Place of Psychic Contagion.--The physician who would treat nervous

patients successfully and use psychotherapeutics to advantage must

recognize the place that psychic contagion has in influencing the

generality of mankind. We know that direct suggestions are profoundly

influential. It must be constantly kept in mind, however, that

indirect suggestion, suggestion that does not come by any formal

method, but that is represented by the examples of those around, also

has great weight.

Favorable Influence.--Fortunately it is not alone for evil that

psychic contagion is manifest. People in a crowd stand fatigue better

than when alone. Soldiers marching in step do not notice their

tiredness to such a degree and even forget their sore feet. People

suffering from hunger, so long as there is a good spirit among them,

will help each other to bear it. The accidents in coal mines in recent

years in which men have been imprisoned for considerable periods have

shown that in groups they stand the hardships of confinement and of

lack of food and water better than they do when alone, men live

longer, they do not suffer so much or at least their suffering is not

so insistent, and they bear up better.

This has been particularly noticed in the cures at various watering

places. The very air of the place takes on a favorable suggestion that

is helpful to patients. The routine, the hopefulness of those who are

completing the cure, the stories of improvement, the evident

betterment, all these things combine to give a psychic contagion of

health. Health is, in this sense, quite as contagious as disease. This

must be taken advantage of just as far as possible for the advantage

of patients. On the other hand, ideas are contagious for ill and

patients may derive from their environment notions that prove

auto-suggestive and against which it is extremely difficult to work.

Ideas derived from the general feelings of those around, without any

direct suggestion, may become obsessions. The physician, therefore,

must be ready to secure prophylaxis against psychic contagion and then

by counter-suggestion relieve the patient, who has become afflicted by

it, of the resulting disturbance of mind. It must not be forgotten

that, instead of being less susceptible as education and civilization

progress, people really become more susceptible.

Psychology of the Mob.--The most interesting instance of psychic

contagion is the tendency just hinted at for crowds to run away with

the sober judgment of serious sensible people that happen to be among

them and do things that may be extremely regrettable. A mob always

follows the suggestions of the worst elements in it unless perchance

there is some extremely strong character who asserts himself and

imposes his views on the rest. The tendencies to panic, to cowardly

flight, sometimes to destructiveness, that come over crowds represent

the power of psychic contagion to override reason. An alarm of fire

will, if a few persons lose their heads, lead to the most serious

consequences. Persons trample over one another, pull and maul one

another, sometimes even pulling out hair or pulling off ears in their

insane efforts to escape what is often an imaginary danger, though a

few moments before they were rational beings and they will be quite

reasonable a short time after. It is possible, however, to overcome

even the worst tendencies in human nature by the suggestive power of

discipline. Fire drills in schools enable children to get out in a few

minutes without confusion when without them the most serious results

could be looked for. Discipline and training, {693} following commands

and observing tactics, helps an army almost more than the individual

courage of soldiers. The suggestive influence of the thought that now

is the time to do something that has often been done before at the

word of command is enough to enable the soldier to control his panicky

feelings. The difference between the trained soldier and the raw

recruit is great, but it consists only in this mental discipline and

self-control.

Prevention.--Evidently, then, in the many circumstances in life in

which psychic contagion manifests itself it is perfectly possible to

overcome its influence by such discipline and mental training as gives

the individual control over himself. In children corporal punishment

is often not effective in breaking up habits and tendencies and the

motive of fear often lessens self-control and makes conditions worse.

In older people the fear of punishment is likely to be forgotten,

whereas the suggestion of discipline will assert itself powerfully.

Psychic contagion can be neutralized by psychotherapy, but its force

in life must be recognized and its unfavorable influence guarded

against. While it concerns mainly the less serious things of life, it

may affect the most serious and imitation leads even to such serious

criminal acts as suicide and murder. The modes of psychic contagion,

then, must be constantly under surveillance.

With this before us it is extremely interesting to realize how

unfavorably suggestive for human health and happiness are our

newspapers. They are constantly suggesting disease and suicide and

murder and sex crimes and crimes against property, by giving all the

details available with regard to these subjects. Such news can do no

good, only excites morbid curiosity which requires still further

satisfaction in the same line, and keeps thoughts with regard to these

things constantly before the mind. We have had many burglaries and

holdups and stealings of various kinds as a consequence of boys and

even girls seeing the pictures of crimes in the moving-picture show.

The saturation of mind with disease and crime produced by daily

reading of unsavory and sensational newspaper accounts is sure to

produce evil effects. There seems to be consolation for some people in

reading of the crimes and punishments of others because they feel

that, bad as is their own state, there are others who are worse. This

_schadenfreude_, "harm-joy" as the Germans call it, is not satisfying

to think of for human nature and it has an inevitable reaction through

the unfavorable suggestion of these crimes.

I have found over and over again that the prohibition of reading the

newspapers for a time did many nervous people much good. This is

particularly true for sufferers from such forms of psychasthenia as

bring down on them dreads and premonitions of evil in fears for the

development of disease and in general a sense of instability with

regard to the future, lest dreadful things should happen to them. At

first patients object strenuously and seem to be deprived of a great

satisfaction. After a time, however, they are invariably persuaded of

the fact that the absence of mental contact with human misfortune, in

this morbid way, is doing them good and that their dreads and

premonitory feelings of evil drop from them.

{694}

SECTION XIX

_DISORDERS OF WILL_

CHAPTER I

ALCOHOLISM

In recent years so much has been said about addiction to alcohol as a

disease rather than as a habit that the treatment of it frankly as a

disease in psychotherapeutics, even though there be not entire

readiness to agree with those who emphasize exclusively the

pathological interest of these cases, will not seem surprising. It is

with regard to the various habits, drug and alcoholic, occurring in

neurotic subjects that psychotherapy proves most effective and has

secured some of its real triumphs. As a matter of fact, it has long

been conceded that all of the so-called cures for alcoholism are

dependent for their success upon the mental effect produced upon the

patient. Most of them emphasize the necessity for building up the

physical condition of the patient as a necessary preliminary to any

lasting cure. There is no doubt that the powers of resistance of a man

whose physical health has been seriously impaired by over-indulgence

in alcohol and the lack of food and irregular sleep and exposure to

the elements that so frequently accompany it, will not be sufficient

to enable him to break off the alcohol habit, nor afford him the

ability to inhibit the craving for stimulants, that he would have in a

state of health. On the other hand, even in good health, unless his

moral character is braced up, there will surely be a return to his old

habit.

Historical Resume of Cures.--We have had many different cures for

alcoholism exploited during the last half century. The older method of

the first inebriate asylums founded in this country was to give a man

a disgust for liquor, as it was then called, by putting a small amount

of alcohol into practically everything that he consumed. This did not

give him enough to satisfy his craving, but it did create in him an

intense distaste for it by constantly keeping the flavor before him.

There was a drop or two of whiskey in his tea, there was some whiskey

in his milk, there was a taste of it in the water that he drank, there

was some of it mixed even in the gravy of his meat, and he always had

weak brandy sauce on his dessert. The consequence was, in most cases,

such a complete disgust for liquor that men were sure that they would

never touch it again. Of course, in the meantime they were fed well

and heartily, they were kept in an environment free from temptations

to excessive indulgence in alcoholic drinks, they had brought home to

them what a mess they were making of their lives and their health,

they had time to reflect what ruin they were bringing on themselves

and their families and usually they {695} recognized that they were

the kind of men who must stay away from alcohol absolutely, for whom

there could be no such thing as a moderate indulgence in stimulants.

This, with the intense distaste for alcohol, amounting almost to

nausea at the sight of it, acquired from the system in vogue, started

them well on the road to reform.

_Moral Cures_.--It was the moral elements in the cure, however, that

were the most important, though its inventors were sure that the

physical elements played the largest role. The physical disgust for

alcohol consequent upon having its taste constantly recur in

everything at table passed off in a few weeks or at the most a few

months. It was then that the moral uplift came in and had to be

effective if the patient was to be preserved for the future from his

old habit. If he was of a weak and flabby character, if,

unfortunately, he was placed in circumstances where temptations were

frequent, if, owing to the enforced absence in the inebriate asylum

his business affairs had become involved and he was subject to many

worries, then almost surely he dropped back. As a result his case was

even more hopeless than before and, indeed, second cures were seldom

of much benefit, for the man's confidence in himself was gone.

All in all, however, this old-time, simple method probably produced as

large a proportion of "real cures" as any other method, even the much

advertised and discussed scientific discoveries of modern times. All

of us have heard stories of men who had seemed to be hopeless

drunkards, who were thus reformed and hundreds of men who appeared to

be drifting into hopeless inebriety were reformed to such an extent

that they became not only useful members of society and supports to

their families where they had before been a drain, but even became

leaders in the work of uplifting the character of others to resist the

temptation of over-indulgence in stimulants.

