, sometimes it would seem worse, than those that are too tight.

_Habitual Motions and So-Called Rheumatism_.--The habitual movements

of various trades are extremely important for the diagnosis of

conditions that develop in the muscular system. Much of the so-called

rheumatism of the working people is really due to the muscular

over-activity demanded by their trades. This affects all kinds of

working people. Men who have to work foot-lathes, or women who have to

work sewing machines, or men or women who have to use their arms much

in repeated vigorous movements, are likely to suffer from achy

discomfort. The strong and healthy ones do not suffer, but the

delicate do. The suffering is much more prevalent in rainy, damp

weather; it is worse during the spring and fall than at other times.

It is particularly noticeable whenever the patient is run down

physically, is worrying about many things, or, above all, is getting

insufficient nutrition. The discomfort is particularly likely to recur

in those who do not know how to use their muscles properly, who are

naturally awkward, and who perhaps have from nature an insufficient

control over opposing and coodinating muscles, so that they do not

accomplish movements quite as readily as would be the case if they

were normal. The personal element enters largely into these

affections. Many patients, however, can be trained to do their

habitual movements under the best possible mechanical conditions,

whereas very often they are found accomplishing them under the worst

possible mechanical conditions.

Men who have to do much writing may have to be taught the application

of Gowers' rule, that the forearm should so move as a whole during

writing that if a pen were fastened to the elbow it would execute

exactly all the movements of a pen held in the hand. The writing must

all be done from the shoulder. People who do typewriting may have to

be instructed not to allow the machine to be too much above them, nor

on the other hand, too much below them when they sit down. Young

people particularly who, from long hours of practice on the piano,

suffer from neurotic conditions, may have to be instructed to do this

under good mechanical conditions.

Men who do much filing of metal will often suffer from painful

conditions in the arms. These will be much worse in case the filing is

done at a table or workbench so high that pressure has to be brought

to bear upon the file by the arms instead of through the weight of the

body. This same thing is true for women who iron much. If the ironing

board is so high that the additional pressure applied is made by the

arms, then painful conditions will {175} almost inevitably develop if

the work is long continued. These details are discussed in the

chapters on joint and muscular affections.

Night Work.--In a large city there are many workmen who are on night

duty. They will be disturbed in many ways in health, unless they make

special arrangements to live under conditions that enable them to have

full eight hours of sleep every day and, above all, to have their

meals regularly. When they come home in the morning they usually have

a rather hearty meal. Most of them can sleep very well with this, but

very few of them sleep the full eight hours, and all need this amount.

Usually they have another full meal about five in the evening. Very

often it will be found that the third meal of the day consists of a

sandwich, with a glass of milk or a glass of beer, and some cake or

some crackers and cheese, or the inevitable pie. Every workman should

have three full meals, and a man who is suffering from almost any

symptoms will be improved at once if the third good meal is insisted

upon. At one time I had occasion to see a number of men whose work

began not later than seven in the evening and did not finish until six

or seven in the morning. They were sufferers from all sorts of

complaints. Most of them were under weight. Not a few were

constipated. Some were suffering from severe headaches that came

rather frequently, and a few from a headache that was severe but came

only every two or four weeks. These patients alternated night and day

work, and it was the week after they had been on day work, and first

went on to night work, that they suffered from headache.

In every one of these cases instructions with regard to eating and

sleeping proved to be the best remedy. Nearly all of them were not

eating enough, and were skimping the third meal. Three of them were

taking only between four and five hours of sleep. They stayed up after

breakfast to read the paper, went to bed about nine and got up about

two o'clock. Just as soon as two or three hours was added to their

sleep, they began to feel better, and various symptoms, digestive,

rheumatic and nervous, of which they complained, began to disappear.

Nearly always night workers are more prone than the ordinary run of

workmen to some indulgence in spirituous liquors. Cold and shivery on

the way home from work in the early morning, they take a nip of

whiskey to brace them up. Alcoholic cirrhosis of the liver is a little

more common among sea captains, policemen, printers and night workmen

on the railroads than among the average of the population. The reason

for it seems to be that undilute whiskey is thrown into the

circulation by being taken into the stomach at a time when that viscus

is empty and all the cells are craving food and drink. It is carried

directly to the liver, and there either produces or predisposes to the

bad effects upon liver cells which we know as cirrhosis.

