This delicate recognition is commonly lost in mankind, but some

abnormal beings like Laura Bridgeman and a perfectly normal lad I

once saw, have possessed the power of distinguishing by smell the

handkerchiefs of a family after they had been washed and ironed. In

this lad I made a personal test of his power to pick out by their

odor from a heap of clean handkerchiefs mine and those of others,

the latter two belonging to his father and mother.

I have seen a woman, well known to me, who can distinguish by mere

odor the gloves worn by relatives or friends. This lady, who likes

cats as pets, is able to detect by its odor the presence of a cat

when I and others cannot.

Two French observers believe that they have proved the sense of

olfaction to be nine times more acute in women than in men.

So far as the present paper might serve in evidence, I should be

inclined to say that the sense of smell was keener in women than in

men, but as to this there is extreme diversity of opinion and the

whole question awaits further investigation. [Footnote 48]

[Footnote 48: This question of the varying acuteness of smell in

different people is very interesting to the psychotherapeutist for

diagnosis and therapy. We have a number of striking cases of very

acute olfactory power. This is what might be expected since

animals whose respiratory and smell apparatuses are very like our

own show extreme differences. The extent to which human power to

recognize odors can go is marvelous. In his "Thinking, Feeling,

Doing," Prof. Scripture says: "I have a case--reported by a

perfectly competent witness who lived for years with the person

mentioned--of a woman in charge of a boarding school who always

sorted the boys' linen after the wash by the odor alone."

Personally, I have sometimes wondered whether this power, like

that of feeling in the blind, could not be developed. The blind

are supposed actually to bring about an evolution in their nerves

of feeling. No such thing happens, however. An examination of them

by means of an esthesiometer shows that their nerves are no better

developed than those of other people, though they may be able to

recognize much minuter differences between the "feel" of things

and may be able to read raised type, which the seeing cannot. This

is all due to a training of their attention to note slight

differences in sensation, however, and not to improvement in the

nervous apparatus. ]

{620}

Dread of the Dark.--The discipline suggested with regard to overcoming

the dread of heights must be applied to any of these dreads if

patients are to be made comfortable. They can form the opposite habit

and by refusing to yield to their fears can do much to lessen them.

Nearly everyone who is unaccustomed to sleeping in a dark house alone

has dreads that come over him when he first tries to do it. Every

noise is exaggerated in significance and the creaking of stairs and

rattling windows and doors and the wind through the trees are all made

significant of something quite other than what they are. Nearly

everyone knows, however, that this can be overcome simply by refusing

to pay any attention to the idle fears that come over us as a

consequence of the tension due to loneliness, and after a time,

sleeping in a strange room and a strange house in the dark is not a

difficult matter. It is harder for some people to accomplish than

others, but it is impossible for none. Here is the lesson that all the

sufferers from dreads must learn. Gradually, quietly, persistently,

they must resist the dreads that come over them, must deliberately,

without excitement, do the opposite to that suggested by their

apprehension, until habits are formed that enable them to accomplish

without discomfort what was before a source of even serious

ill-feeling.

The dread of darkness that so many people have is usually supposed to

be cowardice. It is not, however, in most cases, but is due to

idiosyncrasy or to certain special physical factors in the

environment. If children have been brought up so that when they were

small a light has been constantly shining in their eyes, even though

only a dim light, it will often be difficult to accustom them to be

quite comfortable in the dark. Much depends on habit in this matter. I

have known men, who, when they came from Ireland, feared the darkness

of the coal mines very much and their dread was increased by the awful

horror of possible ghostly appearances, since so many accidents had

taken place where they worked. After some years, however, they were

quite placid about it and would calmly go into the mine as fire bosses

at three and four in the morning, long before others were to go in,

examining absolutely dark passages by the mile, with no human being

near them and with the creaking of the pillars, the dripping of water,

the rumbling of the sides and the occasional fall of a small particle

from the roof, besides the noises of rats to add to the disturbing

factors. Like going up on a high building, one may get entirely

accustomed to it so as scarcely to notice it at all.

When the fear is allowed to take hold of one, however, and no effort

is made to overcome it, it may prove quite seriously disturbing. The

unaccustomed, however, means more than anything else in this matter.

Sometimes, {621} indeed, people have a dread of the dark that seems to

be inborn and that apparently cannot be overcome, that, like the fear

of cats or of lightning, may be quite beyond rational control. Hobbes,

the English philosopher, was so perturbed by darkness that he kept a

light in his bedroom all night. I know this to be the case in a

clergyman who had been quite undisturbed about darkness until he was

awakened one night by a burglar. He demanded "who's there?" and

received as answer without further parley a bullet that fortunately

struck only the head of the bed, but so close that it singed him. The

burglar escaped, but the clergyman was never afterwards able to sleep

without a light. Rousseau, the French philosopher, was also much

afraid of darkness. Ordinarily it is presumed that superstition has

something to do with this fear and that the victim of it has ghosts in

mind or at least dreads spirit manifestations. Neither Hobbes nor

Rousseau, however, was likely to be timorous about ghostly visitants.

It was with them a physical idiosyncrasy.

Associated with dread of darkness is the fear of finding some one in a

dark room whose presence may startle us. Sir Samuel Romilly, famous

for his labors for the reform of the English criminal law, and who

must be considered one of the great humanitarians of the nineteenth

century, had this dread to an acute degree. It went so far that

whenever he slept in a strange place he carefully examined all the

possible hiding-places in the room and in wardrobes or closets

connected with it and, as a last precaution, never failed to look

under the bed. He did this even when he was in his own house.

[Footnote 49] This, however, is not so unusual, even among men, as

might be thought. Most women who sleep alone want to investigate under

the bed and in a hotel closets and wardrobes and even bureau drawers

are likely to be examined. Habit in this regard may make one quite

miserable and over-solicitous. I have had patients whose sleep was

seriously disturbed by the remembrance that they had not looked under

the bed and who feared to get up and light a light to do so lest there

should be someone there. Indeed, the idea of putting their feet on the

floor before the light had come to reassure them seemed quite out of

the question.

[Footnote 49: Curiously enough. Sir Samuel Romilly, in spite of his

dread of the dark, committed suicide and went prematurely into the

darkness of the beyond, apparently without his usual tendency to

precaution.]

Dreads Connected with Water.--Strange as it may seem, water

constitutes a source of dread for some people. We have the records of

it in the peculiarities of great men and it is not unusual to meet it

in common life. Dropping water is a source of disturbance for most

people. It is quite impossible for the majority of men and women to go

on writing or reading with any comfort if water is dropping near them.

Dropping water, when one is trying to go to sleep, is one of the worst

of awakeners. The Chinese are said to put people to death in horrible

torture by having a drop of water fall at regular intervals on their

heads. Robert Boyle, the great father of chemistry and a very sensible

man in many ways, is said to have been thrown into convulsions by the

sound of water dropping from a faucet. The splashing of water on some

people is a poignant source of torture. I have had a woman patient who

could not go to services where there was a sprinkling of water, for it

seriously disturbed her and gave her a sense of depression that would

not be overcome for some time. Peter the Great, though the father of

the {622} Russian navy, and though he passed many years of his life in

Holland, used to shudder at the sight of water, and if, when out

driving, his carriage passed near a stream or over a bridge, he would

close the windows and be overtaken with terror that brought the

perspiration out all over him.

Dread of Death.--The fear of death is one of the dreads that bothers

young as well as old, and, curiously enough, as its inevitable

approach becomes more certain, men are prone to dread it more. Long

ago Sophocles said:

None cleave to life so fondly as the old,

-- and this has remained true for all the centuries since. A young man

is quite ready to throw his life away, but the old man hesitates and

even in the midst of suffering, if it is not absolutely continuous,

craves that death shall not come. Sophocles' great rival, the elder

Greek dramatic poet AEschylus, had said:

How far from just the hate men bear to death

Which comes as safeguard against many ills,

-- but his message was only for those with the character to face the

worst. One may reason with the dread of death, however, and patients

can be given motives from philosophy, literature, religion and

experience that will help to relieve, though it will not entirely cure

them. Shakespeare said in "Julius Caesar":

Cowards die many times before their deaths.

The valiant never taste of death but once,

-- and people may be aroused to appreciate this.

_Fear of Early Death_.--Many fear that if they have shown symptoms of

delicacy of constitution at some time in life or suffered severely

from some serious disease, that they are not likely to live long and,

above all, that they are almost sure not to be able to accomplish

anything worth while in life. The old proverb is "a healthy mind in a

healthy body." This is, however, the ideal. There are very few ideals

realized in life. Just because a man has a weak body is no argument at

all that his mind may be weak and some of the world's finest work has

been accomplished by men whose bodies were always delicate.

Metchnikoff is the apostle of old age to our generation, but it is he,

also, who has pointed out that many distinguished workers in science,

in poetry, in art, men who have left a precious heritage in succeeding

generations, were delicate all their lives. He cites such typical

examples as Fresnel, the great French physicist; Giacomo Leopardi, the

distinguished Italian poet; Weber and Schumann, the great German

musicians, and Chopin, the Polish composer and pianist, all of whom

did work that the world would not willingly miss, in spite of delicacy

of health and weakness of body which shortened their lives.

Intellectual power is not dependent on bodily energy and

accomplishment is not a question of years of work, but intensity of

work.

It would not be difficult to add many other names to those mentioned

by Metchnikoff. Naturally his thoughts recurred to men of distinction

on {623} the Continent, but in English-speaking countries we have a

number of typical examples of strong minds doing fine work in weak

bodies. Robert Louis Stevenson is the best remembered by our

generation. Elizabeth Barrett Browning, delicate all of her life, a

neurasthenic during the precious adolescent years that are supposed to

mean so much for future accomplishment, always an invalid to some

degree at least, did some of the best work that was given to any woman

to do during the nineteenth century. J. Addington Symonds, the

historian of the Renaissance and of Italian literature, is another

striking example of a man who had to do his work under great physical

difficulties, yet who left a long bookshelf of large volumes after him

as the product of the hours that he could cheat from caring for his

health. Henry Harland, whose recent death all too young was a blow to

the English-speaking world, is another striking example. The names of

such men and women and their stories must be made familiar to people

who are themselves delicate in health and who fear for their future

and, above all, are despondent about the possibility of ever doing

anything worth while.

Dread of Insanity.--People who have relatives who are already

sufferers from such severe forms of insanity as require asylum

treatment are often likely to be much disturbed over the possibility

that they themselves should become insane. Of course, there is no

doubt but that these people are much more liable to suffer from

insanity than others, but their worrying over the matter is sure to do

them harm rather than good. There are quite enough sources of worry in

life without the additional one of dread of a future event that may

not occur, and this must be made as clear to them as possible. The

people who have no obligations on them, who have nothing to do that

they feel they have to do, are especially likely to suffer from such

obsessions. The best possible relief for them is afforded, not by the

effort not to worry about their dread, which usually has exactly the

opposite effect and emphasizes their fear by the constant effort which

they make to put it aside, but by getting something else to interest

them. This must not be merely a passing interest, if possible, but a

serious attraction of some kind that fully occupies the mind. A hobby

is an excellent thing for this, but alas! a hobby must be cultivated

for many years, as a rule, to become powerful enough to bring relief

in such serious matters.

Occasionally the thought of the insane asylum or the sight of an

institution of this kind passed even at a distance in the train is

enough to give some people a fit of depression that may last for some

time. The thought of going to visit their ailing relatives is enough

to make them even more depressed. I have sometimes found that in

chosen cases, especially among women and those of sympathetic

disposition, the apparently heroic remedy of making them visit their

relatives in the asylum was excellent for them. It is the usual rule

for people who are themselves sane to consider that it is the greatest

hardship of asylum confinement for the patients to be associated with

those whom they recognize to be insane. Exactly the opposite effect is

the usual result. To be among people, many of whom are more irrational

than themselves and some of whom are quite beside themselves, proves a

stimulus and an encouragement. Contentment has been defined by a cynic

as the feeling that things might be worse.