_Modern Cures_.--Of late we have had a number of "cures" for

alcoholism widely exploited by well-directed advertising in the hands

of men who realized what a fortune there was in this sort of thing and

who actually have made immense sums of money out of them. Needless to

say these "cures," though supposed to be secret, did not long remain

so. Perhaps the most famous of them, the one whose institutes were

found all over the country, was said to have used only two drugs,

strychnin and apomorphin. The strychnin was given as a needed and

well-chosen tonic for the physical condition of the patients who came

to the institution usually in a rather seriously broken down

condition. When patients began the treatment they were distinctly told

that if they wanted whiskey at any time they could have it, but that

the next injection of the "cure" after they took the whiskey would

show how directly opposed to alcohol the ingredients of it were, by

producing vomiting and prostration.

As a rule, the patients came in perfectly confident of the effect of

the remedy they had heard so much of. The strychnin injections made an

excellent tonic for these nervous wrecks, bracing them up at once so

that they felt better from the very beginning and this betterment was

confirmed by the growing assurance from the physician and the patients

around them that now, at last, they were to be relieved of their

degrading habit. To those whose craving for alcohol returned in spite

of the favorable condition in which they were placed and the

stimulation of the strychnin, which made up so well, as a {696} rule,

for the absence of their accustomed alcohol, whiskey was actually

allowed. When the next time for their injection came, however, these

patients who had been given whiskey on their request did not now

receive an injection of strychnin but instead a small injection of

apomorphin. The apomorphin acted promptly in making the stomach

relieve itself and produced a complete and immediate sense of

prostration. The limpness and discomfort of seasickness is as nothing

compared to the state that, as a rule, develops after such treatment.

Anyone who has ever had to handle, in a hospital, a wildly drunk,

long-shoreman, whose brute strength in his irrational condition made

him a dangerous object for patients and physicians, who has seen even

large doses of morphin fail to produce quiet, and then has felt bound

for the patient's sake as well as those around him, to administer a

tenth of a grain of apomorphin with the result of having an eminently

tractable patient in a few minutes, will have a good idea of what

happened to the poor alcoholic who got apomorphin instead of

strychnin.

After that the inebriate knew that any further indulgence in liquor

would be followed by this extremely unpleasant result and so he had a

new argument for avoiding it. After a month or six weeks of careful

treatment, the preliminary rest that would restore physical health and

strength being followed by a course of exercise in the open air with

plenty of good food, pleasant surroundings, and hope constantly held

out to them, it is no wonder that these patients went out of the

sanitariums as a rule confident that their habit was conquered for

good. In many cases this proved to be true. It was soon found,

however, that there were many relapses. This hurt the prestige of the

"cure" and the gradual diffusion of this idea spoiled its

effectiveness. It still continued to do good, however, and though it

has been modified in various ways, and, indeed, in various parts of

the country is said to be applied quite differently, there are still

many reformations worked by these cures every year and they

undoubtedly do good. The secret of its success, however, is not any

marvelous drug or other mode of treatment that is employed, but is

because the victims of alcoholism are given an opportunity to retrieve

their physical condition and then to brace up their moral characters

so as to resist their craving for alcohol.

_Mental Influence_.--Other so-called cures and treatments have

followed almost exactly similar lines. The main element in the cure

has been the producing in the mind of the patient a definite idea that

he can stay away from liquor if he really wishes to and then helping

his run-down physical condition so that he craves stimulants less than

before. Whenever such "sure cures" are used on the worst forms of

alcoholic patients as we see them in the large general hospitals of

our greater cities, the bums of the streets, the drunkards of a score

of years or more, they have practically no effect. The man must have

moral stamina, he must have some character left, besides, as a rule,

he must have some good reasons in worldly interest to help him to

brace up and then he may get away from alcoholism if he sincerely

wills to reform. The important element, however, is the will to do so.

If he is firmly convinced that he cannot stay away from liquor, if he

feels in spite of all that has been done for him that he cannot resist

his craving, then, of course, he will not reform. Men, however, who

have sunk to the lowest depths, who, according to their own and

others' testimony, have scarcely drawn a {697} sober breath for ten or

even twenty years, sometimes have something happen to them, often it

seems very trivial to everyone but themselves, that stiffens their

relaxed moral fiber, that wakens their sense of manhood, that serves

quite beyond expectation to give them a new purpose in life, and they

reform and never drink again.

It is this successful phase of the cure of alcoholism, however it may

be explained, that is most interesting. It represents the most

encouraging aspect of the whole question. Probably nothing more

harmful has ever been done than the public proclamation that

alcoholism is often an hereditary disease against which it is hopeless

to struggle, and that the poor victims of it are to be pitied and not

blamed. Except in those of low mentality, whether of intellect or

will, or in the actually insane, there never was a case of alcoholism

that did not deserve at least as much blame as is usually accorded to

it. This is said after making due allowances for temperament. It is

quite clear that for one man alcohol has no attractions at all, while

for another the craving for it is almost an insuperable temptation. It

is idle to say that these two contrasted men are equally free as to

whether they shall take alcohol or not. Of course they are not equally

free. If the man who has no craving for alcohol prides himself on his

power of resistance against the vile habit, he is simply fooling

himself. He probably knows nothing about the real nature of the

temptation of alcohol. The Spaniards have a proverb: "He who doesn't

drink wine and doesn't smoke, the devil gets by some other way." There

is probably something else with regard to which the non-alcoholic has

quite as little freedom as the poor victim of alcoholism and the great

law of compensation comes in to make up to both of them, for their

failings. Man has the defects of his virtues.

Supposed Inheritance.--No man is such a slave to the habit, however,

that he cannot correct it if he will. We have heard much about the

inheritance of this disease. We have heard even more about its

essentially morbid character, though people used to think it a moral

defect. It must still be considered a moral defect, however, even

though we all concede that there is an element of the pathological in

it. We are getting away entirely from the ordinary idea of inheritance

of disease. There is no inheritance of acquired characters. The fact

that a man's father acquired the drinking habit because he was placed

in circumstances where it was easy for him to indulge himself and

because he did not have the moral stamina to resist, is no reason why

his son should have an unconquerable or even a very strong craving for

alcohol. One might as well say that because a father lost a finger

when he was young his son would be born without that finger. Alcohol

destroyed certain cells in the father's body and injured certain

others, but produced no change deep enough to lead to hereditary

influences.

_Contagion More than Heredity_.--Perhaps some tendency to take alcohol

runs in a family, that is, perhaps there is lessened resistance to the

craving for stimulants that awakens in every human being if it is once

aroused. This is what is true in tuberculosis. Some people have less

resistive vitality to it than others. Careful autopsies show that

practically every man who lives to be over thirty has or has had

living tubercle bacilli in his tissues. Seven-eighths of us are

thoroughly able to resist them. The other eighth succumbs. Their lack

of resistive vitality may in some degree be due to hereditary taint,

{698} but that is doubtful and we know that they acquire the disease

by contact with others who have it already and, as a rule, it is able

to work its ravages because they are not living in conditions that

would help them to resist it. If they live in the free open air and

have plenty of good, simple food, the disease will not run its fatal

course, but nature will cure it. If the craving for alcohol is lighted

up by association, aroused by indulgence, rendered strong by

environment and by exposure to temptations of all kinds with regard to

it, then the resistive power of the individual is so lowered that the

alcoholic habit rules him instead of his being able to command it.

_Inherited Resistance_.--The most curious fact that has come out in

our studies of heredity in recent years has been that far from

heredity working its will in causing degeneration and deterioration of

mankind, immunity, for the race at least, is acquired in the course of

subjection to disease and to various morbid habits. Nations, for

instance, that have been subjected to diseases for long periods no

longer display the susceptibility to them which they formerly

possessed. After a disease has been endemic among a people for many

generations that people gradually becomes quite insusceptible to its

effects and suffers much less from it than before.