It is usually useless to treat such men for the indigestion and other

symptoms that are likely to develop as a consequence of their habits,

without getting at their story completely. It is easy, as a rule, to

relieve them of certain of their symptoms by ordinary drug

therapeutics. Unless their habits are changed, this relief, however,

is only temporary. It must not be forgotten that in recent years women

have come to do a good deal of work at night that was not usual to

them before. In the telephone service of certain cities, as cashiers

in restaurants, as ticket sellers in various places of entertainment,

{176} as office help at busy seasons of the year, women may be kept

occupied either all night or at least until quite late. Not

infrequently during times when rehearsals are on, chorus girls are

kept until the wee small hours. They are particularly likely to suffer

from such variations in normal habits, and no treatment is so

effective with them as pointing out how they must live, if they want

to preserve their appearance and continue in such exacting

occupations. A healthy young woman can burn the candle of life at both

ends with less protest from nature at the beginning than man, but she

suffers more for it and the suffering begins sooner.

Positions During Occupations.--The question of position during

occupation, especially as regards its influence upon digestive

processes, has always seemed to me much more important than most

people think. Our idea of digestion has been so largely one of

digestive secretions, to the neglect of the motor side of the gastric

and intestinal functions, that we have missed some important points.

If a person leans over a desk shortly after a meal, there is no doubt

that the crowding of the abdominal viscera hinders peristalsis, at

least to some degree, not of course in the robust and healthy, but in

those who already have some irregularity or sluggishness in this

region. The old high desks at which many clerks used to stand, at

which even proprietors did not hesitate to take their position, had a

reason in common sense that has been forgotten in the modern times,

and the variation of position thus permitted seems to have been good

for the workers.

A good deal of comfort may be obtained by having a suitable desk and

chair for business hours. Not infrequently it happens that a desk is

too high for comfortable writing. Any discomfort that is continuous

and makes itself felt intrusively during occupation with other things,

will have an unfortunate effect. Such things seem trivial by contrast

with serious disease and may seem safely negligible. Trivial they are,

but little things count both in themselves and as to the attitude of

mind which they occasion. It is the attitude of mind that we try to

modify by psychotherapy, and even the removal of little sources of

annoyance help a patient materially to get through life more happily

and through work more efficiently and without any more discomfort than

is absolutely unavoidable.

_Positions After Meals_.--While we have talked thus of business

people, what is said refers, also, to the positions assumed out of

business hours, as, for instance, at home after dinner. A Morris chair

that permits of a somewhat reclining position, or a rocking chair that

temps one to sit back, pretty well distending the abdomen and giving

all due play to the internal viscera, will be found not only much more

comfortable than a straight-back chair which tempts a man to lean

forward, but also there will be less interference with gastric

motility, the most important digestive function of the stomach.

Arm-chairs which really support the arms, and therefore tend to keep

the shoulders up, have something of the same effect. We naturally

assume these positions, though occasionally social usage forbids them.

The tendency, for instance, for elbows to be put on the table,

especially toward the end of a meal, represents a natural instinct to

lift up the shoulders and keep the weight of the upper part of the

trunk off the abdominal organs. Children's instincts often curiously

guide their postures--as is illustrated by the story of the little boy

who, when asked by his grandmother if he could manage {177} another

tart, said that he thought he could if he stood up. (See chapter on

Position.)

Mental Conditions of Occupations.--While the details of manual

occupations have to be learned with great care if we are to modify the

conditions so as to prevent certain unfortunate effects, just as much

care has to be exercised, with those not employed manually, in finding

out details as to mental worries, and the various disturbances

consequent upon business conditions. Many a man has not brain enough

to run his business and his liver. This is the old English expression,

and the liver, as the largest of the abdominal organs, is taken for

the physical life generally. Many people have not vital energy enough

to waste any of it on worries and then be able to complete their

digestion and other physiological functions with success. The

preceding mental condition is a predisposing cause of many a purely

physical ailment. It used to be said that during a cabinet crisis in

England, or rather just after it was over, attacks of gout were most

frequent among prominent politicians. Mental influence usually kept

the attacks off until the very end of the crisis. Merchants come down

with pneumonia or digestive disturbances more frequently during

periods of acute business depression. Physicians are attacked by

pneumonia, or influenza in bad form, after they have been wearing

themselves out in an epidemic and worrying about patients. Just after

a mother has nursed a child through a severe ailment she herself is

prone to suffer from some acute infection. Such common-place

infections as boils, styes, abscesses and even the more serious

osteomyelitis are likely to come at these times.