{624}

DREADS OF MEN OF GENIUS

The insane are particularly prone to suffer from dreads, so that some

people argue from their dreads to the thought of insanity. It is quite

a mistake, however, to think of dreads as necessarily connected with

insanity in any way. They are irrational though they will commonly be

found to be dependent on some special physical condition. This is

usually some exaggeration of attention to a sensation natural enough

in itself but disturbing when dwelt on to such a degree that it

produces a much greater reaction in these individuals than in other

people. These dreads have existed in all sorts of people. It is said

that they are more frequent in the highly intellectual, especially in

the class known as geniuses, and they are often said to represent the

definite evidence of a relationship between genius and insanity. I

have always felt, however, that they are quite as common among

ordinary people who have no genius and no signs of it as among the

so-called geniuses. They are not so much spoken of by ordinary people,

however, because they are rather ashamed of them. Genius, on the

contrary, is quite willing, as a rule, to exploit its peculiarities

for the benefit of the public, or what is even more true, its

peculiarities are remembered and commented on as details of history.

With this in mind the following paragraph from Dr. Dorland's book on

"The Ages of Mental Virility" [Footnote 50] deserves to be

recalled. He has gathered a number of examples that are very

interesting:

[Footnote 50: The Century Co., New York, 1908]

Fear has played an important role in the development of the

antipathies of the great--fear that was often groundless in its

origin and inexplicable in its manifestation. The unaccountable fear

of dogs is not so common as ailurophobia, although it is said that

De Musset cordially detested them, and Goethe despised them,

notwithstanding, forsooth, he kept a tame snake. Much more frequent

is the fear of spiders, centipedes, and other insects. Charles

Kingsley, thorough naturalist though he was, entertained an

unconquerable horror of spiders, even the common house spider;

Turenne became weak when he saw a spider; while the author of the

"Turkish Spy" once asserted that he would far prefer, with sword in

hand, "to face a lion in his desert lair than to have a spider crawl

over him in the dark." Lord Lauderdale, on the contrary, while

declaring that the mewing of a cat was "sweeter to him than any

music," had a most intense dislike for the flute and the bag-pipe;

and Dr. Johnson was so fond of his cats that he would personally buy

oysters for them, his servants being too proud to do so.

There are curious contradictions to be found in these matters.

Montaigne confesses that he did his best writing and was in the best

humor for keeping at his Essays while stroking his favorite cat with

his left hand, his other being occupied with his writing. This would

be seriously disturbing to many people, but apparently occupied

certain distracting sensory tendencies and enabled him to concentrate

his mental energies. To many people the very thought of doing anything

like this would put all ideas for writing out of their mind. Other of

Montaigne's peculiarities are quite as interesting. He always refused

to sit down with thirteen at table, his liking for odd numbers was so

great that he made all sorts of excuses in order not to use {625} even

numbers and his aversion for Friday made the quota of work that he

could do on that day much less than any other day of the week.

OBSESSIONS

There are many curious obsessions that disturb people and that are

often extremely difficult of explanation even by themselves. Dr.

Johnson, one of the most sensible men in many ways in his time in

England, could not, it is said, pass a post on the street without

touching it. At least if he did so he felt that somehow he had omitted

to do something that he ought to have done and it would make him

uncomfortable. There are many people who have some idea that it is

lucky to touch posts as they pass along and the number of people who

do things like this is larger than might be imagined. Many people put

themselves out of the way in order to avoid letting a post come

between the person with whom they are walking and themselves because

it is said to be unlucky. Most of them will laugh at it, but still

they continue the practice in spite of the bother it may occasion

them. Occasionally there is some incident in their past life which

accounts for such obsessions, though the patients themselves are

occasionally not quite conscious of them. Dr. Boris Sidis tells the

story of a man who could not take a car with an odd number.

Psycho-analysis showed that he had once seen a child run down by an

odd-numbered car.

In such cases there has been a long series of suggestions that have

created a dominant state of mind. The only way to overcome this when

it becomes a serious annoyance is to undo the influence of the

suggestions by a continued series of counter-suggestions, and by such

discipline of mind as will prevent the former suggestion from exerting

itself. The cure can be accomplished in this way, though, as a rule,

the patient will need the help of someone else.

FORGOTTEN FRIGHTS AND DREADS

Dreads founded on terrifying or seriously disturbing incidents of the

past, the details of which at times have gone out of the patient's

mind, are not infrequent. It is probable that many of the unreasoning

dreads have some such foundation and occasionally, if patients'

memories are carefully searched, the whole story can be reconstructed.

All that is needed, as a rule, is to get the patients interested in

conjunction with the physician in tracing the origin of their

affliction and not infrequently an interesting story will turn up.

Hypnosis used to be considered of great value for such

reconstructions, but unfortunately patients then become so suggestible

that it is often difficult to decide how much of what is brought out

by questioning is due to the suggestive quality that cannot well be

kept out of questions, and how much to a true redintegration of

memory.

Frights in children may for a time be forgotten and yet the memory of

them may come back, or a dread connected with them develop, that will

make the patient profoundly miserable. One of my patients slipped and

fell on a smooth steel plate at the head of a coal breaker and was

only saved by good fortune from falling a long distance. This happened

when he was a {626} boy of ten. There were times when the memory of

this recurred so vividly as to set him all atremble and he could not

look down from a height without something of the feeling of goneness

coming over him that he felt at the time of the accident. The calling

of his attention to the fact that his memory probably exaggerated the

danger he had been in as a boy led him to go back and have another

look at the conditions in which he had fallen some thirty years

before. He found that they were not so dangerous as he thought and

that while he would have been scratched and his clothes would probably

have been soiled and torn, he would not have been seriously injured.

This has greatly diminished his dread of heights.

Various physical manifestations may be due to dreads which are often

supposed to be the result of some physical process in the nervous

system. Occasional fits of trembling, for instance, are, in sensitive

people, due to more or less forgotten memories of dangers or frights.

Occasionally even slight convulsive seizures may follow such recurrent

dreads. Not a few of the cases of so-called hystero-epilepsy in the

borderland between hysteria and epilepsy but always one or the other,

are due to such mental states rather than to any physical conditions.

Such incomplete memories are sometimes spoken of as subconscious. The

word subconscious has been so much abused, however, that I prefer not

to use it. The reminiscences have been obscured by an accumulation of

other facts but may with an effort of attention and concentration of

mind be recalled. Hypnosis, or the milder form of it spoken of as the

hypnoidal state, may enable the patient to recall them more vividly by

enabling him to concentrate his attention, but there are always risks

that suggestion will vitiate the old story in these cases. With care

all the details can usually be recalled and the patient is thus given

renewed confidence in himself and his own powers and does not learn to

lean on someone else in the process.

TREATMENT

The most important psychotherapeutic factor for the relief of the

discomfort due to dreads is the knowledge that there are so many and

such different varieties of them and that so many people suffer from

them. Many of those afflicted are inclined to think that their cases

are almost unique. To have them know that there are all forms and

phases of these curious aversions is to make them laugh a little at

their own because they laugh so readily at others, and it gives them

new courage for the attempt to conquer them. The aversion cannot be

entirely overcome, but it can be prevented from seriously influencing

sleep or appetite or occupation. This is after all the important

feature of the case from the standpoint of psychotherapy. Besides,

patients are encouraged not only to take up, but, above all, to

continue, the practice of that mental discipline and self-control

which will enable them to lessen their natural aversion, if not to

remove it entirely. I have many cases in which patients' aversions

have been entirely overcome. Curiously enough, there are rather often

relapses when the patients are run down in weight, or are in an

irritable condition from worry or emotional stress, and then something

of the former mental discipline has to be reinstituted to make them

once more free from disturbance.

{627}

I have sometimes found that the recommendation to patients suffering

from dreads to read Mary Wollstonecraft Shelley's "Frankenstein" has

proved an excellent therapeutic agent. This is particularly true when

the patients are women, for it is likely to bring them close to the

sad lives of the Shelleys. The circumstances in which the book was

written add to the appeal. "Frankenstein" itself is interesting, so

that the mood created by this combination of interests is excellently

therapeutic. It will be recalled that in "Frankenstein" the inventor

seeking to make a man does make an automaton that is able to move and

to talk, but that then haunts its inventor, demanding of him a soul.

It proves a plague to him, but he cannot escape from it. Fly where he

will his creation follows him and bothers the life out of him, killing

a friend, strangling his bride, and making existence intolerable. The

symbol is complete and to the point. The things that bother us in life

are to a great extent of our own invention. The dreads that make so

many people miserable are practically always without any groundwork in

reality, figments of our imagination without the soul of real life,

but capable, as was Frankenstein's monster, of making their creators

intensely miserable and with them, to an even greater degree, their

friends.

CHAPTER IV

HEREDITY

There are so many false and, indeed, from a scientific standpoint,

utterly groundless notions with regard to heredity which, as a result

of the popularization of science, have become widely diffused, that

notions about inheritance are a most copious source of dreads and

discouragement and even produce inhibition of resistive vitality

against disease on the part of many patients. At first it seemed to me

as though the subject should be treated in the chapter on Dreads. It

is so much more important than the other dreads, however, and there

are so many people with so many different notions as to the evil

influence of heredity that it seems advisable to devote a special

chapter to it in which to provide contrary suggestion. Many patients

are constantly suggesting to themselves that, because they are

suffering from certain symptoms due to real or supposed hereditary

conditions, there is little or no hope of their recovery or of any

effective relief. In the old days, when tuberculosis was considered to

be hereditary, it was almost hopeless to try to rouse patients into a

state of vital resistance to their disease because of this overhanging

dread. Such a prepossession of mind must be overcome.

In spite of all that has been said about the power for evil of

heredity, and in this as in every other phase of pseudo-science, the

reason why there are false popular notions is because the medical

profession first cherished them and then they spread popularly, we now

know that it means comparatively little in pathology. The false

notions will continue, however, to be popularly diffused probably for

another generation, at least, and will have to be combated. Their

force must be lessened, for they are a heavy incubus on the patient's

mind, imposing a burden on vitality that inhibits normal, vital

reaction. This can only be done by a frank and complete statement of

{628} our present knowledge of heredity, which is even yet not nearly

so definite as we would like to have it, but which contradicts

entirely most of the older impressions. In the matter of disease what

we know of heredity, instead of being a source of distress and

discouragement for patients, provides rather new incentives for

vigorous reaction, since nature helps rather than hampers the effort

of the individual to throw off disease from generation to generation.

False Impressions and Expression.--Probably the commonest expressions

that the physician hears from his patients, though we hear many

stereotyped phrases in our time when patients so freely discuss their

ills and their physicians' opinions among themselves, are such as: "My

father suffered from rheumatism, and I suppose I must expect to be

bothered by the same ailment." "My mother died of heart disease and I

think I have a weak heart; I suppose that we have weak hearts in the

family." "I have had three relatives die of cancer in the last three

generations, so I presume that cancer is in the family, or at least we

are much more liable to cancer than the generality of people." And,

finally, what used to be the commonest of all, but fortunately we have

changed that at least, though we sometimes hear it still:

"Tuberculosis runs in our family, my mother and an uncle died of it

and one of my brothers is suffering from it, so I suppose I must just

make up my mind that I, too, am sure to get it." Even the rarer

affections, like kidney disease, liver disease, various nervous

troubles, stomach and intestinal disturbances of many kinds,

flatulence, constipation or diarrhea, are all supposed to be

hereditary and patients explain their ill feelings by an appeal to the

supposed principle of heredity and its application to themselves and

their families.

In many chapters in this book the subject of heredity has been

considered with regard to specific affections. We have no evidence at

all, or the evidence is so trivial as to be quite negligible, that

anything acquired by the individual, be it for good or evil, is ever

transmitted to the next generation. That acquired characters are not

transmitted is now almost a universally accepted principle among

biologists. The more a biologist knows of recent biological research

and investigation the more will he be likely to consider this

principle of the non-transmission of acquirements as definitely

settled. According to this, then, no disease is ever transmitted to

the next generation. This is such a complete reversal of former

opinions, such an open contradiction of popular beliefs, that the

subject merits thorough discussion from this newer standpoint for

medical applications. We must not forget that popular medicine, even

when egregiously wrong, is founded on opinions held by the medical

profession aforetime and, indeed, on this subject of heredity many of

the medical profession still cling to the former opinion.