Just this same thing is true of alcoholism. Nations that have been the

longest in a position to be subject to the temptation to use alcohol

in its stronger forms suffer least from the ravages of alcoholism. The

southern nations of Europe using wine daily and knowing well the

process of distillation to help them to make stronger drink for many

hundreds of years, now exhibit much less tendency to over-indulgence

in strong drink than the northern nations whose ancestors have only in

comparatively recent times been subjected to the temptation of craving

for strong alcoholic liquors. The attitude of any nation toward

alcohol is a function of the length of time that nation has had a

chance to procure strong drink easily. Our American Indians

discovered, as has every people at some time, that intoxicating liquor

could be made by allowing solutions of starch and sugar to ferment. It

was only with the coming of the European, however, that they were

provided with "fire water"--strong drink--in quantities. Its effect on

them is a matter of history. Two things the white man brought his

Indian brother to which the Indians were unaccustomed and that

gradually obliterated the original inhabitants of this

country--infectious diseases and strong alcoholic liquors. They proved

equally fatal because of Indian susceptibility to them.

From these considerations it is clear that just such an immunity to

the effect of alcohol is produced in a people exposed to its effects

in concentrated form for a long time as with regard to an infectious

disease when they have been correspondingly exposed to it. Heredity,

then, instead of playing a role that brings about deterioration in the

race, on the contrary, carries on the higher qualities and gives us,

as might be expected in the course of evolution, a better, that is, a

more resistant, race. Most of what is commonly said as to alcoholism,

and unfortunately most of the recent so-called popular scientific

articles on this subject, seem to point to just the opposite

conclusion to this. Men are supposed to be condemned by heredity to an

inevitable craving to take alcoholic drinks that, in certain of them

at least, cannot be overcome by any natural power of resistance. At

this stage of our western civilization this is not true for anyone, as

the more susceptible families have been long {699} since eliminated

and it is a personal weakness and not a family characteristic that

leads people to indulge this appetite to their own destruction.

_Unfavorable Suggestion of Heredity Idea_.--An alcoholic patient, or

even a man with only a moderately strong tendency to take alcohol to

excess, who harbors any such notion as this, has a serious impediment

to the full exercise of his will in overcoming the difficulties that

he encounters in any attempt at reform. In going counter to so much

that has been written and still more that has been said and generally

accepted on this subject I feel it necessary to quote a good recent

authority on the matter and so here insert these passages from "The

Principles of Heredity" by Dr. Archdall Reid. [Footnote 53] He says

(p. 157):

[Footnote 53: Author of "The Present Evolution of Man," "Alcoholism,"

"A Study in Heredity," etc. Chapman and Hall, London, 1905. ]

Formerly all the world believed in the transmission of acquirements,

and consequently all the world was constantly finding conclusive

evidence of its constant occurrence. To-day there is hardly a rag of

that evidence left, and, with rare exceptions, only certain French

medical observers are able to discover fresh evidence. It is a

remarkable fact, however, that the problem of evolution--of

adaptation--has excited singularly little interest in France, and

it is equally curious that these French observations relate almost

entirely to laboratory work which it is not easy to repeat. In Great

Britain or Germany, you may cut off the tails of a thousand dogs, or

amputate the limbs of a thousand men, or observe the non-infected

offspring of a thousand tuberculous patients, and get no evidence of

transmission.

With regard to alcohol Dr. Reid in the same volume insists on the

proposition that alcohol does not cause degeneration of a race,

creating, as is claimed, ever more and more a tendency for people to

take it because their immediate ancestors have taken it, but, on the

contrary, there is a distinct evolution against it, and that what is

hereditary, not by acquisition, but by family trait, is an immunity

against the disease which eventually protects the nations that have

been longest exposed to the effects of alcohol from the evil

consequences of the substance. He says (p. 196):

How, then, has alcohol affected the races that have used it? Are the

Jews and the races inhabiting the South of Europe the most

degenerate on earth? Are North Europeans only less degenerate? Are

the races that have never used alcohol, the Terra del Fuegians, the

Esquimaux, and the Australian blacks, for instance, mentally and

physically the finest in the world? We have only to state the

proposition to see its absurdity. There is no evidence that the

hereditary tendencies of any race have been altered by alcohol

circulating in the blood and acting directly on the germ plasm. Once

again the sufferings of the peoples have produced no effect, but the

deaths among the peoples have produced an immense effect. Every race

that has had experience of alcohol is temperate in the presence of

an abundant supply in proportion to the length and severity of its

past experience of the poison. The South Europeans and the Jews are

the most temperate peoples in the world. West Africans also are very

temperate. North Europeans are not drunken. Those savages, and those

only, who have had little or no experience of alcohol--Esquimaux,

Red Indians, Patagonians, Terra del Fuegians, Australian blacks--are

beyond all the peoples the most drunken on earth.

Lest it should be thought that this discussion of the subject is only

of significance with regard to nations and does not touch the

individual, and, therefore, has but little significance for the

problem that we are treating here. Dr. Reid's succeeding paragraph

deserves attention:

{700}

Stated in this brief and direct way, the thesis is apt to excite

incredulity. It is sharply opposed to popular beliefs, though that

need not trouble us. Popular notions on abstruse points of science

are occasionally erroneous. Of more importance is the fact that a

mass of statistics purporting to prove that the children of

drunkards tend to be degenerate has been compiled, especially by

medical men in charge of lunatic asylums. But no "control"

observations appear to have been made. We know that many drunken

parents have normal children; certainly, therefore, parental

drunkenness is not invariably a cause of filial degeneration. We

know also that many temperate parents have defective children. There

is nothing to show that the proportion is greater in the one case

than in the other. Even were it established that the proportion of

defective children is higher in the case of drunken parents, it

would still have to be proved that the relation is one of cause and

effect. People who have an inborn tendency to mental defect, who are

abnormally depressed, nervous, restless or irritable, are often so

constituted as to find solace in drink. Their children are liable to

inherit their inborn mental defects with spontaneous

variations--that is, to inherit the defect to a greater or lesser

extent. The unborn child of a drunken and pregnant mother is

practically another drunken person, as liable, or more liable to

suffer from the effects of drink; but in such a case the resulting

defect, though a mere acquirement, is tolerably certain to be

regarded as a congenital (i. e. inborn) defect by the medical man

who sees it. Mere acquirements, also, are the defects due to the

ill-treatment, want and neglect to which the children of drunken

parents are particularly exposed. Indeed, were it fully established

that drunken parents, other than pregnant mothers, tend to have an

excessive number of their children "congenitally defective," it

would still be a question whether the filial defects were not mere

acquirements. Prof. Cossar Ewart's observations on diseased pigeons

renders this not unlikely. All these sources of error render the

success of a statistical inquiry peculiarly difficult, if not

impossible, but there is no indication that they ever occurred to

the minds of the compilers.

Warnings as Suggestions.--I have a case in my notes in which a rather

prominent professional man insists that he is quite sure that the

alcoholism from which he suffered during the ten years between

twenty-five and thirty-five was entirely due to suggestion. As a boy

of sixteen he had gone off to boarding school, but not until his

mother had taken him aside, told him that his father had drunk himself

to death, had done it by secret tippling, and that they had found that

for many years he had been accustomed to have whiskey near him in his

office and take it rather frequently. He had never tasted spirituous

liquor at this time and his mother begged him not to, for she felt

sure that if he did his father's craving would awaken in him and would

become uncontrollable. The day that he went away his father's eldest

brother took him aside and said practically the same thing to him. A

maiden aunt was not quite so emphatic, but she, too, pleaded with him

to understand all the dangers. For his first year at school he did not

touch liquor, but in his second year he tasted it once or twice but

had no particular craving aroused in him. By chance when he was home

at Christmas time some college mates who were visiting him gave his

mother the impression that he belonged to a rather jovial set. Once

more he was warned by mother and uncle. Above all they told him never

to keep strong drink near him because that was what his father used to

do. During his college years the fear of this hung over him. He

resented it and probably took more liquor than he would have so far as

actual craving went. After getting out into active life once more he

suggested himself into the habit of taking an occasional glass of

whiskey by himself. After a time he was constantly taking too much.

For {701} ten years he hurt all of his prospects, broke his mothers

heart, and was looked upon as a hopeless alcoholic. Then one day the

thought came to him that it was not that he craved alcohol so much,

but that his thoughts turned on it constantly and at first he dreaded

it overmuch, then wondered what attraction there could be and then

acquired a habit by suggestion. Once this train of thought worked

itself out in his mind, he quit spirituous liquors for good. For ten

years he has not touched them, he does not care for them, they do not

constitute a temptation.

It must not be forgotten that many warnings may so preoccupy the mind

with regard to a danger as to constitute temptations by suggestion.

This is eminently true of alcoholism, the drug habits, sex habits and

the like, in spite of the foolish present-day notion that information

and warning must necessarily be helpful. In all these, teaching may be

suggestively harmful.