It is important, then, to know as much as possible about a business

man's affairs. Any one who has had a series of tuberculous patients

(who were getting along quite well in spite of latent or even active

lesions) disturbed by anxieties of one kind or another, knows how much

worries may mean. Men will lose weight and appetite and weaken in

their general condition as a consequence of some serious business

incident, while all the time physical conditions are the same as they

were when they were improving. And it must not be forgotten that even

in those who do no physical labor, there may be physical conditions of

their occupation that are important. Many a business man does his work

cooped up in a small office, with insufficient ventilation, and

sometimes, especially where his business is on the ground floor of a

large building, with so little sunlight that his environment is quite

unhygienic. The great air purifier is sunlight. Unless sunlight is

admitted for hours every day to the rooms in which people live, the

dust that is inevitably breathed will contain living germs, active and

noxious, though had they been exposed to sunlight these germs would be

harmless.

Especially then for people with respiratory defects of any kind,

whether these be tuberculous or of chronic bronchitic character, the

conditions surrounding the occupation should be carefully inquired

into. Once the family physician knew such things as a matter of

course. Now he is likely to know very little. The lack of such

information may not be important for the more serious conditions that

he has to treat at patients' homes, but they usually mean much for the

submorbid conditions, so to say, the discomforts and chronic

conditions, which come for office treatment. They mean much for

comfort in life, and for the conservation of health and strength. They

{178} represent that newer medicine which people are asking of us now

so much more than before, which shall keep them in good health and

prevent them, as much as possible, from suffering even from minor

ills.

Business Habits.--The modern idea of having a flat-top business desk,

instead of a roll-top desk, and having it thoroughly cleared off every

evening, so that each day's work does not accumulate, is an important

psychic factor in the strenuous life, which in recent years many

corporations have been taking advantage of. It is well for those who

are their own masters to realize the value of this principle. Nothing

so disturbs the efficiency of work, nor adds so much to the incubus

that work may become, as having a number of unfinished things which

keep intruding themselves. It is not always possible to dispose of

problems, but discipline is necessary to keep us from pushing business

matters aside. Then they have to be done in a rush, very often at a

moment when other things are also pressing. The result is poor work,

but, above all, a waste of nerve force and energy that leads up to

nervous symptoms and eventually nervous exhaustion. The orderly man,

who has learned to settle things as they come up, or at definite

times, can accomplish an immense amount of work. Some men are born

orderly, but any one who wants to do much work must have order grafted

on his makeup--a habit which can be made a second nature. It may seem

that a physician is unwarranted in intruding on a man's business

affairs thus to inquire about the ways he does things, but this is the

difference between psychotherapy and the regulation of life as

compared with cures by more material but less effective means.

Personal Hygiene.--Expert Advice.--For many men who are much occupied

with business, the best possible safeguard for health, as well as the

best guarantee against nervous or physical breakdown, would be a

detailed consultation once a year with a physician regarding their

habits of life and their business in relation to their health, present

and future. In recent years many a business firm has found it not only

expedient but profitable to turn to an expert accountant or auditing

company and ask advice with regard to the management of its business.

It is often found that certain business customs are causing serious

drains, and that there are newer ways of doing things that save time

and money. Sometimes a reorganization of the accounting system, or of

the method of dealing with credits and debits, or the receiving or

shipping department, proves advantageous to the business. Sometimes it

is found that the capital invested will not justify the extension of

business that is proposed, and not infrequently it is shown that a

proposed extension adds to business movement but does not add to

profits. Sometimes there are departments that can be dropped to

advantage, though they seem to be adding to both business and profit.

All of this may well be transferred to the question of health in its

relation to business. Not infrequently it is found that the capital of

strength of the business man is not sufficient to justify the

extension that he is planning or has already attempted. Sometimes

suggestions can be made with regard to the mode of doing business, the

hours employed and the hours of relaxation, that will make business

less of a drain on the system. Occasionally arrangements for sleep and

exercise, as well as for afternoons or special times of diversion, may

save a man from that concentration of attention on one thing {179}

which frequently leads to nervous breakdown. Not infrequently business

men who are of neurotic habit have customs of doing business which add

to their nervous irritability, and these might be modified so as to

lessen the call on nervous energy. There is need that the physician be

looked to as an expert in personal health and its relation to

business, just as the expert accountant or auditing firm is looked to

for advice with regard to business methods.