Tuberculosis, which used to furnish the most serious argument in this

matter, has now come to be the best possible explanation that we have

for the fallacy of the transmission of anything acquired. The disease

followed families so constantly that it seemed impossible to explain

it unless the principle of its heredity was conceded. Now that we know

its contagiousness, however, it is comparatively easy to explain its

occurrence in families. When we recall how carelessly people coughed

and even expectorated around the house, while children crept on the

floors and carried the germs of the disease to their mouths on their

hands, the wonder is, not that so many members of the family acquired

the disease seeing the manifold opportunities for contagion, but that

{629} any of them ever escaped. We know now that practically every

adult above the age of thirty either has or has had tuberculosis.

Careful autopsies show us remains of the disease even in the bodies of

those who, without any history of tuberculosis, die from other

diseases. One out of eight of the population dies of tuberculosis, but

the remaining seven are quite capable of resisting the disease and so

we find healed lesions at autopsies in this proportion of cases.

Family History Favorable.--It is certain, then, that tuberculosis is

not hereditary. On the contrary, as we have learned more about the

disease in recent years, it has been recognized by specialists that

patients who have a family history of tuberculosis are notably less

likely to succumb to the disease early than those who have no such

history. An acute case of tuberculosis with considerable loss of

weight has a very unfavorable prognosis unless there is a history of

the disease in the preceding generation, when at once the outlook

becomes more hopeful. This newer view is confirmed by what we have

learned from the ethnological pathology of the disease. Peoples

exposed to the disease for the first time rapidly succumb to it. This

is practically true for all the infectious diseases. Our American

Indians succumbed in large numbers not only to tuberculosis but also

to smallpox and even to measles when each was first introduced among

them. The same thing was true in the South Sea Islands. Where nations

have been exposed to the disease for some time they have acquired not

an immunity, but at least they possess a greater resistive vitality to

its ravages and while they still may be susceptible they are not so

subject to the fatal forms of the disease, and even if they acquire it

they live on for many years.

Many people may insist that this immunity or comparative immunity to

tuberculosis and increased resistive vitality against the disease is

transmitted and illustrates the principle of heredity. The reaction of

the system to the disease increases in each generation and this

increase is an acquired character which passes down with the family

strain. This immunity should be viewed from another standpoint,

however. Certain families possess a resistive vitality to the disease;

others lack it. The resistant families do not succumb to it, and

propagate themselves. The others gradually die out. What caused the

resistant families originally to possess this quality we do not know.

We have no trace of its being acquired. Like so many other characters

by which men differ from one another, we do not know the beginning of

it. Once it comes in as a family trait it is transmitted. In

successive generations we have no evidence that it is stronger, only

the danger is recognized from experience and better precautions are

taken; the consequence is that the original resistive vitality has a

better chance to make itself felt and so the family is preserved. This

is as true with regard to the conquest of the tendency to excess in

the taking of toxic substances, as alcohol and opium, as with regard

to disease. It is not the transmission of an acquired character, but

the descent of a family trait the origin of which we do not know.

Hereditary Syphilis.--Many physicians will protest that, at least, we

have ample evidence for the transmission of syphilis by heredity. We

have for many years talked of hereditary syphilis as if it were

absolutely sure that its transmission by inheritance took place. There

is no doubt, of course, that the disease is conveyed from mother to

child. If a mother is actively syphilitic, {630} then her child will

surely have syphilis when it is born. This, however, is no argument

for the hereditary transmission of syphilis. We know now that if a

mother is tuberculous, in an active stage of that disease, her child

will almost surely have the disease, but this is a question of

contagion not of inheritance. If a mother with active tuberculosis

nurses her child she is likely to give it tuberculosis. Usually the

idea is that the milk is not infective unless there are tuberculous

lesions in the breasts, and in cattle it is well known that such

lesions in the milk apparatus inevitably bring tubercle bacilli into

the milk. The demonstration of tubercle bacilli in the blood of

patients in the active stage of the disease is now much more frequent

than used to be the case and there seems no doubt that the bacillus

can pass through glandular structures into the secretions.

In the same way syphilitic nurses are likely to infect nurslings,

though, of course, in this case there are usually syphilitic sores on

the nipples which directly communicate the disease. It is almost

impossible for a syphilitic woman to nurse a child, if she is in an

active stage of the disease, without the production of such infective

sores on her nipples. When children are born with syphilis it means

only that in the process of feeding the child through the placental

tissues, a mother has infected her child quite as she might infect it

by nursing afterwards, in case she acquired syphilis after the birth.

Lesions corresponding to those on the nipple occur in placental

tissues and can be demonstrated without much difficulty. Congenital

syphilis, however, can always be traced to contagion and the being

born with the disease or having the manifestations of it occur shortly

after birth is no argument for heredity at all. It merely emphasizes

the danger of contagion.

_Mothers of Syphilitic Children_.--But there are some cases in which

the child who shows symptoms of syphilis after birth is born from a

mother who never had any manifestations of syphilis and therefore it

has been supposed that the infection must have come from the sperm,

and that in these cases, at least, there is a true heredity. It is

perfectly possible, however, that syphilitic infective material may

accompany the spermatozoon and so bring about the occurrence of

syphilis in the offspring. Even this would be infection, however, and

not heredity. Much more frequently it would seem that the disease in

the infant was contracted from the mother while suffering from a

latent form of syphilis, rather than from the paternal contributory

particle to its existence. The mother gives no sign of the disease,

but Colles' Law is that the mother of a syphilitic child may, without

danger to herself, be allowed to nurse her own infant even though she

herself has never had any symptoms. This can only mean that she is

thoroughly protected against the disease. We would not think for a

moment of allowing an ordinarily healthy women to nurse a syphilitic

child. Such immunity in the mother of the syphilitic child can only

come, so far as the present state of our knowledge goes, from her

having had the disease. It has been said that as the result of the

intimate communication with her child in utero she has acquired an

immunity by the passage across the placental membrane which separates

maternal and fetal blood of protective substances of various kinds due

to the reaction against the disease already beginning in the child. As

a matter of fact, however, there is no evidence of any such reactive

substances in the blood of the child which after birth proceeds to

have a series of acute lesions that are, as a rule, indicative {631}

of almost complete lack of resistive vitality. Maternal immunity is

evidently due to the occurrence of the disease in some form within the

maternal tissues which produces the usual protection against the

disease in a briefer time than usual. This certainly seems to be a

more satisfactory explanation than that of a transmission of an

immunity from the child to the mother which the child itself does not

possess. It is easier to understand the transmission of an infection

that does not manifest itself externally than of an immunity which

there has been no time to acquire. Both explanations leave a mystery,

but the mystery in the second case can be explained more in consonance

with what we know about syphilitic transmission and immunity than in

the other case. It does away with the transmission directly from the

father almost completely, of course, leaves practically no ground for

the heredity of syphilis, but it accords much better than older

explanations with biological principles.

_Late Lesions and Heredity_.--Many physicians will be likely to insist

that the late developments of syphilis in children, in which not only

three or five years afterwards, but even fifteen or twenty years after

birth, there are syphilitic manifestations, are beyond all doubt

examples of heredity. In the last twenty-five years, however, our

ideas with regard to the after-effects of syphilis have been entirely

modified by what we have learned of such diseases as locomotor ataxia,

paresis and the like. These are undoubtedly parasyphilitic diseases in

most cases, yet they not infrequently develop from ten to twenty years

after any manifestation of syphilis and they seem to occur, by

preference almost, in cases where the preliminary symptoms have been

very mild. In not a few cases, indeed, the symptoms of syphilis have

been so transient in these patients that the true significance of them

was missed until the later developments showed their real character.

Krafft-Ebing, at the International Medical Congress at Moscow in 1897,

detailed some experiments that he had made on paretics in Vienna. They

were patients in whom no history of syphilis could be found, yet they

were suffering from typical paresis. As they were in the ultimate

stage of the disease it did not seem unjustifiable to inoculate them

with syphilis, and in most cases it was found that they would not take

the disease, showing that they were probably protected by a previous

attack, though there was no history of it.

The development of the late symptoms of syphilis in the second

generation can then be much more satisfactorily explained on the basis

of a mild infection with very few primary symptoms, almost lacking in

secondary symptoms, yet followed by subsequent symptoms of great

severity consequent upon the deterioration of vitality produced by the

disease. As for the manifestations in the third generation, they are

not directly syphilitic, but are, whenever they occur, due to

conditions consequent upon the degeneration that had been effected in

the preceding generation and which directly weakened the offspring--on

the same principle that weak parents give birth to weak children, and

starving parents cannot have strong, healthy children--but not because

of any direct influence of the disease. It is worth while to discuss

this subject from this standpoint, since it disposes of the only

supposed evidence left for the hereditary transmission of disease that

we now have, though only a few years ago most diseases were supposed

to be hereditary.

Heredity in Cancer.--With regard to other diseases, the evidence for

any inheritance has been founded entirely on coincidence. All the

human race {632} dies and must die some way, and so in families a

certain number will die of the same disease. The argument for heredity

in cancer is extremely weak. When all the relatives of a person

afflicted with cancer as far out as the third generation are taken

into account, only about one in five of them are found to have

suffered from cancer. When we remember, however, that more than one in

thirty of all those who die, die of cancer and that the death-rate of

this disease is greater than that of typhoid fever, smallpox, scarlet

fever, measles, and all other infectious diseases put together, it is

easy to understand how large a role coincidence plays in any such set

of statistics, and how little the significance of the occurrence of

cancer in different members of the same family means, unless possibly

there is an occasional element of contagiousness which must not be

left out of the reckoning.

Heredity in Other Affections.--Other ailments present much less

possibility or probability of any element of heredity. For instance,

over-indulgence in meat or drink may readily bring about various

ailments of the gastro-intestinal tract. These are, of course,

definitely acquired conditions, some of them temporary and some

persistent, that will continue to give trouble so long as the patient

continues to produce irritation of them. They may, of course, lead to

permanent pathological conditions. To say that any of these are likely

to be inherited would be quite as absurd as to say that a corn could

be inherited, or the permanent deformities produced in toes by wearing

badly-fitting shoes could be transmitted to the next generation. We do

not think for a moment that because a man has lost a finger his

children are likely to be born without a finger, and still less if by

some accident or abuse he has been deprived of the use of an arm or

leg, that that is likely to be transmitted to the next generation. Yet

people calmly talk of the heredity of similarly produced conditions

within the body, and even physicians are not entirely free from the

superstition, for such it is, of the influence of heredity in

producing pathological conditions.

Habits of various kinds, physical and mental, are calmly accepted by

many people as influenced by or having their origin in heredity. Under

Alcoholism and Drug Addictions we have discussed this phase of the

subject, but a word or two more may make it clearer. A tendency to

form the same habits may be a family trait and descend from one

generation to another. That a specific habit should be the subject of

heredity or transmission is as much out of the question as that a

facility for doing anything should be transmitted. The son of an

acrobat must practice quite as faithfully as did his father in order

to secure his father's skill. He may inherit from his father that

particular constitution of body, that specific combination of muscle

and sinew and bone that enables him to become an acrobat by practice,

though with a different kind of body it would be impossible, but his

father's acquired facility influences in no way the son's ability. We

often hear of a man being the descendant of a series of generations

each of whom has gone to the university, as if that somehow assured

him a readier and better facility for education, but we know very well

that this is not true and that the boys straight from the soil are

often the best students and far ahead of the scions of long-time

academic families.

Inheritance of Defects.--Acquired characters are not transmitted,

though family traits are the subject of inheritance. Disease is not

hereditary, but {633} defect is. Crossed eyes occur very commonly in

families and are evidently a subject of transmission. Family noses are

often very peculiar and may be traced for many generations. The

Hapsburg lip has been noted in sixty per cent. of the Hapsburgs since

the family came into prominence in the thirteenth century. Features of

all kinds are inherited, as anyone who has ever spent some time in a

family portrait gallery where the ancestors were genuine and the

paintings reasonably true to life, knows very well. Certain features

of European families can be traced for many generations. The tendency

to have six toes or to have an extra finger runs in certain families.