Prophylaxis.--The most important part of the treatment of alcoholism

through mental influence is by prophylaxis, and that, to be effective,

must begin very early. Just as with regard to overeating, as I have

pointed out in the chapter on Obesity, it is extremely important not

to permit children to acquire habits with regard to alcohol when they

are young. During the growing years the system, indeed one may say all

the systems of the body--the nervous, the muscular, the digestive and

the mental systems--are all more or less unstable. Deep impressions

may be produced on them then, and if children are allowed, much less

encouraged, during their growing years (and this includes practically

all the years up to twenty-five) to indulge in alcohol, then one can

look for the development of a craving very hard to eradicate later in

life. Many of them will be able to conquer the desire thus awakened,

but a great many of them will not. We have some very definite evidence

on this point and some of it collected here in America is very

valuable. Dr. Alexander Lambert of New York made a study of over 250

cases of alcoholism seen in the wards at Bellevue Hospital, paying

special attention to the age at which the patients remembered they had

begun the use of alcoholic liquors. If anyone doubts the influence of

youth in this matter, then his statistics should be read:

Of 259 instances where the age of beginning to drink was known, four

began before six years of age; thirteen between 6 and 12 years;

sixty between 12 and 16; one hundred and two between 16 and 21;

seventy-one between 21 and 30; and eight only after 30 years of age.

Thus nearly seven per cent. began before 12 years of age, or the

seventh school year; thirty per cent. began before the age of 16;

and over two-thirds--that is, sixty-eight per cent.--began before 21

years of age.

Dr. Henry Smith Williams, commenting on Dr. Lambert's study of this

subject in his article on "The Scientific Solution of the Liquor

Problem," [Footnote 54] states emphatically the conclusion so

inevitable from these statistics that more than anything else

alcoholism is the result of habits and occasions created in early

years. He adds some remarks that are worth noting for those who are

interested in the prevention and cure of alcoholism, not only in

particular cases, but also for the community:

[Footnote 54: _McClure's Magazine_, February. 1909.]

{702}

In the light of such facts, it is clear that the drink problem is

essentially a problem of adolescence. The cumulative effects of

alcoholic poisoning frequently fail to declare themselves fully

until later in life; but the youth who does not taste liquor till

his majority minimizes the danger of acquiring the habit in its most

insistent form; and the man who does not drink until he is thirty is

in no great danger of ever becoming a drunkard. As to the man who

has passed forty--well, according to the old saw, he must be either

a fool or his own physician. His habits of mind and body are formed,

and if he becomes a drinker now he can at most curtail by a few

years a life that is already entering upon the reminiscent stage. As

factors in racial evolution, the youth of each successive

generation, not its quadragenarians, are of interest and importance.

Treatment.--The conclusions that naturally flow from the historical

introduction to this chapter which show mental influence as the basis

of all cures, simplify very much the treatment of alcoholism on

psychotherapeutic principles. There is no doubt that moral means are

the only really effective remedies in this matter. They fail often,

not because of any lack of power, but because of lack of co-operation

on the part of the patient. There are men whose mentality and

responsibility is breaking down, and who are on the way to the insane

asylum for various causes, who cannot be thus influenced. They are,

however, not alcoholics, but incipient insane patients likely to go to

excess in any line. There is no pretense that psychotherapy will cure

mental disorder that rises to the height of real insanity. On the

other hand, just as after several relapses of tuberculosis due to the

foolishness of the patient, further improvement by sanatorium

treatment is usually out of the question, so each relapse of the

alcoholic patient makes it increasingly difficult to bring about

noteworthy improvement. There are examples, however, which demonstrate

that even after seventy times seven relapses men may still encounter

something that rouses their dormant wills to real activity and then

their alcoholism is a thing of the past, for good and all.

_Sanitarium Question_.--There always comes the question whether these

cases need to be sent to a sanitarium or can be treated at home. The

answer to this question is the same for alcoholism as it is for

tuberculosis or, indeed, for any of the exhaustive diseases. It all

depends on the individual's physical condition and his circumstances.

If tuberculosis is discovered, as it should be, at a very early stage

in the disease--not when the patient is coughing up bacilli in large

numbers and already has many physical signs in his lungs, but when he

has a slight unproductive cough and over-rapid pulse and some

prolongation of expiration at one apex--then he may be cared for at

home, if the physician is confident that he can make his patient feel

the absolute necessity for following instructions and can make him

realize the seriousness of his condition in spite of the few symptoms

that are present. If his environment is unfavorable, in a crowded

tenement house or where an abundance of fresh air cannot be readily

obtained, the patient may have to go to a sanitarium for proper

treatment even at this early stage, or at least he will have to change

his living conditions.

This question has received a very different answer in recent years

from what used to be given to it. Formerly the physician hesitated to

say "tuberculosis" to his patient until the disease was well advanced

and then he advised the distant West or some other change of climate,

though, as a rule, this brought only a palliation of symptoms, the

case being too far advanced, and {703} the fatal termination came in

the course of two or three years. Now the careful physician diagnoses

tuberculosis much earlier, detects the disease in its incipiency, and

is able to treat the patient at home quite successfully, if conditions

are at all favorable. It is true he has to make him give up fatiguing

occupations, and especially those in dusty places; he has to insist on

his living out of doors a good part of the day, even though there

should be no better means of securing this than the roof or a

fire-escape, and on keeping his windows open all night. He has to

watch his nutrition carefully and see that he gains in weight. If all

this can be accomplished, however, there is no reason why a

tuberculosis patient in the incipient state should not get better at

home almost as well as he would at a sanitarium. The only difference

between the two methods of treatment is that in a sanitarium the

patient realizes that his one duty in life is to care for his health

and he does not bother about other things, as he is likely to do if he

remains at home.

If this precious development of teaching with regard to tuberculosis,

which is founded on such thorough-going common sense and the

application of good therapeutic principles to the treatment of the

disease, be transferred to the sphere of alcoholism, then the answer

to the question whether there shall be sanitarium treatment or not is

practically arrived at. If the patient is in an early stage of his

alcoholism, if the pathological character of his tendency to take

intoxicants has been recognized and made clear to him early, then

there is little difficulty in treating him at home. The crux of the

problem is just that which occurred with regard to tuberculosis years

ago. The physician does not take the early symptoms of the affection

seriously enough. He does not want to disturb his patient's equanimity

by the suggestion that he is in the incipient stage of alcoholism any

more than a few years ago the family physician cared to suggest the

awful thought of tuberculosis until the condition had reached a

serious stage. But this is the essential preliminary to the successful

treatment of alcoholism just as it is to the successful treatment of

tuberculosis.

It is almost useless to send advanced cases of tuberculosis, in which

cavity formation has already occurred, to a sanitarium. The course of

their disease may be delayed for a while, but scarcely more than that.

Their resistive vitality has been so overcome by the ravages of the

disease that their ultimate cure seems beyond hope, yet not

infrequently wonderful results are obtained even in these cases. Just

this same thing is true with advanced cases of alcoholism. No one can

do anything with them, though careful treatment in a sanitarium may,

on a number of occasions, afford them opportunity to brace up and be

themselves, i.e., their better selves, for several months. Just as

with tuberculosis, however, even the quite advanced cases will

sometimes be so much bettered by sanitarium treatment that, though

their prognosis seemed absolutely hopeless and was so pronounced by

good authorities, all the symptoms are relieved and the patients get a

new lease of life that may last for many years.

In the same way some apparently hopeless cases of alcoholism will

brace up after sanitarium treatment and have many years of useful

sober life without a break. In alcoholism, as in tuberculosis, the

will of the individual is the all-important consideration. Someone has

said that tuberculosis takes away mainly the quitters. Those who have

the courage to insist that they {704} _will live_ in spite of

everything being apparently against them, pull through crises that

seem absolutely hopeless and survive for years. Robert Louis Stevenson

bravely doing his work, living on in spite of fate and disease, is the

typical example. Alcoholism completely overcomes only the quitters. If

a man wants to give up drinking even when he seems practically a

hopeless wreck from the effects of alcohol, he can do so if he has a

physician in whom he has confidence, who will relieve him from

depressing symptoms due to previous excess, who will lift him up and

strengthen him by food and stimulation, and, above all, by faithful,

unending, never discouraged assurance that he can conquer the craving

which has such a hold of him, if he only persists a little and does

not give up the struggle. The victory is worth while and it is not

hard to lift a man up if he has any remnants of character left.