CHAPTER IV

THE MIDDLE OP THE DAY

Information regarding the mid-day meal will be of value to the

physician in many cases. In cities, luncheon, likely to be rather an

apology for a meal, is taken rapidly, and immediately there is a

return to work. As a medical student in Vienna, I was much interested

in the mid-day meal of the bankers and merchants of the old Austrian

capital. At that time--I hope they have not changed the good custom

since--the banks closed at 12 o'clock and did not open again until 3

o'clock. This gave time for taking the mid-day meal in comfort, and

for a proper interval for digestion. In all the southern countries of

Europe, for seven or eight months in the year at least, little is done

during the two or three hours in the middle of the day. The people get

up earlier and rest at mid-day as a break between the afternoon and

morning. It is quite beyond expectation that anything like this will

ever again be possible in the great commercial cities. The fact that

this was the custom of our European forefathers, however, shows how

business has obtruded itself on the habits that man would naturally

form for himself. Business men hurry to luncheon, or if they take any

time over it, it is because they have invited some one to lunch with

them with whom they wish to talk over important matters. This means of

saving time recalls the well-known expression of James Jeffrey Roche:

"Time is money. Every second saved from your dinner now is a sequin in

your doctor's pocket later on in life!"

Hurried Lunch.--The seeds of our frequent American dyspepsia are sown

partly at the hurried breakfast and then at the hurried mid-day lunch.

When a physician finds this to be the case, then the patient's habits

must be reformed. Otherwise there is little prospect of relief from

neurotic digestive symptoms, or from those uncomfortable feelings so

often supposed to refer to the heart, or other important organ, when

digestion is interfered with. There should be pleasant company at

luncheon if possible; it should be preceded by fifteen or twenty

minutes in the open air, with, as far as possible, complete seclusion

from business thoughts so as to allow the stomach to secure its share

of blood, and it should be followed by at least half an hour of

pleasant occupation that does not call for serious mental work. This

may not be possible for every one, and many will complain that this is

asking too much in our busy time. We physicians are not here to make

the nice customs of medicine courtesy to great kings of finance or to

the busy tyrants of the professions, but to tell them what we think

should be {180} done in order that nature may not be abused. Men

should be advised to take their luncheon in some building different

from that in which their offices are located, or, if they eat in the

same building, to go out on the street for a while before the meal. In

the old days men used to call on one another in order to transact

business, and these little trips were often made just before or after

luncheons.

Now the telephone and the messenger boy have done away with this, with

a great saving of time, but with an increase of intensity of labor

that makes for nervous exhaustion. Luncheon clubs are excellent things

when men do not talk shop, but they have one fatal defect. Almost

invariably they lack simplicity of menu, and, because of the variety

supplied and the example of others, there is a tendency to eat to

excess. A game of billiards after eating is often excellent, because,

when standing, digestion is accomplished with more comfort than when

seated. A walk after the lighter midday meal is a good thing, though

the old saw said "after dinner sit a while," but that was in reference

to the largest meal of the day, and may still hold good for the

evening meal, which is likely to be the heaviest one.

Women's Lunch.--Women are very likely to take their mid-day meal, when

it is their luncheon, very irregularly. If they have to get it for

themselves they are likely to be satisfied with almost anything. If

they get it outside the house they are likely to take it rather late,

so that if they have breakfast before eight o'clock, this putting off

of the next meal causes some disturbance of the economy. When the

stomach gets to be empty, either there is a tendency to swallow air,

or there is a rumbling sense of fullness that disturbs the appetite,

or the appetite itself is capricious, and a headache develops. How

many headaches are due to missed meals it would be hard to say, but

this is one of the most fruitful causes of the ordinary passing

headache. Delicate women, and especially those who work, are likely

not to eat enough luncheon. All the details with regard to this meal

must be known or the physician will find it hard to get rid of many

neurotic symptoms, particularly in working women. The same thing is

true for the so-called society woman, since she is likely to have a

late breakfast and then skip her mid-day meal. This is permissible if

she is so stout as to be able to spare it, but it is all wrong if she

is thin and needs every ounce of weight.

Nature of the Noon Meal.--During the last two generations fashion,

custom and the increasing demands of business have pushed the hour of

taking the principal meal farther and farther away from mid-day. There

are, however, cases in which it seems better that the principal meal

should be taken in accordance with the old custom, about noon time.