So small a thing as a patch of white hair in a particular part of the

head may be the subject of hereditary transmission. Moles on a

particular part of the body are inherited. All these, however, are

characters with regard to the acquisition of which we know nothing,

but that have somehow found their way into the family strain and have

become subjects of transmission from generation to generation. They

provide no evidence, however, as to the transmission of acquired

characters.

Variation.--What is even more surprising in biology, however, is that

there is another marvelous force at work quite as incomprehensible in

its way, perhaps even more so, than that of heredity. This is

variation. All creatures have a tendency to vary from their parents. A

very small proportion of the offspring resemble parents so closely as

to be quite similar. The great majority of them, however, have

noteworthy, individual, distinctive qualities. Occasionally these

qualities may be traced to the less immediate ancestors and then we

talk about reversion. Occasionally there appears in a child some trait

or anomaly supposed to be remotely ancestral and it is spoken of as

atavism. Whenever there is a tendency of the offspring of exceptional

parents to regress toward the racial average, we talk of regression.

Tall parents often have tall children, some of them may, by a special

tendency of heredity, be taller even than themselves. Most of them

will be shorter, however, and tend to regress toward the racial

average.

Few people understand what a wonderful power among living things is

exerted by this very opposite of heredity--variation. All the

possibility of improvement not only in humanity but among all living

things is dependent on variation. It does not seem difficult to

understand how offspring resemble parents. They are of them, therefore

they are like them. When we analyze the problem of heredity, however,

and find that the connecting link between offspring and parents is

always only a single cell of less than one one-hundredth of an inch in

diameter, the mystery of heredity looms up in all its immensity. This

minute bit of protoplasm, so small that it requires a rather strong

power of the microscope to see it, somehow contains compressed within

itself all the qualities that characterize the parent and are to be

transmitted to the offspring. Among animals, the color of the eyes and

hairy covering, the form and height of the animal, its generic

characteristics, and its individual characters--all are contained

within this minute spherule. The white blaze on the horse's hind leg,

the black blotch on the puppy's face, the white lock on a human head,

are all carried over from one generation to another with all the other

qualities in this small package. That is the mystery of heredity.

To this must be added another mystery quite as great and even more

{634} difficult to understand--variation. This tendency to vary is the

basis for whatever evolution there is in the world. Some living things

vary in such a way as to be better suited to their environment than

they were before and then these outlive others because more favorably

situated, and natural selection brings about a maintenance of the

favorable variation. Instead, then, of patients being impressed with

the unfavorable influence of heredity, they should rather be made to

feel the weight of the idea that whatever evil tendencies the parent

has the child is more likely to have less of them than more, so that

variation tends to make the race better. We have had too much stress

laid on the heredity of unfortunate qualities and entirely too little

made of the variation tendency, which is constantly lifting the race

up. It is, of course, only what happens in everything else,

unfavorable are likely to have more weight than favorable suggestions,

and unless these latter are emphasized their influence becomes

swamped. This has happened with regard to variation. It is quite as

important a biological element as heredity and it makes for the

removal of unfortunate qualities, yet it has never become a popular

idea and is little appreciated even by physicians.

Patients who are worried about their heredity will, after a frank

discussion of our present knowledge of heredity and its co-ordinate

factor of variation, lose most of their dread of this specter of

supposed evil influence which so often proves the source of

discouragement and failure to react properly against pathological

conditions. There is probably no phase of modern biology in which the

so-called popularization of science has done more harm by providing an

abundant source ol unfortunate suggestions. Whatever influence

heredity has in relation to disease is favorable to the human race. It

is true that this is exerted by the elimination of the unfit, yet the

very consequence of this is that the children of parents who have

suffered from a particular disease are likely to have greater average

resistance to it than the generality of mankind, since their parents

passed the age up to reproductive activity without succumbing to it.

For cancer, tuberculosis and syphilis this teaching is of special

value and is probably more effective than any other single means could

be to prevent the ravages of the disease if it should occur, since it

keeps the patient from interfering with his own resistive vitality by

the discouraging conviction that there is no possible hope for him

because his parents also suffered from the disease.

CHAPTER V

PREMONITIONS

A state of mind that disturbs many people seriously, sometimes even

producing physical results, because of the burden of dread that hangs

over them, is that in which attention is paid to premonitions of evil.

There are two of these general conditions to be considered. In the one

there is a definite feeling that some special evil, occasionally very

particularly outlined in the mind, as a railroad accident, fire, or a

street accident of some kind, is to occur. In another mental condition

there is a generic premonition of evil, {635} as if the worst were

sure to happen and the patients must be constantly preparing for it.

Occasionally this takes on some such form as an assurance of early

breakdown in health, or of death at an untimely age, or of some

crippling infirmity. This represents, of course, only one form of lack

of control over the mind, but it is surprising how much physical

suffering it may occasion. Only those who have had much to do with

patients who suffer from this state of mind realize it. Sympathetic

knowledge of the conditions that bring it about and of the real

significance of premonitions will do more to help patients than

anything else.

Every now and then newspapers tell the story of someone who had an

impending sense of danger, perhaps of a particular form of accident or

misfortune, which he could not shake off and which finally came true.

Sometimes it is a fire that was anticipated, though without any reason

except the dread, and precautions that eventually proved life-saving

to the patient were taken, or at least friends were told of it so that

the person seemed actually to have had some warning beforehand of the

danger that was to come. Sometimes it is the story of a railroad

accident, which some particularly fortunate individual escaped,

because of a premonition that made him take another train or make a

happy change of cars. Nothing is said of the times when premonitions

failed, nor of the disappointments of such dreads. Most people laugh

at the stories, but a few individuals become seriously impressed with

the possibility of such warnings and then make themselves miserable by

having frequent premonitions.

Etiology.--As to the origin of these premonitions it is hard to say.

They occur more frequently on dark days than in bright weather and are

complained of much more in spring and fall than during the cold brisk

winter or during the summer time. A succession of very hot days,

however, brings a series of premonitions, especially with regard to

accidents by heat, that is not surprising since the newspapers have

many accounts of sunstrokes and there is every suggestion of the

possibility of danger of this kind. How large a role suggestion plays

in the matter can be realized from the fact that after some

particularly serious railroad accident many people have premonitions

that they may be hurt and occasionally they put themselves to

considerable inconvenience in choosing the car in which they will sit,

if the last serious preceding accident of which they have heard

happens to have brought death mainly in a particular car of a train.

It is always suggestible people who are likely to have premonitions.

The thought comes very simply at first, they dwell on it a little

unwillingly, then they find it impossible to banish it and finally it

may become a positive obsession. The soil and the seed for suggestion

are both needed to produce premonitions.

Royce suggests that many of the supposedly fulfilled premonitions are

really only pseudo-presentiments and represent an instantaneous and

irresistible hallucination of memory, which may give rise to the

impression that there has been a previous dream or other warning

presaging the facts, though no such phenomenon actually took place. In

other words, there would be an auto-suggestion consequent upon the

hearing of other fulfilled presentiments that sometime some such thing

must also occur to us, and then when a happening that reminds us of

something in the previous stories of {636} presentiments comes there

is the sudden responsive feeling "why, this is what I saw or must have

seen in my dream."

Podmore suggests an illusion of memory magnifying or rearranging the

details of a recent dream or premonitory impression, so as to make it

fit into the happenings. Dreams are so vague that unless they have

been written down we are not quite sure of them an hour after they

occurred and a day or two later we have only the merest hint of what

they were. If this can be made to have any connection with a casualty

of any kind that happens subsequently we may very readily recreate the

dream with its details concordant to the event. Certainly no reliance

can be placed on a story of a dream fulfilled unless the dream was

told before the happening.

Premonitions of Death.--Certain premonitions are common and are

frequently brought to the physician's notice. Among old people it is

not unusual to find that a premonition of death will hang over them

for days, seriously disturbing them and their friends, hampering often

a healthy reaction against disease and always lowering resistive

vitality. Many of them have heard stories which make them credit the

belief that such premonitions are likely to come true and therefore

they cannot shake them off. They have heard stories of people who have

become convinced that they were going to die at a particular time on a

particular day and whose conviction has been proven by the event. Like

all the other premonitions, whatever truth there may appear to be in

them, is due entirely to the fact that nearly everybody has

premonitions and occasionally, therefore, one of them must come true.

Those that are fulfilled create such an impression that they are

remembered, while those that fail are forgotten, until, though it is

not realized, it becomes true that fulfilled premonitions represent

exactly that much misunderstood principle that the exception proves

the rule. The rule is that premonitions fail. Exceptionally, however,

a premonition comes true. Instead of proving that premonitions mean

anything, the rarity of their fulfillment proves the rule of their

non-significance and demonstrates that they are merely coincidences.

Persuasion of Short Life.--Much mental suffering occurs in nervous

people as a consequence of a premonition or persuasion which comes to

them in middle life that they are destined not to live very long. This

is a commoner impression than is usually thought and comes to nearly

everyone at some time in life. Especially is it likely to come to

those who have suffered some severe illness and who know how weak they

were during their convalescence and, in spite of their thorough

recovery of strength, cannot quite persuade themselves but that an

ailment which made them so weak must surely have sapped their vitality

so as to make long life for them impossible. It is, of course, one of

the vague dreads that men always seem to be harboring, but there are

times that it becomes so prominent and so influential in the

production of depressive feelings that it is worth while to have the

means at hand to counteract it as far as possible. In the last ten

years I have made it a practice to ask, not only all my patients but

most of my acquaintances above 70 years of age whether they had ever

experienced such a premonition. I have particularly asked what were

their feelings with regard to the hope of long life for them when they

were in their forties and fifties. Without exception I have been told

by all those who had the education and leisure to {637} be at all

introspective, that they had felt sure that they would not have long

life.

Most of the men consulted took out life insurance in such a way as to

benefit their families after their death rather than themselves during

life. Indeed it seems not an unusual thing for men to have some

experience with an ailment between 40 and 55 which makes them realize

their mortality much more than the deaths of their friends around them

had succeeded in doing. Premonitions and impressions, then, of this

kind evidently mean nothing, so far as the prospect of long life is

concerned. Practically everyone has them, and since, of course, the

great majority of men do not live to die of old age, it would seem

that their premonition of comparatively short life was fulfilled.

Occasionally a man will be found at the age of fifty unwilling to take

up further work or develop his business because of the dread that has

come over him that he may not live long enough to make it worth the

while. Where there is serious kidney or heart trouble such an

abstention from business is commendable, but in many cases it leaves a

man without occupation or with insufficient occupation and he becomes

short-circuited on himself with more serious results from worry than

would have come from work.

Publication of Fulfilled Premonitions.--The publication of fulfilled

premonitions has always seemed to me to be an especially fertile

source of premonitions for other people. Every now and then someone

goes to bed in a hotel having communicated to friends the idea that he

fears there may be fire before morning. I do not suppose that one out

of ten people who sleep in a strange hotel fail to have some such

thought, they do not consider it a premonition, however, but only a

suggestion for the taking of proper precautions so as to know where

exits and fire escapes and other means of escape are situated, so that

in the excitement of the fire they may not have to do any thinking,

but may have already made up their minds what they shall do. This sort

of premonition, if we call it by that name, has a definite useful

purpose. Occasionally it seems marvelously provident. The other makes

its possessor toss sleepless a portion of the night, does no good and

much harm. If, however, the premonition has been communicated to

someone else and then a fire should occur, the reporting of the

fulfilled premonition comes to a lot of weak-minded people as a

confirmation of their worst fears. It is, of course, only a question

of coincidence in a succession of events by no means connected in any

causal relation, yet by the unthinking set down as showing the

possibility of such premonitions being supremely significant. If we

had all the stories of unfulfilled premonitions also published then

the true significance of the others would be clear.