_Confidence_.--In the treatment of alcoholism, then, just two things

are necessary. One of these is that the patient has confidence in

himself, the other that he has confidence that his physician can help

him over the hard spots on the road. There is no doubt that many drugs

can be used that will lessen the patient's irritability, increase his

nerve force, stimulate organs which are depressed by the reaction

against over-stimulation, arouse appetite and correct disturbed

functions. All these things must be done. It is no use laying down any

set of rules as to how they shall be done, for they must be done

differently in individual patients. It is not alcoholism that is

treated nor the effects of alcoholism, but an individual alcoholic

patient, and a set of symptoms that are very different in every

individual. The more physiological disturbance can be relieved by

proper drug, dietetic, hydropathic and remedial measures, the more

chance is there for the patient to get over his habit without trouble.

Every ill feeling that he has tempts him to think of alcohol. Above

all, he must be made to sleep, his bowels must be thoroughly

regulated, and he must be made to eat heartily. For stimulation full

doses of nux vomica, not less than thirty drops three or four times a

day or even oftener, are probably best.

For cases of alcoholism in the earlier stages there is but little

difficulty. Those who try the effect of favorable suggestion, of

confident assurance, of constantly repeated encouragement on

individuals who have begun to be afraid that they cannot break the

habit, will frequently have the most gratifying results. The important

point to remember is that men are suffering from alcoholism who are

indulging in alcohol every day and to whom it has become more or less

of a necessity, though even as yet its effect upon their business is

not marked and they are not known, even among their acquaintances, as

drunkards. Whenever a man must have three or four whiskeys a day or he

cannot do his business and his appetite fails him and he does not

sleep well, he is an alcoholist. He has the cellular craving that

later may become an absolute tyrant. If we can educate the community

generally to realize this as we are gradually educating them to the

knowledge that tuberculosis must be caught in its incipient stage and

that pulmonary consumption begins in very mild symptoms after a person

has been exposed to it, we shall have little difficulty in curing

tuberculosis or in treating alcoholism successfully by suggestion.

For alcoholism, as for the drug habits and also the sex habits, moral

influences are all-important. Hence the necessity for exercising them

{705} frequently. It is probable that the best way to break any of

these habits is to have the patient come regularly to the physician's

office, at least once, and at the beginning twice a day. In cases of

alcoholism the method of giving for the first week, at least, the dose

of the stimulant drug which replaces the alcoholic stimulation

directly to the patient is often of great service. It seems a good

deal to ask the patient to come three times a day just to get a drug

(tonic), but it is comparatively easy to resist the craving for liquor

for four or five hours, that is, until the doctor is seen again, while

sometimes twenty-four hours will seem a long while. The personal

element in this matter is extremely valuable. It is this that has made

the efficiency of all forms of cures, and it is only this that can be

successfully used.

How much can be accomplished for even the worst forms of drunkenness

and under extremely unfavorable circumstances once a really strong

impression is made on the individual's mind and his will is aroused to

help himself seriously may be readily learned from the lives of any of

the great temperance advocates. Their experience is illuminating. It

shows clearly that strong personal influence will do more than

anything else for these sufferers. Sometimes their efforts are

supposed to affect only certain classes of individuals who have

character but who, for some reason, have fallen into an unfortunate

habit. A little investigation will show, however, that they affect all

classes and kinds of individuals and, indeed, may reform a whole

community. The story of Father Matthew is very interesting in this

regard because there is some striking testimony as to his reformation

of whole neighborhoods that had been given over to drink before and

that among a people especially emotional and susceptible. The movement

that he initiated still lives in the temperance societies of the

English-speaking peoples everywhere which help by prophylaxis in youth

and the moral force of association in later life.

After-Treatment.--In alcoholism the most important feature of the

treatment is what has come to be known in our time as the

after-treatment. This department of therapeutics has taken on great

importance in recent years in every form of disease. For early and

middle life most diseases have a definite tendency to get better,

though many of them leave distinct pathological tendencies. The

after-treatment, then, has become much more important than the cure

for the patient during the existence of the acute or sub-acute stage.

Even in children's diseases it is now generally recognized that while

measles and whooping cough are not dangerous affections as a rule,

they may prove the forerunners of tuberculosis, because of the

weakened pulmonary resistance consequent upon their invasion. For

scarlet fever, the possibilities of injury to the kidneys after the

great irritation to which they have been subjected, is now recognized

and convalescence is prolonged. In typhoid fever we realize that not

weeks but many months of convalescence are needed to put the patient

beyond the risk of various degenerative processes that may be serious.

There is even question in the minds of many observant physicians

whether the weakness incident to typhoid fever may not, if a premature

return to work is allowed, prove a potent cause of precocious

arterio-sclerosis.

In a word, after-treatment has become one of the most interesting

subjects of modern therapeutics. It will not be surprising, then, if

we insist that the after-treatment of the alcoholic is the most

important part of the remedial methods to be employed. If a man who

has suffered from tuberculosis because {706} he was working in one of

the many dusty trades and living in a badly ventilated tenement house

is restored to health or at least has all his symptoms disappear as a

consequence of sanitarium treatment, it is almost needless to say that

he must not be allowed to return to the conditions in which his

disease originally developed. If he does, he is absolutely certain to

have a relapse. This phase of tuberculosis has been much discussed in

recent years. It is often said that it is impossible to keep working

people from a return to their occupations. Just so far as that is

impossible, so far will any real hope of keeping their tuberculosis in

abeyance be reduced. They are much more likely to suffer from the

disease, as a rule, after their return from the sanitarium than they

were before they originally contracted it, because apparently some of

their immunity has been destroyed by the invasion of the bacillus.

It is only recently that we have thus planned for the after-treatment

of tuberculosis. If we are to be successful in the after-treatment of

alcoholism, at least some of this same thoughtfulness must be

exercised. The victims must be discouraged from going back into the

conditions in which their habit developed. It is comparatively easy,

especially at the beginning of his alcoholism, to stimulate a man back

to normal physical condition, to reduce his craving for intoxicants,

give him back his appetite and set him on his feet again. The

affection is quite curable. If a man returns to the conditions in

which it originally developed, however, it will develop again quite as

inevitably as tuberculosis does under similar conditions. We do not

blame the sanitarium if, after having given a man a new lease of life

in spite of tuberculosis, he resumes the unsanitary life in which his

disease originally developed and has a relapse. It is not the fault of

the system of treatment for alcoholism if men relapse, but the blame

is upon them that they do not take their danger of relapse seriously

enough, permit themselves to get into an unfavorable environment, and,

as a consequence, suffer once again from their affection.

_Religious Motives_.--More and more we are realizing the place of the

higher motives of life in the reform of alcoholic patients. Religious

motives probably form the best possible source of suggestions that

enable a patient to lift himself out of the slough of despond of

chronic alcoholism. Many of the best workers for the reform of the

drunkard were themselves drunkards for many years. The motive of

helping others is particularly important in its effects upon any

alcoholic. Some motive apart from himself is more helpful than any

appeal to his selfishness or even to what he can do for his children

and his wife. It is the newer motive that appeals most strikingly. In

recent years certain church movements have done much for alcoholic

patients. In this they are only repeating the effect of other great

church movements and the effect of the lives of apostles of temperance

in recent generations. Without these higher motives cure is probably

impossible in many cases. With them it not only becomes possible but

even comparatively easy in the most hopeless-looking cases.

In the light of what we have heard recently of the success of the

Emanuel movement in the treatment of alcoholism, it is interesting to

recur to what was said in this relation by Prof. Forel of Zurich on

the treatment of alcoholism, in a communication read to the South

German Neurologists and Psychiatrists at its meeting in Freiburg over

twenty years ago. Prof. Forel, who is not what {707} would be called a

particularly religious-minded man, insisted that "an inebriate asylum

can only with great difficulty be successful without religious

auxiliaries, since most inebriates, and especially at the beginning of

their reformation, are entirely too weak to get along without

religious consolation. To secure this, however, the nicest tact is

required in order to permit the practice of all the different nuances

of faith that men have, in peace and comfort. This can only be secured

if in practice faith is subjected to charity for one's neighbor as the

basis for religion."

Many such expressions have been used before and since in practically

every country in Europe. The assertion that physicians have failed to

recognize the part that religion plays in such cases is entirely

without foundation and can only be made by those who are quite

ignorant of our medical literature.