For tuberculous patients this is especially important. They often have

fever in the afternoon that seriously disturbs appetite. They may eat

with comfort and relish a couple of hours before the fever is due. For

delicate persons, especially those who have not much appetite for

breakfast and who can not be persuaded to eat a sufficient amount

early in the morning, a hearty meal at noon is almost a necessity.

They should be shown how low their nutrition is during working hours.

Their principal meal of the day before was taken between six and seven

o'clock. They have had a light breakfast, a meager lunch, and

naturally have little reserve force during the afternoon hours. As a

consequence they become overtired, this lessens the appetite, they do

not eat properly, and, {181} above all, they do not digest as well as

they would if their last good meal were not so far away. They are

suffering from inanition, and, as is well known, starving people

cannot be allowed to eat heartily, because their stomachs have not

enough vitality to digest well.

It is often difficult to change the hour of taking the principal meal,

but in special cases this can be done with decided advantage. I have

seen such a change make all the difference between slow recuperation

from bad colds, and have seen it of the greatest possible importance

in tuberculosis. The very changing of the hour will sometimes

suggestively react to make the patient eat more heartily than usual,

the day is broken up better, the reaction against the morning

discouragement comes earlier, and the patient's general condition

improves. Many people rest better at night if their principal meal is

taken at the middle of the day.

CHAPTER V

THE LEISURE HOURS.

Then comes the return from business. Here once more the ordinary

method of getting on a crowded train, standing up to be pushed and

jammed, to have all sorts of unpleasant things happen, to have the

pessimism of one's nature stirred to its depths by the utter disregard

for women, the heedless rush of men, the roughness of railroad

employees, and the general lack of humanity that characterizes the

evening rush from business in a large city, is eminently unsuitable as

a preparation for dinner; while a calm walk of three to five miles is

ideal. To walk home will probably take twenty minutes or half an hour

longer, but not more than this--and it avoids the undesirable features

of the usual method.

Gymnastics.--Occasionally one finds that men rush through the last

hour of business in order to spend an hour in a gymnasium. Often this

is quite undesirable. Exercise within doors, taken in a routine manner

and merely for the sake of exercise, with no diversion of mind, is

eminently unsuitable for the busy man. What he needs is air much more

than exercise. Walking out of doors is the very best thing for him. If

he walks at a rapid pace, swinging his arms a little freely and

carrying a cane in one hand and perhaps a book in the other, because

this exercises his fingers and keeps him from having any unpleasant

congestion of the hands when they hang down, then the exercise is

almost ideal. Owing to the novelty of it, and the interest that a new

occupation arouses, great benefit will at first be derived from the

gymnasium. Very often, too, the cold plunge after the exercise does

more good than the exercise itself. The plunge is real fun, especially

when taken with many others, but the exercise itself is likely to

degenerate into the sorriest kind of a task. If the man who walks home

will take a bath before dinner, the temperature of the water being

made suitable to him and the reaction that comes to his particular

nature, there is no need of anything else, and there is nothing better

that he could do. The walk must be varied. The course must not always

be through the same streets. Occasionally it {182} should even lead

one to see some monument or new building, or to go out of the way with

a friend, so that variety is introduced.

Work at Home.--There are men who in busy times take some of their work

home with them. This is a mistake. And though it is the custom to tell

the doctor that they cannot do otherwise, it is practically always a

bit of self-deception. When the case is properly put before them, they

realize, if they already have any neurotic symptoms, that to continue

home work will be a serious risk. Most men who carry business home

with them, easily get into the habit of pushing certain details away

from them during the day with the idea that they will have more time

for that in the evening. They do a certain amount of dawdling over

their work. If they really resolved to finish work during business

hours they could do it, and do it better than during the evening at

home. Six hours of work is about all that a man ought to do with his

intellect at high pressure. This should be pretty well divided into

two periods of three hours each, with an interval of an hour to an

hour and a half between. The nearer a man can come to this arrangement

the better for him, and the better, also, for his affairs. If he has

assumed obligations that require more of his time and attention than

this, he is trying to do too much.

After-Dinner Hours.--The evening hours and their proper occupation are

important for the business man, or for anyone who is much occupied

during the day. The temptation to let the work of the day run over

into the evening must be overcome at all costs, or it will prove

serious for the health of most men. It is important as far as possible

to get something completely different for men to do at night. Many men

settle down to the reading of a newspaper or of a magazine or novel.