An Unfulfilled Premonition.--There is an excellent story of a strong

but unfulfilled premonition told by Carl Schurz in his

"Recollections," which seems to me such a good antidote to the

influence of supposed premonitions, that every physician should know

its details for their psychotherapeutic value with patients prone to

be troubled in this way. The ease with which the depression consequent

upon the premonition was relieved as soon as another forcible

suggestion that the danger was past took possession of him, shows how

such states of mind can be altered with no more real reason for the

alteration than there was for the original depression.

{638}

On the morning of the battle of Chancellorsville General Schurz awoke

with the absolute persuasion that at last his time had come and he was

to be killed that day. He had never had such a premonition before. He

had heard of many cases in which such premonitions proved the

forerunner of death. He realized how ridiculous was the idea that he

should know anything about what the future held for him, even vaguely,

and he tried to shake it off. He found it impossible to do so. He

thought that after he took up the routine work of the day the force of

the premonition would be lost. It was not, but, on the contrary,

seemed to increase in power over him. Finally the idea became so

imperative that he sat down and wrote letters of farewell to his wife

and friends, telling them that he had been tempted to do so because of

this premonition of danger. When he went into battle--and it may be

recalled that the Eleventh Corps did some fighting at Chancellorsville

that day--he was sure that now the end was not far off. It did not

take away his courage, however, and though he was well in the zone of

danger, he issued his orders and kept his troops well in hand as we

know from the history of the battle.

Finally his aide-de-camp, riding toward the front of the line beside

him, was killed by a cannon ball. All in an instant the thought came

over him that this was the only danger that was likely to be near him

for the day. The burden of premonition lifted from him as if the fact

that a friend had been killed beside him gave him an assurance that he

himself was not to be taken. There was absolutely no reason for his

thinking so, but his feelings of solicitude with regard to himself and

his fate faded completely and at once. He continued in the thick of

the fight and of danger and was untouched. He himself called attention

to the fact that if his premonition had come true, as well it might in

the midst of the very serious danger which he faced, it would have

seemed a strong confirmation of the impression that premonitions have

a meaning other than that of coincidence. It was, however, a

magnificent example of a failed premonition quite as striking as any

of the stories that are told about premonitions that came true.

Role of Coincidence.--This must be remembered in many of our arguments

in medical and other scientific matters. Most diseases are

self-limited, therefore anything that is given as a remedy for them

just about the time that nature has succeeded in conquering the

virulence of the disease and bringing about the cure of the patient,

seems to be curative. Such cures, often remedies of supposed wonderful

potency, come and go in medicine by the hundred every ten years. Such

curious doctrines as that of the influence of maternal impressions in

producing deformities and defects in the unborn child are founded on

nothing better than these coincidences. They are often very startling,

but the rule by which they must be judged is the number of times in

which in spite of similar conditions no premonition takes place.

Literally thousands of people go to bed every night who are to be

waked by the danger of fire before morning and yet have no premonition

of it. Literally millions of people have gone to bed in recent years

without any premonition of earthquake, yet have been wakened before

morning with their houses tumbling around them. If a few people have

premonitions in these cases it is easy to understand that it is

coincidence and not anything else, for these are exceptions, and this

again is a case of the exception proving the rule.

{639}

Premonitions and Superstitions--Thirteen.--Occasionally premonitions

are connected with certain events that are themselves, even though

happening quite accidentally, supposed to be portentous. How many

people, for instance, feel quite uncomfortable if they sit down

thirteen at a table. The very fact of the gathering of thirteen is

supposed to be a spontaneous or automatic premonition that is a

forewarning of evil that has to come to some of them. Unfortunately,

this superstition continues to have a vogue and an influence over

people's minds because stories are told that are supposed to confirm

it. Needless to say, when these stories are true, they are merely

coincidences. Out of any baker's dozen of people who sit down to

dinner it is not surprising if one should die or be killed during the

year. Some of the stories, however, are merely sensational inventions

worked up to be given to the public because a number of people are

interested in this sort of thing. Probably one of the stories that has

gone the rounds most and that has served to confirm many people in

their uneasiness over the number 13 is that which is told as happening

to Matthew Arnold and some friends, supposedly the year the great

English litterateur died.

The story runs that just as Mr. Arnold and his friends were about to

sit down to the table it was discovered that there were thirteen

present. According to the old tradition in the matter it is the one

who first gets up from table under these circumstances that is likely

to be affected by the malignant influence. When the end of the dinner

had arrived, by previous arrangement Mr. Arnold and two very healthy

friends, brothers, arose simultaneously. According to the widely

diffused newspaper account of years afterward, Mr. Arnold himself died

within the year and one of the brothers was lost in the wreck of an

English passenger vessel off the coast of Australia in six months,

while the other brother committed suicide before the end of the year.

Careful investigation of the details has shown, however, that the

story was made out of whole cloth. Mr. Arnold himself, who was

suffering from heart trouble towards the end of his life, was not

likely to take part in any such arrangement because of the constant

danger, well-known to himself, of sudden death in his case. This might

happen at any time and might seem to confirm the superstition. The

dates of the story, moreover, are all wrong. Matthew Arnold's death

and the loss of the English passenger vessel in Australian waters,

referred to, do not occur within five years of each other. The story

has gone round the world. The correction will never reach so far. The

story is startling; the explanation commonplace. Many people will

continue to believe that here, at least, was one striking confirmation

of their superstition.

It is curious how the force of this "13" superstition has continued in

spite of education and enlightenment. Most passenger vessels now built

have no staterooms numbered thirteen. On certain streets in large

cities one finds the number 12-1/2 (until this year it was so on my

own) substituted for thirteen. Sometimes one finds "twelve a" or

something similar. In the large hotels, where they have immense

banquet halls with the tables numbered so that guests may be able to

find their places, I have often noted that there was no table number

thirteen. It is said that in some of the new skyscraper buildings

twenty stories and more in height there has been question of skipping

the thirteenth floor as a designation, because while most {640} people

would be quite undisturbed about it, some do not care to have an

office on the thirteenth floor, giving as an excuse that clients or

patrons do not care to come to the thirteenth floor. In automobile

races men are willing to risk their lives by going a hundred miles an

hour on roads never intended for such performances, but they refuse to

race behind the fell number thirteen. This, after all, can be readily

understood. The slightest thing that takes away a man's complete

confidence in himself may be serious in an automobile going as fast as

these. Men must not think of fear or they lose some of their power and

control over themselves and their machine. They must simply forget

everything except the task before them.

The belief in the thirteen superstition is one form of acceptance of

premonitions. That of itself should be enough to enable sensible

people to throw them off. Above all, it must be remembered that such

supposed malignant influence, when allowed to affect people, impairs

their presence of mind and may thus lead up to the accident or mishap

which it is supposed to foreshadow. This is the serious feature of

such premonitions and dreads. Unless people can be persuaded sensibly

to be rid of them they handicap themselves whenever they are placed in

danger that causes them to recur to the thought of the premonition or

dread. While there is absolutely nothing but coincidence in even the

supposed true stories, and many of the stories are merely sensational

inventions, yet people need to be persuaded to rid themselves of the

incubus that settles over them because of such ideas.

Premonitions and Telepathy.--There are many people who think that

premonitions have something to do with telepathy. Somehow the future

event is supposed to be able to send some message to specially

susceptible minds. Either that, of course, or there is some being in

another world whose interest is sufficient to convey some inkling of

the future. A little consideration of this subject, however, shows the

utter lack of rationality in any such opinion. Future events, having

as yet no existence, cannot in any way influence intelligence. Such

future events, when dependent on human free will, are quite impossible

of being foretold and, as has been said, no being except the Creator

Himself knows anything about them. It would be only from Him, then,

that information might be supposed to come and it would be hard to

think such information would be so vague and indefinite as to leave

room for doubt and, besides, often defeat its purpose of protection by

seriously disturbing patients and lessening their presence of mind.

There is no reasonable explanation by which a human being can be

supposed to obtain knowledge of a future event unless there is a

complete overturning of the ordinary laws of nature and then it would

be reasonably supposed that no doubt of the significance of the event

would be left.

Nearly all of us have premonitions that fail. Only a few especially

introspective people who are constantly afraid of what will happen to

them, and who are sure that the worst is always preparing for them,

have their premonitions come true more than once or twice in life. The

striking fulfillments of a few premonitions could be paralleled by an

endless number of just as striking failures, only that most people

dismiss the idea completely from their minds as too foolish to be

further talked about. It is quite the same with dreams. All the world

dreams and there would be a serious violation of the theory of

probabilities if some dreams did not come true. The great {641}

majority of mankind, especially after the age of thirty, is fearful

lest something ill is going to happen to them and their premonitions

are rather frequent. If some of these did not come true then the

mathematics of coincidences as based on the theory of probabilities

would prove false.

CHAPTER VI

PERIODICAL DEPRESSION

Fits of periodical depression, familiarly known as "the blues," occur

in the experience of practically everyone. In some people they are

only slight and passing. In others they last for hours and make the

individual quite miserable. In still others, without actually running

into melancholia, they produce serious discouragement and continuous

discomfort which persists even for days and makes life intolerable.

They come and go quite unaccountably. During their occurrence all

vitality is lowered, appetite lessened, aches and pains are

emphasized, sleep may be disturbed, exercise becomes distasteful, and

they usually present an interval when health is at a low ebb.

Ordinarily when described as "the blues" they have no definite

connection with any known physical cause. They are passing incidents

which seem to recur at irregular intervals. When connected with

physical ills they are thought of directly as symptoms of these ills.

All forms of disease may be associated with such fits of depression

and many physical symptoms seem to be due to the fact that during

these periods there is a distinct lowering of physical vitality so

that the nerve impulses which ordinarily enable functions to be

performed without interference are interrupted, or at least are

inhibited, to a noteworthy degree. While to a certain extent the

condition is a mental disease, it may be modified by the correction of

physical derangements, by stimulation and, above all, by suggestion

and a change in the point of view.

Serious Pathological Conditions.--Of course, such periodical fits of

depression are associated with various serious progressive ailments

and then are primarily physical, and are only secondarily psychic.

From the standpoint of psychotherapy it is important to remember that

certain serious organic lesions may show their first signs in the

patient's mental state. It is not unusual, for instance, for the

disposition of a patient suffering from kidney disease to change so

materially that the attention of friends is called to the change

before any physical symptom of the nephritis has been noted. Sometimes

for a year there will be a progressive clouding of what had previously

been a rather happy disposition. Decisions will be made more slowly

than before. The judgment will be impaired. There are some striking

examples of this in history, of which the unfortunate Athenian

general, Nicias, put to death for incapacity that was undoubtedly

pathological, is one. Pleasures will be taken half-heartedly; men who

have been bright and jovial will now become saturnine. Men who have

been the life of parties will try to hold the place they acquired

before, though all around them will perceive how difficult it is for

them to maintain the role they have set for themselves. Whenever there

is a notable change in disposition, it is well not to attribute it to

some passing mental condition and, above all, not to dismiss {642} it

as a peculiarity unamenable to treatment, but to look for the

underlying pathological basis of the new condition.

In this way physical disease will sometimes be discovered long before

it otherwise would be. This must be particularly noted when there have

been a series of worries. Occasionally it seems enough to many people

to ascribe a change of disposition to the troubles that have come over

a patient. If a business man fails or passes through a crisis in his

affairs in which failure is very near, or he has many business worries

over a prolonged period, these are sometimes thought to be quite

enough to explain a change of disposition. They are, but not to the

degree that is often noted, for, in excess, melancholic tendencies are

always pathological, that is, they have some basis in a serious mental

or physical change. If there is an insidious nephritis already at

work, its symptoms will be much exaggerated and its progress

accelerated by the worries and disquietude of such a time. If a wife

loses her husband, or an only son, or a favorite child, the occurrence

of a prolonged period of depression should lead to a careful

investigation of physical conditions and of the underlying mental

state in the hope of guarding against serious developments.