CHAPTER II

DRUG ADDICTIONS

Much of what has been said with regard to alcoholism finds ready

application to the treatment of drug addictions. At the very beginning

it must be realized that there is no specific remedy that will enable

the patient to overcome his craving for a drag to which he has become

habituated. There is no method of treatment that will infallibly and

without serious and prolonged and determined effort on his part enable

him to overcome his craving. The first and most important thing in any

system of treatment is the patient's good will. If the patient is not

ready to give up the drug, then nothing that a physician can do for

him will make him do so, or will turn him against it; above all,

nothing will make the process of cure so easy that there will be no

trouble involved or only a passing period of struggle required to

accomplish it. There have been many claims made in this matter. We

have wanted such remedies and methods of treatment so much that it has

been rather easy to persuade us sometimes that they have been

discovered. It is like the question of specifics in medicine. For

centuries men devoted themselves to trying to find a specific remedy

for each disease. It was thought they must exist in nature. Now we

know that they probably do not exist, though those who claim to

discover them find an easy livelihood exploiting the credulity of

those who still cherish the belief in them. Scientific students of

medicine have practically given over the search for them in order to

devote themselves to strengthen the patient to resist the disease

rather than spend more time trying to find something to give him that

cures it.

Treating the Patient rather than the Habit--This principle holds with

special force with regard to drug addictions. We do not treat the

patient's habit, but we treat the patient. He must be braced up, must

be made to understand that if he wants to quit the habit, no matter

how slavishly he is addicted to it, he can do so. He must be told of

men who had habits like his, often of longer duration and to a greater

degree, yet gave them up when firmly resolved and properly stimulated.

It is not hard to find such examples, since medical and even ordinary

literature abound with them and every physician's experience furnishes

him with instances. The first and {708} most absolutely necessary

preliminary of the treatment is to lift up the patient in his own eyes

and make him understand that, low as he has sunk, his case is not

hopeless, that his degradation is not at all uncommon nor so rare as

he might think, and that men and women have succeeded in lifting

themselves out of conditions worse than his. The psychotherapeutist

must, above all, not be of those who insist that human nature is

degenerating and that people are much weaker physically and morally

than they used to be, though of course he must be thoroughly aware

that drug habits are more frequent than they were and are quite

alarmingly on the increase. This is not due to any deterioration in

human nature, however, but mainly to the excitement of modern life and

its inevitable reaction, the strenuousness with which men now take

existence and the consequent craving for artificial relief from

over-activity, and then, above all, the facility with which the

habit-forming drugs can be obtained.

Prophylaxis.--This last point accounts for the frequency of drug

habits in our time more than anything else. Men have always been ready

to do something for the sake of novelty and excitement. Everyone is

curious to experience for himself the effects produced by drugs that

can make people such slaves to them. We hear too often of the intense

pleasure that the drug habitue gets from his use of drugs. The

curiosity thus aroused constitutes the suggestion that has led many to

try the effect, confident that he or she would be able to resist any

craving just before it became seriously tyrannous. Psychiatrists agree

that one of the worst elements in modern social conditions is the

impression generally maintained that there is such intense pleasure in

the taking of drugs. A clear statement of the reality of the case is

eminently desirable. It is not positive pleasure that the drug habitue

has, but mere negative pleasure, as a rule. His "dope" does not so

much add to his good feeling as take away the bad feelings that he has

because of depression or ennui at the beginning and later because of

the craving for the drug.

Physicians to whom many drug habitues have told their experience

frankly are not at all inclined to think that the usually accepted

opinion of pleasure in drug taking is true. It is not that it is

heaven to have the drug so much as it is hell to be without it. The

patient's system has learned to crave it so much because of the

surcease of painful consciousness of self it gives and this it is that

compels these unfortunates to go back to ever-increasing doses. The

pleasant side is a very dubious affair at all times, accompanies only

the earliest steps of the formation of the habit at most, and usually

whatever agreeable feelings there are are accompanied by such a

nightmare of solicitude and anxiety as a background that the pleasure

is more poignant than agreeable. As a prophylactic against the

formation of drug habits this aspect of the experience of drug

habitues deserves to be emphasized and knowledge of it widely

diffused. Of course, the morphin fiend brightens up after his dose of

morphin, his eye lightens, his expression becomes happy, and his

nerves get steadier, but that is only because the depression in which

he was sunk before has now been stimulated away, the struggle with his

worst feelings is over and the consequent reaction has developed. Of

course, the cocain-taker is pitiably helpless and downcast without his

"dope," but it is only by contrast with this previous state that his

succeeding condition can be said to be pleasant or agreeable, even to

himself.

{709}

_Favorable Suggestion_.--One of the most helpful sources of favorable

suggestion for these patients is to be found in the stories of cured

drug habitues. These may be used tactfully to bring confidence to

patients that they, too, can be broken of their habit if they are

willing to take the pains to do so. De Quincey, taking his thousand

drops of laudanum a day, represents one of the most encouraging

examples of this since he succeeded eventually in breaking away from

his habit. Coleridge succeeded, also, in breaking his habit more than

once, but unfortunately returned again and again, and illustrates the

danger of the almost inevitable tendency to relapse, if the patient

permits himself to think that now that he has once conquered the habit

he is too strong ever to let it get hold of him again. If he ventures

to think complacently of his self-control and that consequently he may

with impunity--always for some good reason--take a dose or two of his

favorite drug in order to tide him over some crisis of mental worry or

some spell of physical pain, relapse is certain. The tendency of

patients to fool themselves in this way is too well known to need

special emphasis, but it is as well to say that there is scarcely a

single cured case that does not relapse. The relapse is due not so

much to craving for the drug, as to the memory of its previous effects

in relieving discomfort and the unfortunate confidence that the

patient has developed that now, knowing the dangers, he will be able

to resist the formation of the habit before it gets a strong hold of

him.

It is curious how even highly intelligent patients will slip back into

their old habits, sometimes deeper than before, on this reasoning, in

spite of the lessons of experience, even their own as well as others.

Like the drunkard, they persuade themselves that just this once will

not count, and when it would have been comparatively easy for them to

say no they yield once or twice and make self-denial for the future

increasingly difficult. This is especially true if patients have the

drug near them, so that it is not difficult for them to have recourse

to it. Hence doctors and nurses are not hard to cure of such habits,

as a rule, provided they are away from their professional duties, but

they almost inevitably relapse when they go back to work. Every time

the relapse is due to the fact that tired feelings, because of

irregular hours or some physical pain, prompt them to seek relief and

they yield to the temptation of taking the old drug, sure that they

need it, only for the moment. They will all assert that they could

just as well resist as not, that, indeed, had not the drug been so

handy, they would not have taken it, and that if anyone had been near

to help them by a word in the matter even then they would not have

indulged in it.

If patients are to be kept from relapsing, all this must be set before

them frankly. After they have been told once or perhaps twice or

perhaps many times and yet relapse into their habits, they must simply

be told it again a little more emphatically, more encouragingly, up to

seventy times seven, if necessary. Patience is needed more than

anything else in taking care of these cases. Over and over again their

confidence in their power to overcome their habit, if they really wish

to do so, must be reawakened. Without this confidence in themselves

success is hopeless. It matters not how often they have relapsed, they

can still break off the habit, and if they will not fool themselves

into over-confidence in their power to keep away, they need never be

slaves to the habit again. There will be quite as many disappointments

in {710} treating drug addiction as in the treatment of alcoholism.

Those who have most experience insist that there are even more, but

there are some wonderfully encouraging examples of men and women who

have broken from their habit, even after a number of bad relapses, and

have for many years lived absolutely without any of their drug and,

though still not over-confident in their power to resist if once they

should yield (such confidence, it cannot be repeated too often, is

always fatal), do actually keep away from the drug without any other

bother than the necessity of living a regular hygienic life and

exercising a little self-control.

In drug addictions as in alcoholisms, the question of sanitarium

treatment comes up in every case. Much more rarely than in the case of

the alcohol habit is it necessary to send a drug habitue to a

sanitarium. Here once more, however, the patient's circumstances and

the possibility of diversion of mind with reasonable freedom from

temptations to take the drug and from ready access to it, are the most

important considerations. If a patient really wants to break off the

use of a drug, it can be done gently and without much bother in the

course of three or four weeks. I have seen cocain fiends who have

tried many remedies and many physicians completely cured in five or

six weeks without serious trouble. The important thing is perseverance

in the effort and in the treatment and the definite persuasion of the

patient that it is not only perfectly possible to get rid of the

habit, but that it is even easy with good will on his part. If certain

other milder stimulants are supplied for a time so that all the

symptoms due to the physiological effects of the excessive use of the

drug are minimized, the physical trial need not be severe. The

patient's mind, however, must be occupied. Time must not be allowed to

hang heavy on his hands and all physical symptoms must be treated

promptly. Drug addictions are indeed more curable than alcoholism and

the danger of relapse is not quite so imminent. The social temptations

do not exist for drug habitues as they do for alcoholics. As I have

said, however, in the cases of nurses and physicians almost a

corresponding state of affairs obtains and in them the danger of

relapse is great.