While this does very well under some circumstances, reading does not

provide diversion whenever there is serious worry or solicitude over

business matters. A man may think that he is occupying himself with

the newspaper, but we all know very well that business cares intrude,

that business troubles are often doubled by reading about others. The

reading of novels does well for a while, but the serious-minded man

tires of them and then, while they may occupy a couple of hours, they

have exactly the same objection as the newspaper. A genuine diversion

should give the physical basis of mind an opportunity literally to

remake itself by storing up new energies.

_Amusements_.--The fact of the matter is that a man must have, if

possible, some other serious interest in life besides his business. He

must have a hobby. We have discussed this in the chapter on Diversion

of Mind and refer to it here only to indicate the importance of

knowing something about a man's recreation as well as his work. It is

not a casual occupation but a real interest that he should have. This

need not necessarily be a useful employment and, indeed, it may be

absolutely useless provided it is absorbing. Card playing is an

excellent diversion for many people. When joined with gambling, new

worries and feverish excitement usually make it harmful for neurotic

persons. Chess is hard work, but of a different kind from that of the

day and, therefore, often makes an excellent recreation. Any games are

good. Bowling, for instance, is excellent, and billiards, if a man has

an interest in it, is a fine sport for evening hours. It has the added

advantage of physical exercise. A man does not sit down during

billiards, crowding his {183} already well-distended abdominal

viscera, but walks around and gives his viscera a better chance for

their work and aids rather than retards peristalsis.

_Encroachment on Sleep_.--There is just one defect about some of the

more absorbing recreations--they keep a man up too late. Whenever a

so-called recreation takes up such time that a man has less than eight

full hours in bed, then a mistake, almost sure to be serious sooner or

later, is being made. When the physician tries to limit a man's

recreation by suggesting an earlier hour for retirement, he may be

told that his patient must have some time for diversion and

recreation. But the physician must insist that no form of recreation

is as good as sleep, and any other form must be limited in order that

sleep may be obtained. A man may easily regulate his affairs so that

he shall have eight hours of sleep, and it is only negligence of such

regulation that gives him the idea that recreation cannot be obtained

except after eleven o'clock at night. Little suppers after the theater

are often fine diversions, but whenever they interfere with sleep they

must not be allowed except at long intervals. Other diversions that

keep a man out of bed after midnight are sure not to do good in the

long run, though an occasional lapse in this matter may prove a

stimulant rather than a depressant. It is custom that must be

regulated; an occasional variant from it is rather good than

otherwise.

Leisure of the Working Woman.--A woman's occupation, unlike a man's,

holds out little future for her. Her occupation does not arouse her

ambition. Daily work is a monotonous grind that must be endured for

the sake of the wages that it brings. For a time this serves to occupy

attention. After some years, when the prospects of matrimony grow

less, and further advance is out of the question, women often need to

have some special interest that will grip them. The working woman may

then need to be tempted to some occupation of mind, especially with

the companionship of others, that will give her renewed interests in

life. Clubs, charities in which they are active, friends, serious

intellectual interests, must all be appealed to, in different cases,

in order to secure diversion. Women must have something to look

forward to each week. They must know on Monday that before the

following Sunday there is going to be a theater party, a lecture, a

visit to friends, something to break the deadliness of weekly routine,

which is anticipated with pleasure and then pleasantly remembered.

This may seem to be only a slight matter, but it is of importance in

many cases.

Feminine Occupations.--The occupations of women who stay at home are

even more important than those of women who go out to work. In our

time the root of much nervousness, as it is called, neurotic symptoms

of various kinds and of many symptoms apparently quite distant from

real nervousness, is really a lack of occupation. Many women who live

in apartment hotels have almost nothing with which to occupy their

minds. They are not obliged to get up in the morning if they do not

want to, or, at least, any excuse, however slight, serves to keep them

in bed. Very often there are either no children or the mother has

nothing to do with her children early in the morning. After the age of

three, they go off to kindergarten; later on they go to school.

Breakfast is sent up, there may be a nap of an hour or two after the

meal, and often a magazine is glanced over lying in bed, and perhaps

it will be twelve o'clock before madame gets up. Anyone in a position

to do this, and who allows the habit to grow, is sure to be profoundly

{184} miserable. Without any real occupation of mind, the mind

occupies itself with the body and emphasizes every sensation, evokes

new pains and aches, and the consequence is likely to be a highly

neurotic state.