_Heart Disease_.--Periods of depression are also common in heart

disease and are often the first symptom of the beginning of a break in

compensation. This effect is not so simple and direct, however, as in

the case of the kidneys. Probably the first physical symptom of a

break in compensation, where there is real valvular heart disease, is

a decrease in the amount of urine. This points to an insufficient

elimination of the products of metabolism and to the retention in the

circulation of toxic substances. The reason for this is the lessened

circulation through the kidneys because of the diseased heart. There

is also a lessened circulation through the brain. This impairs the

function of the brain and quite naturally leads to mental depression,

slowness of decision, and unwillingness to occupy one's self with many

things. Besides, because of the lessened function of the kidney the

circulating blood not only does not nourish so well but it tends still

further to depress the brain cells by the toxic substances that are in

it. Depression in such cases is rather to be expected and at the

beginning is not continuous but comes in ever longer periods with

shortening intervals as the disturbance of the circulation progresses.

At first, like other diminutions of function, it is conservative in

order to spare the heart work.

_Respiratory Affections_.--Very curiously an affection of the lungs

has exactly the opposite effect and is likely to create in the patient

an artificial sense of well-being. _Spes phthisica_, the

characteristic hope of consumptive patients, is well known, and has

been described by many a careful observer from Hippocrates and Galen

to our own time. A lessened amount of oxygen in the blood produces a

certain sleepiness, but this seems to be preceded by a period of

slight excitation. The most familiar example of this occurs at the

beginning of the inhalation of laughing gas. Practically the only

direct physical effect of the inhalation of nitrous-dioxide is to shut

off our oxygen and it is a slight period of deoxygenation that

produces the anesthesia by this agent. Whether we have not in this the

explanation of the feeling of the consumptive, so that often on the

day before his death he plans a number of things that he is going to

do next year, may require more careful {643} investigation, but the

suggestion may serve to show how much disposition, both lively and

serious, depends on physical factors as well as on the natural state

of mind.

MENTAL STATES OF DISAPPOINTMENT

Quite apart from these serious ailments, however, there are passing

phases of depression that come to nearly everyone after adult life is

reached that are likely to be somewhat more frequent as years go on,

but that are not entirely unknown even in early years. They are more

likely to come to those who feel that life has been somewhat of a

failure and that they have accomplished very little in spite of all

that they have tried to do. Not infrequently they come, however, to

those who in the estimation of other people have made a magnificent

success of life. The rich man, after he has made his fortune, unless

he continues to engross himself with some time-taking and

interest-claiming work, may be the subject of repeated attacks of

mental depression. Social leaders among women who begin to feel

something of the emptiness of social striving, after they have made

what is called a success in society and at the time when they are the

envy of many on the social ladder below them, are particularly likely

to be subject to attacks of "the blues." The only men and women who

are free from them to a great extent, and even they not absolutely,

are those who are busily engaged with some occupation not entirely

selfish in which they can see that what they are doing is

accomplishing something for the people around them.

Very often an attack of depression is ushered in by some small

disappointment. As a rule, however, this is not the causative factor

but is only an occasion which makes manifest the depressed state that

has existed for some time and that now declares itself openly. In the

same way only a slight occasion is necessary apparently to dispel

clouds that hang over a person in the milder attacks of depression,

because, for some time before, relief has been preparing itself and a

livelier phase of existence has been gradually coming on. Relief can

be promised with absolute assurance, but freedom from relapse cannot

be assured and the only true source of consolation that is helpful is

the frank recognition of the fact that these are successive phases of

existence quite as likely to be periodic as certain physical facts in

life. Depression is likely to be a little more manifest in the morning

than at other times, partly because the interests of the day have not

yet come to occupy the mind, but mainly because the physical life as

indicated by the pulse and the temperature is lower during the morning

hours than in the afternoon and evening. Just as soon as people

realize the physical nature of certain dispositional changes they give

much less depressive significance to them.

Occupation of Mind.--The most important feature of the treatment of

depression of mind is to secure somehow such occupation as will catch

the attention and arouse the interest. This is not always an easy

matter. How effective it is, however, can be best judged from what one

notes of the effect of such things as physical pain or great

solicitude for someone else besides themselves. I have known a mother,

whose fits of "the blues" were getting deeper and the intervals

growing shorter to be roused from her condition when all means had

failed by the elopement of a daughter who had been partly pushed into

leaving because things had become so unpleasant around home {644}

during her mother's depression, and any change seemed welcome. On the

other hand, I had a doctor friend who felt quite alarmed about his

growing depression and who even had some fears lest, if it continued

to deepen, he might commit suicide. He was completely lifted out of

his increasing depression by the occurrence of pneumonia in his boy of

sixteen. The pneumonia did not end by crisis but by lysis and for

weeks he had very little sleep. He confessed that the intense

preoccupation of mind had completely driven away his blues and had

even done much to relieve him of various digestive symptoms to which

he had previously attributed his depression.

Again and again I have known men who, in the midst of prosperity,

found life dull and rather hard to bear, and who just as soon as a

crisis in their affairs compelled them to pay attention to other

things than themselves and the state of their feelings, grew better

mentally and physically. It seems almost a contradiction in terms to

say that it is the man of little occupation, as a rule, or at least of

occupations that are not insistent, who is likely to be troubled with

insomnia, while the very busy man, especially the man busy not about

one or two narrow interests, but about a number, is seldom so

bothered. Nothing contributes more to the depression of mind than loss

of sleep or supposed loss of sleep. Even women who, while living in

ease and comfort, had much to complain of as regards depression, often

lose entirely their tendencies to "the blues" or have fits of them at

much longer intervals, when necessity compels them either to earn

their own living or, at least, to occupy themselves much more with

absolutely necessary duties.

_Provision of Occupation_.--It is a hard matter to create such

occupation of mind as will be satisfactory. Patients have to be tried

by various suggestions. The tendency to periodic fits of depression

deep enough to be called to the physician's attention is much more

noticeable in recent years than it used to be, and seems to me at

least to bear a corresponding ratio to the decrease of home life. Home

duties usually mean joys and of late there has been a neglect of the

joys of life while seeking its pleasures. Certain phases of city life

are responsible for much dissatisfaction with existence and depression

of spirits. Most of the women who live in apartment hotels have

practically no serious occupation of mind. They need not get up if

they do not feel quite right or quite rested--and who after the age of

forty ever does feel quite all right in the morning hours unless sleep

has been in the open air? Nothing is so likely to start a day of

depression than failure to get up promptly, lounging around with forty

winks here and there, reading in bed, and the like. If breakfast is

taken in bed, then some reading indulged in, and then some sleeping,

and only an hour or two of dawdling around comes before lunch, that

meal is not properly enjoyed and the afternoon is started badly;

unless there is some special diversion of mind depression is almost

sure to get the upper hand.

_Place of Children in Psychotherapy_.--Where there are children the

interests are much more urgent and there is little time for such

preoccupation with self as gives one "that tired feeling." We are very

interesting to ourselves, but just as soon as we have no other subject

to occupy us than ourselves we soon grow very tired of the subject.

Children are the best interest that one can think of, for women

particularly. When they have none of their own an interest in orphan

asylums, in day nurseries, in various children's {645} institutions,

and, above all, in the adoption of a child, will do more than anything

else to relieve the tendency to blues. Of late years the adoption of

children has been much less frequent than used to be the case in

childless families, and doctors see the result in mental depression.

Children are a great care, but they are a great blessing to women, and

while the present trend of social life eliminates them as far as

possible, this elimination, beginning with their relegation to nurses

when they are infants, to nursemaids as they grow a little older, and

then to the kindergarten up to six years of age, far from adding to

comfort rather increases the discomfort of many mothers. Nature takes

her revenge. The reason why the mothers of past generations could

stand the suffering that they must have borne with patience before

gynecology developed to relieve them, was that they had their children

around them, and their minds and their hearts and their hands were so

full that they had no time to think of themselves, to brood over their

ills, and consequently these troubled them much less than would

otherwise have been the case.

Delicate mothers really interested in their children undoubtedly

suffer very little compared to delicate women who are alone in life,

and what is thus true of the mother is true also of those who have the

care of children. It is not alone a satisfaction of the maternal

instinct, but it is an occupation of mind and heart with cares for

little ones. Other people's children serve just as good a therapeutic

purpose, if only their necessities are imposed on the attendant. The

reason why women in religious orders have such happy peaceful lives

and are happier in spite of a routine of life that would seem to be

fatal to happiness, is that their minds are filled with the interests

of others, every moment of their time is occupied, and, above all,

they have to care for children, the ailing, the poor, sometimes the

vicious, who make many demands on them, many calls on their sympathies

and keep them from thinking about themselves.

_Occupation with Living Things_.--After occupation with human beings

the most important therapeutic factor against periods of depression is

occupation with living things of various kinds. Horseback riding is an

excellent remedy for the blues and the outside of a horse in the old

axiom is literally very good for the inside of man or woman. There is

a sympathy between man and animal that in itself means much, but the

most important element is the absolute impossibility of preoccupation

with oneself and one's little troubles and worries while one is trying

to manage a somewhat restive animal. If the horse, however, is old and

very quiet--so that one can throw the reins on his neck and allow him

to jog on for himself, then horseback riding may mean very little.

Where the care of the animal is entirely taken off the rider's

shoulders by a groom who brings him to a particular place and takes

him afterwards, then, also, much of the benefit of horseback riding is

lost. Care for other animals as well as the horse is of great service

and especially is this true if the owners feel the duty of exercising

the animals. Many a downhearted person finds that to take an animal

out for a stroll will do much to lift the clouds of depression.

With the disappearance of children from the families of the

better-to-do classes, pet dogs have grown in favor mainly because of

this influence. They awaken sympathies and so keep people from

thinking too much about themselves, For many an elderly woman who is

alone in the world her dogs or her {646} cats or a combination of both

are the best possible remedies for depression. At times it will be

found necessary to prescribe them. There is no better way to get an

elderly person to go out at certain times than to have them feel that

their pets need exercise.

_Garden Cures_.--After animals the next best thing is the care of a

garden. Here once more human sympathies with living things are aroused

and it is easier to cultivate a forgetfulness of self while

cultivating flowers and plants. Growing plants do not arouse the

interest that growing animals do, but still they have advantages over

things that do not vary, and their growth is a subject of day-to-day

interest and the effect on them of vicissitudes of the weather arouses

feelings of solicitude which help to dissipate the little insistent

cares for self that depress. The care of a garden is the very best

thing for the "pottering old." Younger people are too impatient to get

much benefit out of a garden, but after middle life many an hour of

depression will be saved in the care of plants.

_Intellectual Occupations_.--It might be expected that intellectual

occupations would serve to brush away "the blues" for educated people.

They are perfectly capable of doing so, but they must be of the kind

that grip attention and must be undertaken seriously, usually with an

appeal quite apart from mere cultural interests. Hobbies of various

kinds, especially the making of collections, even of such trivial

things as stamps, will often serve the purpose of distraction from

gloomier thoughts. Unfortunately, a hobby cannot be created all at

once and usually does not take a strong enough hold to be available

for mental therapeutic purposes unless it was acquired when the person

was comparatively young and has been indulged in for many years.

Reading and study utterly fail unless there is some end in view apart

from the reading and study itself. The reading of novels and

newspapers is particularly likely to be a failure. The gloomier

thoughts obtrude themselves in the midst of the reading and very often

what is read proves suggestive of melancholic thoughts and all the

time the mind and the person are not occupied seriously enough to push

away the state of depression which exists. The mind must be

interested, not merely occupied superficially, or the depression will

continue.

It might be thought that the reading of books that concerned human

suffering might have a similar appeal to that to be obtained from real

touch with human suffering. This is true to a certain extent when the

books concern real and not fictitious suffering. For this reason the

trials and hardships of travelers at the North and South poles or in

the heart of tropical Africa--Nansen and Peary and Stanley and

Livingston--have all been excellent therapeutic agents. The stories of

mountain climbers have something of the same effect. Adventures in

Alaska and in the Far North, especially, come in the same category.

Novels, however, even though they use the same material, soon fail to

have a corresponding effect. Even when the novel does touch the

emotions deeply it is prone to make the reader forget the suffering

around him and does not prove a good diversion from his own feelings.