Early Treatment.--It is quite as important for drug victims as it is

for alcoholics that the case should be taken under treatment early.

Every physician knows how curiously easy it is for some people, indeed

for most people, to acquire a drug habit. I have seen one of the

solidest men I ever knew, with plenty of character that had been tried

by many a crisis in life, recommended cocain for a toothache when he

was past fifty years of age and in the course of ten days acquire a

thorough beginning of the cocain habit, so that he was taking several

grains a day. He had no idea that he was unconsciously slipping into a

drug habit. When the druggist refused any longer to supply the cocain

solution without a prescription he was quite indignant. It was not

until he had forty-eight hours of nervous symptoms and craving that he

realized that he had created a need for stimulation of his nervous

system by the mere taking of cocain by application on his gums. This

habit was broken up at once and there has never been any tendency to

its recurrence. He had his warning, fortunately, without evil effects.

If the cocain habit can be formed as unconsciously as this, there

should be little difficulty in treating it. It is not a profound

change in the organism, but only a habit. It is not the habit itself

that is hard to break, but the effects {711} upon the nervous system

of the patient are such as to create a series of symptoms that can

only be soothed by the drug. It is these symptoms of depression,

irritation, sleeplessness, lack of appetite, constipation and the rest

that it is the physician's duty to treat in order to help the patient.

The patient breaks the habit by his will-power when properly persuaded

and when it is made clear to him that it is neither so difficult as he

thought, nor is he so likely to fail in the matter as he has imagined,

and as has perhaps been suggested to him even by physicians. The

mental treatment consists in making him realize that he can do it and

that if he wants to get rid of his habit he must do it for himself.

With this must come the assurance that every annoying symptom will be

met, that he need not recur to his favorite drug for this purpose,

that his appetite will be gradually restored and that, though perhaps

for a week he will have considerable inconvenience to bear, after that

it will be plain sailing. Usually three days can be set as the term at

which his craving ceases to be so disturbing as to make the

possibility of his relapsing into the habit a positive danger. As in

alcoholic and sex habits, the patient to be helped in breaking the

habit should be seen once a day at least, usually oftener. If he can

be made to understand that whenever the old tendency seems about to

get the upper hand is the time to see his physician, and if something

physical as well as moral is done for him, the breaking of the habit

is comparatively simple.

This method of treatment looks too simple to be quite credible to

those who have so often tried and failed in the cure of drug habits.

It is not the doctor, however, who fails, but the patient. We cannot

put new wills into a patient, but we can so brace up even an old and

tottering will as to make it possible for the worst victims of drug

habits to reform. The doctor, too, easily becomes discouraged. He has

not confidence enough in his own methods to make assurance doubly sure

for the patient as to his cure. This is what many of the pretended

specific purveyors of drug habit cures have as their principal stock

in trade. They assure patients with absolute confidence, while the

physician only too often says the same thing, but half-heartedly. A

half-hearted physician makes a hesitant patient, and success is then

very dubious from the beginning. Every patient can be cured. They may

relapse, but then they can be cured again. This is the essence of the

psychotherapy of drug habits, but it is also the only successful

element in any treatment of the drug habit that is really effective.

Specifics come and go. Sure cures cease to have their effect. The only

really effective element in any cure is the absolute trust of the

patient.

In his "Drugs and the Drug Habit" (Methuen, London) Dr. Harrington

Sainsbury, Senior Physician to the Royal Free Hospital of London, has

emphasized all these points that can only be touched on very briefly

here. He has called particular attention to the fact that the victim

of one drug habit is rather prone to acquire another if by any chance

he should once begin to take another habit-forming drug. The original

drug habit has broken down the will. It is not so much the craving for

a particular drug as the lack of will power that proves unfortunate

for the patient. He suggests "incidentally, if this explanation hold

good, it proves the solidarity of the will that it works as a whole

and not by compartments." He has dwelt on recoveries from the most

discouraging depths and insists "we must teach that {712} no one is

ever so enslaved by a habit as to be incapable of relief--this alone

is _right_ teaching, justifiable moreover by records well

substantiated of recoveries from desperate plights."

Heredity and Unfavorable Suggestion.--As to the suggestion, sometimes

encountered, of the influence of heredity and its all-powerful effect

in making it practically impossible for the son of a man who has taken

drugs to keep from doing the same thing, we must recall very

emphatically here the principles discussed elsewhere. So far as

concerns heredity, opium and the other drugs are exactly in the same

position as alcohol in their effect upon the human race. Instead of

being justified in saying that by heredity individuals of succeeding

generations are rendered more susceptible to them, just the opposite

is true and, if anything, an immunity is produced. This is not only

racial and general but is personal and actual. In recent years we have

come to realize that individuals born of tuberculous parents who care

for themselves properly are much better able to resist the invasion of

the tubercle bacilli than those who come from stocks that were never

affected by the disease. They are the patients who, in spite of the

fact that their disease reaches an advanced stage, sometimes live on

for years with proper care. Just this is true for drug addictions so

far as we know anything about it. The whole subject is as yet obscure,

but heredity rather favors than hurts the patient in these cases.

Hereditary Resistance.--Instead of being discouraged by the fact that

his father took a drug to excess and that therefore he is weaker

against this than other people, a man should rather be encouraged by

the thought that a certain amount of resistance to the craving has

probably been acquired by the particular line of cells through which

his personality is manifested. Dr. Archdall Reid has said that "the

facts concerning opium are very similar" (to those that concern

alcohol). Then he continues:

That narcotic has been used extensively in India for several

centuries. It was introduced by the English into China about two

centuries ago. Quite recently the Chinese have taken it to Burma, to

various Polynesian Islands, and to Australia. There is no evidence

that the use of opium has caused any race to deteriorate. Indeed it

happens that the finest races in India are most addicted to its use.

According to the evidence given before the late Royal Commission on

Opium, the natives of India never or very rarely take it to excess.

When first introduced into China it was the cause of a large

mortality; but to-day most Chinamen, especially in the littoral

provinces, take it in great moderation. On the other hand. Burmans,

Polynesians and Australian natives take opium in such excess and

perish of it in such numbers that their European governors are

obliged to forbid the drug to them, though the use of it is

permitted to foreign immigrants to their countries. In exactly the

same way alcohol is forbidden to Australians and Red Indians in

places where It is permitted to white men.

After-Cures.--I have said so much about the after-cure of alcoholism

that applies directly to drug addictions also, that it does not seem

necessary to repeat it here. Patients must be warned that if they

become overtired, if they lose sleep, if they are subject to much

excitement, if they put themselves in conditions of anxiety and worry,

if any form of recurrent pain develops--headache, toothache,

stomach-ache--they are likely to be tempted to take up their old

habit. If they are in a position where they can easily get the drug it

is almost inevitable that something will happen to make them feel that

{713} they are justified in taking one or two doses and from this to

the reestablishment of the habit is only a small step. Often these

patients need a change of occupation. Some of them are over-occupied,

some of them have not enough to do. In either case it is the doctor's

duty to know enough about his patient to be able to give directions.

We do not treat a drug addiction with the hope of curing it, but we

treat a patient suffering from a particular drug habit and we try so

to modify that patient's life that after we have succeeded in getting

him away from his habit, which is never difficult, he will not relapse

into it. The after-cure is the more important of the two.

CHAPTER III

SUICIDE

In spite of the gradual increase of comfort in life and its wide

diffusion--far beyond what people enjoyed in the past--there has been

a steady progressive increase in the number of suicides in recent

years. It is as if people found life less worth living the more of

ease and convenience there was in it. This increase in suicide is much

greater (over three times in the last twenty years) than the increase

in the population. Surprising as it may seem, prosperity always brings

an addition to the number of suicides. Stranger still, during hard

times the number of suicides decreases to a noteworthy degree. It is

not those who are suffering most from physical conditions who most

frequently commit suicide. Our suicides come, as a rule, from among

the better-to-do classes of people. While suicide might seem to be

quite beyond the province of the physician, it is a duty of the

psychotherapeutist to prevent not only the further increase of

suicides in general but to save particular patients from themselves in

this matter. A careful study of the conditions as they exist,

moreover, will show that he can accomplish much--more than is usually

thought--and that it is as much a professional obligation to do so as,

by the application of hygienic precautions and regulations, to lessen

disease and suffering of all kinds and prevent death.