In his play, "The Night Asylum," Maxim Gorky, the Russian novelist and

playwright, brings this out very well. One of his characters, a young

scrubwoman, wears her fingers to the bone during the day for a

miserable pittance and sleeps in a squalid night lodging house, yet

this comparatively young creature, {647} crouched near the only light

in the room, sheds tears over the imaginary sufferings of the

fictitious people that she reads about, while the real human suffering

around her fails entirely to arouse her sympathy or affect her

emotions, except to anger her if lodgers come in between her and the

light or when the complaints made by some of those who are suffering

around her annoy and distract her from her reading.

In younger folks, study, provided there is some definite object to be

attained by it, is often helpful. Correspondence schools are of value

by setting a definite purpose before the mind. In a number of cases I

have found that the suggestion to make translations from a foreign

language when the patient knew that language even tolerably well,

afforded excellent relief from that over-occupation with self which

was the real cause of the depression. There are many people who know

enough French to be able to translate fairly well and there are many

articles and books a translation of which may at least be submitted to

editors and often proves available for publication. To have some such

end as this in view is of itself one of the best means that can be

provided for these people to relieve their tendency to depression.

Occasionally even the suggestion to write stories may prove helpful.

One hesitates to add to the number of story-writers in this country,

but it may be remembered as a last resort. I know at least two people

saved from themselves by even a very moderate success as writers of

short stories.

_Consolation from History_.--Perhaps the most serious thing about

depression is the feeling of those afflicted by it that they are

singular in this respect and that other people who seem gay never have

depressed states. There is probably no one who has not periods of

depression. They may not be very deep and "the blues" may be only of

a light tinge, but they are there. The higher the intelligence, as a

rule, the more tendency there is to feelings of discouragement and

depression at intervals when one is not occupied. Those who have the

artistic temperament and the striving after the expression of the

beautiful as they see it, whether it be in art or in letters or in the

betterment of humanity, usually suffer more than others because they

realize poignantly their failure to reach their ideals. This is well

illustrated by the experience of writers and artists. As a rule, most

men and women look forward to the completion of any intellectual work

with confidence that after it is finished they will have a period of

rest and peace. Commonly just the opposite is true. The completion of

any work leaves one with a sense of dissatisfaction with what has been

done, for no man of real intelligence ever thinks that he has so

realized his ideals as to be satisfied, and only the foolishly

conceited fail to feel the many defects that there are in their work.

There is abundance of evidence, however, that it is not alone artists

and writers who thus feel the hollowness of life and the tears there

are in things. Many of the men who have accomplished great things in

science and in politics have been prone to times of depression.

Virchow told me there were moments when life seemed very empty to him

and that he had to shake off feelings of depression in order to be

able to go on with his work. At one time in the sixth decade of his

life he suffered considerably from what we would now call neurasthenic

symptoms, gave up his medical work and spent a long time with

Schliemann in the Troad. His presence was valuable to the excavator in

his work at Troy, and the change gave Virchow back his health.

{648}

Even more striking is what we know of Von Moltke, who seemed in many

ways to have an ideally happy life. He had had the fulfillment of all

his desires or, at least, the fruition of all his hopes, and the

successful accomplishment of what he worked for beyond what is usually

given to man. He had come to be one of the most highly respected men

of Europe and was the subject of veneration on the part of his own

German people and of intimate affection from his sovereign, who loaded

him with honors. He was a man who had probably no enemies and many,

many firm friends. It was said that "he could keep silence in eleven

languages" and so he had avoided most of the pitfalls of life. His

domestic life was ideally happy and his letters to his wife for over

fifty years read like those of a lover, before all his great battles

his last thought and written word was for her, after them his first

thought and message was for her. In spite of this, towards the end of

his life, when the question of reincarnation was a subject of

discussion in Berlin and it was brought particularly to his attention,

he declared that looking back on his career, in spite of all its good

fortune, there seemed to him to be so many chances in life, so many

possible sources of failure, so many springs of discouragement, that

he would prefer not to have to live again. Surely, if anyone, he might

be expected to be ready to take the chances of re-incarnation after

such happy experiences of life, yet he was not. Such an expression

could only come from a man who had looked depression often in the

face, who had shaken off the blue devils and who knew that even the

joy of success was followed by the gloom of uncertainty as to the

future and solicitude as to the real significance of accomplishment.

_Literature and Life_.--We have many examples of this tendency to

depression that come to the literary man in the lives and letters of

distinguished writers that have been published so frequently in recent

years. Perhaps one of the most striking is to be found in the life of

Robert Bulwer Lytton, the second Lord Lytton, so well known as a

diplomatist in European circles and throughout the English-speaking

world as a poet, under the pen name of "Owen Meredith." [Footnote

51] It might be thought that Lytton would be one of the men safely

harbored from storms of depression and discouragement, for his life

seemed ideally situated to enable him to get the best out of himself

without worry or dissipation of energy in occupation with mere

personal matters. His father had made a distinguished success as a

literary man and a politician, had been raised to the peerage and the

son began life with every possible advantage. He made a distinguished

success in literature so that he even converted his father to praise

him and as a diplomatist he occupied nearly every important post in

English diplomacy and had hosts of friends all over the world.

[Footnote 51: Personal and Literary Letters of Lord Lytton,

edited by Lady Betty Balfour. New York, 1909.]

It is all the more surprising, then, to have many passages in his

letters refer to periodic attacks of depression. He says, for

instance, "My physical temperament has a great tendency to beget blue

devils and when those imps lay siege to my soul they recall those

words of Schopenhauer's and say to me 'thou art the man.'" Perhaps the

price that the artistic temperament pays for the satisfaction that it

gets out of life in other directions is this occasional tendency {649}

to depression because achievement does not equal aspiration. Certainly

the price often seems excessive to those who have to pay it. In the

same letter to his daughter, Lytton continues:

When my blue devils are cast out, and I recover sanity of spirits,

then I say to myself just what you say to me in your letter--that

the main thing is not to do but to be; that the work of a man is

rather in what he is than in what he does; that one may be a very

fine poet yet a very poor creature; that my life has at least been a

very full one, rich in varied experiences, touching the world at

many points; that had I devoted it exclusively to the cultivation of

one gift, though that the best, I might have become a poet as great

at least as any of my contemporaries, but that this is by no means

certain to me for my natural inclination to, and unfitness for, all

the practical side of life are so great that I might just as likely

have lapsed into a mere dreamer; that the discipline of active life

and forced contact with the world has been specially good for me,

perhaps providential, and that what I have gained from it as a man

may be more than compensation for whatever I may have lost by it as

an artist.

It is surprising to think of a man of this kind becoming so depressed

by the death of a son that all the world and the meaning of life took

on a somber hue for him. In 1871 Lord Lytton lost a young boy by a

very painful illness which had probably been more painful for

sympathetic onlookers than for the patient himself. The incident

proved sufficient, however, to make the father think that there could

not be a beneficent Providence ruling over the world. He felt sure

that somehow God's power must be shortened, if such suffering, for

which he could see no reason, had to be permitted. He was much

depressed after this and never was quite the same in his outlook upon

the world and the significance of life. It was easy to understand that

this was due rather to his character than his intellect, but it

illustrates forcibly how much a deeply intelligent man may be affected

by something that seems after all, only the course of nature.

It is sometimes surprising to find from the life stories of men how

often those who would be thought least likely to suffer from

periodical depression were victims of it. Few Americans in our time

have apparently had a more satisfying career than that of James

Russell Lowell, a successful author as a young man, then a successful

editor, a teacher whom his students appreciated very much, and in

later life the subject of many honors and such honors as provided him

with splendid opportunities for the exhibition of his special genius.

He would seem to be the last who should suffer from depression. His

post as Minister to Spain gave him an opportunity which he took

magnificently to study the great Spanish authors and to store up

material for writing about them. As Minister to England few men were

so popular. He was constantly in demand for occasional addresses and

his special style enabled him to respond to these demands with

brilliant success. Here in America no great occasion was complete

without Lowell. In spite of all this that would surely seem ample to

satisfy the aspirations of any man, Lowell was often depressed and

sometimes even talked about the possibility of suicide. Life seemed at

times very empty to him. The story of the lives of such men, if made

familiar to patients, proves a source of consolation, for it makes

them realize that they are not alone in their experiences, that

depression at some times is the lot of man, and that very few people

are without the sphere of its influence.

{650}

Depression an Incident, not a State.--This suggestion may, in the case

of some of those inclined to longer periods of depression, lead to

indulgence in the luxury of being depressed and so putting off the

doing of things. It must be pointed out, however, that just inasmuch

as depression has this effect it is pathological. It seems to be

natural to man to suffer from periods of discouragement and depression

which keep him from devoting himself too persistently to lines of work

that may be insignificant and make him take cognizance of the real

values of what he is doing. Depression, however, that continues after

the recognition of this takes place is morbid and must be actively

resisted. Just inasmuch as depression precedes and prepares patients

for a reaction, it is an incident in practically all lives. Indulged

in as a luxury, it is abnormal.

Suggestive Treatment--The most important thing for patients who suffer

from periodic depression is to make them understand that this state of

mind, far from being personal to them or very rare, or even uncommon,

is an extremely frequent experience of men and women. There are

certain men and a few women eminently occupied with the external life,

busy with many things, though often they are trivial enough, and even

when they are important, significant only in a financial or a social

way, but meaning nothing for the great realities of life, who seem

during their younger active years to escape the periodical attacks of

depression that come to most people and come almost without exception

to people who think seriously. Some of the best thoughts and

inspirations of men come to them as the result of the serious mood

that follows an attack of depression. A butterfly existence lacks

these sources of inspiration. Far from being objectionable then,

attacks of depression, if not allowed to proceed too far, and if kept

from paralyzing activity, prove to be intervals when life values are

seriously weighed and when a proper estimation of such values is come

to. Men are prone without such interruptions to get too interested in

trivial concerns that seem to them important because they are occupied

with them to the exclusion of other ideas, but that prove to be of no

real import when seen on the background of a certain hollowness that

there is in human life, if lived merely for its own sake.

The occurrence of periodical depression is a part of the mystery of

life and it affords us a better opportunity to get a little closer to

the heart of the mystery than almost anything else. It is out of such

periods that men have risen "on stepping-stones of their dead selves

to higher things" and have even risen to the highest that there is in

life. Geniuses have nearly always had deep periods of depression, but

in the midst of them have read new meanings into life and have read

the lessons of humanity in their own souls better than at any other

time. Depression throws a man back on himself and makes him think

deeper than in his mind--in what has been called his heart. "The

fascination of trifles obscures the good things in life" are words of

old-time wisdom and men are weaned from this by fits of depression

that are really moods of precious dissatisfaction with their work

inasmuch as it falls short of the best accomplishment. Without

periodic depression, apparently, a man never gets as close to the

heart of life as he otherwise would. Far from being an unwelcome

visitant, it should be rather welcome as a stimulus to the possibility

of further study of self and the realities of life.

{651}

CHAPTER VII

INSOMNIA

To the minds of many people insomnia is one of the most serious ills

to which human nature is heir. Most of this quite false impression is

due to the sensational cultivation of dreads with regard to insomnia

by newspapers and in general conversation. If we were to credit such

impressions, there is a certain number of unfortunates who, for some

unknown reason, find it impossible to sleep and who, night after

night, drag out the weary hours wooing sleep that does not come, until

when daylight dawns they are in despair, distracted by lack of rest.

This is presumed to occur night after night, until finally the

worn-out mind succumbs to the intolerable anguish of being kept

constantly on the rack of wakefulness and the patient becomes insane

or saves himself from that by suicide. No wonder, then, that many a

one of these patients takes to the use of habit-forming drugs to

produce sleep. These, though effective only to a small degree, soothe

him for the time, but finally render him such a wreck that there is

not even will power enough for him to take his own life and end his

intolerable suffering.

Such gruesome pictures of the awful effects of insomnia run rife and

produce dreads in the community until just as soon as the ordinary

nervous supersensitive person loses an hour or two of sleep two or

three nights in a month, he begins to conjure up the specter of

insomnia with its awful terrors and still more awful possibilities,

and begins to bewail the fate that has chosen him as an unfortunate

victim. This exaggerated dread that slight losses of sleep, for which

there are often excellent reasons, will develop into an incurable

condition of persistent wakefulness has more to do than any other

single factor with the production of the state called insomnia which

is, however, never half as bad as it is pictured.

Absolute Sleeplessness.--A certain number of patients insist that they

sleep very little at night and some tell their friends and even their

physicians quite ingenuously that they sleep none at all, and that

this has been the case with them for a prolonged period. Practically

every physician has heard such stories, and at the beginning of his

professional career has usually wondered how the patients continued to

live and enjoy reasonably good health in spite of the lack of

absolutely necessary brain cell rest. After the physician has the

opportunity to investigate some of these stories he understands them

better. Patients in hospital, who insist that they are wakeful all the

night, prove usually when faithfully watched by a nurse to be wakeful

for an hour or two at the beginning of the night and then to sleep for

hours at a time, and all of them sleep for intervals more or less

prolonged, though they may wake a number of times during the night and

may think that they have not been asleep because they hear the clock

regularly or some other recurring noise. It is improbable that

patients ever spend several nights in succession without sleep and

their story is only an index of the persuasion that they are under

that they do not sleep, though they are having so many thoroughly

restful intervals that their brain cells suffer but little from {652}

the need of sleep. _Indeed, the principle source of nervous wear and

tear for them consists in their persuasion that they do not sleep and

the resultant impelling suggestion that a breakdown must before long

be inevitable._

Individual Differences.--There are too many safeguards in nature's

ordinary dealings with human beings for us to think that people can

pass many nights absolutely without rest. Brain cells may apparently

be very wakeful, they may be quite ready to take up at once and

seemingly without a break trains of thought interrupted sometime

before, yet somehow they succeed in obtaining their needed rest. In

this matter, as is well known, though it needs to be emphasized again

for the benefit of nervous individuals, different people have very

different needs. Some require many continuous hours of sleep or they

soon begin to have symptoms of nervous exhaustion. Others live on only

with snatches of sleep at intervals, or with interrupted sleep during

a limited portion of the twenty-four hours, yet enjoy good health for

many years. A few seem to be able to live in health and strength with

but a few hours of sleep. It may possibly be thought that those who

are living their lives with a small amount of sleep are drawing drafts

on their future vital powers, and that what they make up in intensity

of activity now by shortening sleep, they will discount by shortness

of life. How utterly untrue this impression is, however, will be best

understood from the fact that many of the men who have worked hardest

and slept the least number of hours in the day, have lived to be

eighty or even ninety years of age and some of them have even been

centenarians.

Cell Rest.--The great differences in the brain cells of different

individuals in what concerns sleep becomes more readily intelligible

when we recall the extreme differences as regards the need of rest of

the various cells in the same individual. While the brain cells seem

to require for healthy life, as a rule, nearly one-third of the time,

and a man who is constantly taking much less than eight hours of sleep

is probably hindering rather than helping his productiveness,

especially if his work is intellectual, there are cells in the body

that need no such amount of rest as this. Peristaltic movements occur

in the digestive tract almost constantly, with only short intervals,

and these cells get their rest between their movements. Pulmonary

cells and tissues must do the same thing, and are able to do it

without any special strain being put on them. The extreme example of

the lack of need for prolonged rest is found in the heart. Two-fifths

of every second the cells of this organ have a rest during the

diastole, but during the remaining three-fifths of every second for

all of life they must not only be ready to work but actually engaged

in it or serious symptoms ensue. The cells in the brain that subtend

cardiac and respiratory activity must be even more able to do without

rest, since their action is ceaseless during life. By analogy with

these it is not difficult to understand that the brain cells which are

involved in consciousness should on occasion be able to stand

prolonged periods of activity, or at least of wakefulness. Persistent

wakefulness does not appeal to us as so surely destructive after this

consideration.

Solicitude Over Sleep.--For those who are much disturbed by the loss

of even slight amounts of sleep and who are prone to complain rather

bitterly if they are not able to get more than five or six hours a

night, I find it a useful preliminary to any more formal treatment of

their so-called insomnia {653} to recall the examples of some of the

great workers who succeeded in accomplishing marvelously good work

though they took much less sleep than the amount the patient secures,

yet seems to think inadequate. In spite of such lack of sleep, these

workers lived to advanced old age. There are many well-authenticated

illustrations of this in recent times. Perhaps the most striking

testimony to the power of the human mind to continue work without

requiring the refreshment of sleep, except for very short periods, is

that of Humboldt, the great traveller, scientist writer and diplomat.

Max Mueller, in his autobiography tells the story. It was when he

himself was about forty. Humboldt said to him: "Ah! Max, when I was

your age I had time to accomplish something, now I find that I must

take at least five hours of sleep every night." At the moment

Humboldt was over eighty. Mueller said to him: "But, Your Excellency,

how much sleep, then, did you take when you were my age?" "Oh!" he

said, "I used to turn the light down, throw myself on the lounge for a

couple of hours, and then get up and go on with my work again."

Humboldt, after a life full of the hardest kind of work of many kinds,

lived well past ninety in the full vigor of his intellectual powers.

There are many other examples that might readily be quoted. The

traditions of the University of Berlin contain many illustrations of

men who did very little sleeping, yet succeeded in accomplishing an

immense amount of work and lived far beyond the Psalmist's limit.

Virchow, whom I knew very well, did not take more than four or five

hours of sleep on most nights in the year. He would be in the Lower

House of the Prussian Legislature, which, like the House of Commons,

holds its meetings late at night, until one A. M. or later and would

be at his laboratory shortly after seven. There was a tradition at the

University of Berlin in my time there of one of the older professors

in the theological department who went to bed only every alternate

night. He had a forty-eight-hour day for work with a seven-hour break.

He lived to the age of eighty-five. I know one of our most

distinguished workers in medicine here in America who was so busy and

so tired at the end of his day that he could not write his book. He

would fall asleep on his chair at his desk to wake up only when the

milkman came in the morning. He had constructed for himself a special

stool without back or sides, shaped like a bench, so that whenever he

fell asleep on it he fell off. The fall would wake him up and he would

then go on with his work for some hours. He did this sort of thing for

many years, and yet he is alive and in the full possession of

intellectual health at the age of eighty-three. He learned this

expedient from a German professor of medicine who told him of it and

at the same time told him that it was no uncommon practice among

German professors. Indeed, most of the famous long-livers of the

nineteenth century were also well known for the small amount of sleep

they required, and apparently there is no need of being anxious lest

loss of sleep should prove serious, unless one is adding to whatever

detriment to health it may be by worrying about it find so setting two

damaging factors at work.

TREATMENT

Probably the most important immediate assurance that can be given to

those who come complaining of insomnia is that practically no one has

ever {654} been seriously hurt by the wakefulness called insomnia.

Patients suffering from brain tumors, from serious disturbance's of

cerebral circulation that give objective signs, from various organic

diseases, as of the heart or liver, or certain constitutional

diseases, have been made worse by the wakefulness induced by their

affections. In the cases where there were no definite objective signs

and wakefulness was the only symptom we have no cases on record of

serious injury resulting. Men have come complaining of wakefulness for

days or weeks and sometimes, though it is strange to understand it,

for months or even years, and yet have lived their lives without

serious developments and have neither gone into insanity nor into any

premature loss of vitality, much less a fatal termination. It is not

subjective symptoms but objective signs that are of value for the

diagnosis of the serious organic conditions. This reassurance lifts a

load from patients' minds at once and does more than anything else to

relieve them of the burden of solicitude which is the main factor in

the continuance of their insomnia.

Suggestive Treatment.--The psychotherapy of sleep consists in changing

the patient's attitude of mind toward his sleep. It is quite

impossible for him to sleep normally and regularly if he worries much

about it and if the afternoon and evening hours are mainly spent in

wondering whether he will sleep, anxious as to when he is going to

sleep like other people, marvelling how long he will last in health

and sanity if his tendency to wakefulness continues. There is no

factor so strong in insomnia as getting one's self on one's mind. It

weighs as an intolerable burden, an incubus that is sure to keep its

subject awake. Insomnia is a mental and not a physical ailment in much

more than nine out of every ten cases. It is not the brain but the

mind that is at fault. Patients must be made to realize that if they

go quietly to bed, confident that if they do not sleep the early part

of the night they will sleep later, and that in case they should lose

considerable sleep, so long as they lie quietly for eight hours in

bed, their physical organism is not likely to come to any serious

trouble. They must be quiet, peaceful and unworried. They must not

begin to toss at the first sign of not going promptly to sleep for by

so doing they may put off completely the possibility of falling to

sleep. Finally they must prepare for sleep by passing a quiet evening,

as a rule, occupied with diversions of various kinds.

There are many factors which inhibit sleep that must be removed or at

least obviated. These are very different in different individuals and

the suggestion of getting them out of the way helps a great deal in

making people realize that they are better prepared for sleep than

before. They have been keeping themselves awake by contrary

unfavorable suggestions. They must be taught to aid themselves in

going to sleep by a series of favorable suggestions attached to the

doing of certain things that are helpful and, above all, avoiding acts

of various kinds that have an unfavorable suggestive influence. In

this way an accumulation of suggestions can be secured that will prove

helpful.

Drugs.--Of course, patients must be warned with regard to the taking

of drugs. Certain drugs may be taken for an occasional loss of a

night's sleep, where the loss of sleep is regular and frequent,

however, drugs are sure to do more harm than good. Opium leads to a

serious habit, chloral is dangerous because it must be increased, most

of the coal-tar somnifacients produce {655} serious after results and

their physical effect is in the end probably more deleterious than

would be the loss of the sleep which they are supposed to counteract.

This is true for even the vauntedly least harmful of them, and it is

important to make patients understand it.

External Conditions to be Inhibited.--In the treatment of insomnia two

sets of inhibitory conditions are particularly to be looked to, those

external to the patient, and those internal. Unless every possible

obstacle is removed there can be no assurance of the relief of

sleeplessness, while very often the careful regulation of a few

conditions that are disturbing the patient will bring sleep fully and

promptly. It is curious what small annoyances will sometimes prove

disturbing.

_No Pillow_.--I have found patients who had heard somewhere the idea

that it was natural for man to sleep without a pillow. The pillow in

this theory was supposed to be an added refinement of men in a state

of luxury, but a real degeneration opposed to nature, and the many

presumed benefits of sleeping on a perfectly level mattress with the

head no higher than the rest of the body was emphasized. While in

ordinary health these patients had found that after the preliminary

discomfort of getting used to sleeping without a pillow, they were

apparently the better for it. People will feel better for almost

anything if they are only persuaded that they ought to. After a

certain length of time, however, worry or work had a tendency to keep

them more or less wakeful and then insomnia came on, that is, for

several hours at the beginning of the night they did not go to sleep

and became very much worried about it.

In several of these cases I have found one of the most helpful

adjuncts to more direct treatment of their wakefulness was the

restoration of the pillow. Just how the hygienic theory of pillowless

sleep originated, or on what it is supposed to be founded, I do not

know. The only theory of sleep that seems to have many adherents at

present is that it is due to brain anemia. With the head a little

higher than the rest of the body the force of gravity tends to help in

the production of this brain anemia. The experience of mankind seems

to confirm this. Certainly, from the earliest records of history men

have slept with something under their head, even though they could

find nothing better than a log or a stone. To sleep without a pillow

is, owing to the conformation of the head and neck and shoulders,

almost inevitably to sleep mainly on the back. From the anatomical

relations of the internal organs it is easy to understand that

sleeping on the side is more comfortable and healthy than sleeping on

the back and hence most people naturally take this position.

Relaxation is much more complete and comfort is greater. What the

majority of men do is almost surely dictated by instinct, and instinct

is the most precious guide we have in the natural functions of life.

We are not so differently formed from the animals that the analogy

from their habits should not have some weight for us. Patients should

then be advised always to sleep with a reasonably firm pillow, not too

low, so that the head is a little higher than the body and the lateral

position perfectly comfortable.