The same two modes of preventive influence that we have over disease

in general can be applied to suicide. The physician can modify the

mental attitude in individual cases and thus save people from

themselves and then he can, by his influence in various ways upon

public opinion, lessen the death rate from suicide. For this purpose,

just as with regard to infectious disease, it is important for him to

appreciate the social and individual conditions that predispose to

suicide, as well as the factors that are more directly causative. The

more he studies the more will he be convinced that what we have to do

with in suicide is a mental affliction not necessarily inevitable in

its results and that may be much influenced by suggestion. Indeed,

unfavorable suggestion is largely responsible for the increase in

suicide that has been seen in recent years. Favorable suggestion might

be made not only to stop the increase, but actually to reduce the

suicide rate. For this purpose it is important to know just what are

the conditions and motives that predispose to suicide and, above all,

to realize that it is not the result of insufferable pain {714} or

anguish, but rather of the concentration of mind on some comparatively

trivial ailment, or exaggeration of dread with regard to the

consequences of physical or moral ills.

Suicides are often said to be irrational; in a certain sense they are.

No one who weighs reasonably all the consequences of his act will take

his own life. This irrationality, however, is nearly always functional

and passing, not of the kind that makes the commission of suicide

inevitable, but only produces a tendency to it. This tendency is

emphasized by many conditions of mind and body that the physician can

modify very materially if he sets about it. Many of the supposed

reasons for suicide are founded on the complete misunderstanding of

the significance of symptoms and dread of the future of his ailments,

often quite unjustified by what the individual is actually suffering.

Indeed, the desperation that leads to suicide is practically always

the result of a state of mind and not of a state of body. It is

exactly the same sort of state of mind which sometimes proves so

discouraging in the midst of diseases of various kinds as to make it

impossible for patients to get over their affections until a change is

brought about in their ideas. This makes clear the role of

psychotherapy with regard to suicide, and there is no doubt that many

people on the verge of self-murder can be brought to a more rational

view and then live happy, useful lives afterwards. For this purpose,

however, it is important that the physician should come to be looked

upon as a refuge by those to whom the thought of suicide has become an

obsession.

A well-known social religious organization not long since established

a suicide bureau, that is, a department to which those contemplating

suicide may apply with the idea that they would there find consolation

and perhaps some relief for their troubles and thus the idea of

suicide might be dissipated. Many a suicide would be avoided if the

reasons that impelled to it had been known to one or two other people

beforehand, so that some relief might have been afforded to what

seemed an intolerable condition. This suicide bureau is said to have

done much good. There is no doubt that the mere act of giving one's

confidence to another is quite sufficient of itself to diminish to a

marked degree a burden of grief and trial. If anything in the world is

true, it is that sorrows are halved by sharing them with another,

while joys are correspondingly increased. The fact that there is

someone to whom they might go, who would look sympathetically at their

state of mind, who would appreciate the conditions, who had been

accustomed to dealing with such cases, would be enough to tempt many

people from that awful introspection and concentration of mind on

themselves which, more than their genuine sufferings and trials,

whatever they may be, make their situation intolerable.

There has always been a suicide bureau, however, in the office of

every physician who really appreciates the genuine responsibilities of

his profession. More than any others we have the opportunity to

alleviate physical sufferings, to lessen mental anguish and to make

what seemed unbearable ill at least more or less tolerable.

Unfortunately in recent years the change in the position of the

physician in his relations to the family has somewhat obscured this

fact in the minds of the public. The old family physician occupied to

no slight extent the position of a father confessor, to whom all the

family secrets were told, from whom indeed, as a rule, it was felt

that they should not be kept; to whom father went with regard to

himself and mother, to whom mother {715} went with regard to all the

family as well as herself, to whom the boy confided some of his sex

trials and the girl some of the secrets that she hid from almost

everyone else, so that to go to him for anything disturbing became the

first thought. We must restore something of this old-fashioned idea of

the doctor's place in life if all our professional duties are to be

properly fulfilled. If those contemplating suicide learn to think of

us as persons to be appealed to when all looks so black that life is

no longer tolerable, we shall soon be in a position to confer

increased benefits on this generation that needs them so much.

Physical Factors.--As a rule there is a physical element as the basis

for nearly all suicides. With the unfortunate, unfavorable suggestion

that has come from the supplying of details of pathological

information--the half-knowledge of popular medical science--without

the proper antidote of the wonderful compensatory powers of the human

body for even serious ailments, a great many nervous people are

harboring the idea that they have or soon will have an incurable

disease. Physicians have abundant evidence of this. All sorts of

educated people come to us to be reassured that some trivial digestive

disturbance does not mean cancer of the stomach, or, when they are

between forty and fifty, come to make sure that some slight

disturbance of urination is not an enlarged prostate. Brain workers of

all classes come over and over again to be reassured that they are not

breaking down because of organic brain disease, of which they show

absolutely no sign. Sometimes they have been making themselves quite

miserable for a long period by such thoughts. It is easy to

understand, then, how many less informed people, yet provided with the

opportunities of quasi-information that modern life affords, are apt

to think the worst about themselves.

_So-called Insomnia_.--The correction of such preconceived notions

will always greatly alleviate the mental sufferings of these patients.

For this purpose there are many chapters of this book which point out

how various symptoms and syndromes that are often amongst the factors

in the production of suicide may be managed. Perhaps one of the most

frequent of these is so-called insomnia. Most people are insomniac,

mainly because they are overanxious about their sleep. A few of them

are wakeful because of bad habits in the matter of work and the taking

of air and exercise. Essential insomnia is extremely rare and

symptomatic; insomnia is not mental, but is usually due to some

definite physical condition that can be found out and, as a rule,

treated successfully. There is always some other symptom besides loss

of sleep. If men will live properly and rationally there is no reason

why insomnia should be a bane of existence, nor even any reason why

the morphin or other drug habit should be formed which is so likely to

come if inability to sleep is treated as if it were an independent

ailment. In the forms in which it incites to suicide it owes its

origin to a nervous superexcitement with regard to sleep in people

whose daily life in some way does not properly predispose them for the

greatest of blessings on which there is no patent right. Additional

suggestions as to these insomniac conditions are made in the chapters

on Insomnia and Some Troubles of Sleep which make it clear that

suicide, because of insomnia is due to a delusion.

_Headache_.--Persistent supposedly incurable headache is another

prominent feature of the stories of suicides and here once more we

have to deal rather {716} with a delusion of over-attention of mind

and concentration of self on a particular part than a real physical

ailment. Most of the so-called headaches that are supposed to be so

intractable are really not headaches but pressure feelings and other

queer sensations in the head originally perhaps partaking of the

nature of an ache but continued through over-advertence. Severe pain

within the head occurs in cases of congestion and brain tumor, and

without the head in cases of neuralgia, but most of these are only

temporary and long-continued headaches are rather neurotic than

neuritic or due to any real disturbance of the nervous system. This is

discussed in the chapter on Headaches. People commit suicide who have

for a long time been sufferers from headache because they fear that

they may go crazy. There is absolutely no reason in the world to think

this probable, and in the one case of continuance of severe

intermittent headaches for years already mentioned--that of von Buelow,

the Austrian pianist and composer, in which we have the autopsy

record--it was found, after a long life, that his severe intracranial

headaches were due to the pinching of a nerve in the dura and not to

any organic change in the brain itself.

Mental Factors.--While physical factors enter into the suicide problem

to a marked degree, it would be a great mistake to think that physical

conditions or material circumstances are the main causes or occasions

in suicide. It is supposed, as a rule, to be due to depression

produced by incurable disease, oppressive weather, financial losses

and the like. There is no doubt that these are contributing causes,

but the physical conditions have very little influence compared with

the attitude of the patient's mind toward himself. As a rule, it is

not those who are in absolutely hopeless conditions who turn to this

supposed refuge of a voluntary exit from life in order to get out of

trouble, but rather those who are momentarily discouraged and who have

not sufficient moral stamina to face the consequences of their acts.

There was a time when it was considered brave to fight a duel and

cowardly to refuse to do so. Looking back now, we know that they were

the real brave men who dared to refuse when a barbarous civilization

would force them into a false position and who, in spite of disgrace,

ventured to be men and not fools. There are those who used to say that

it was brave to take one's own life rather than bring disgrace on

loved ones, but the mitigation, if there be any, of the disgrace that

suicide brings with it, comes from that lowest of all motives, pity

for the survivors, and the cowardly suicide leaves to others the

thankless task of making up for his faults.

_Suicide and the Weather_.--An investigation of suicide records shows,

as we have said, that it is not nearly so often bodily or material

hardships that lead men to it as mental states. These mental states

are not mental diseases, but passing discouragements in which men are

tempted beyond their strength and do irretrievable things for which

there is no rational justification. It is not in dark damp weather

that men commit suicides most, though this was supposed to be a

commonplace in our knowledge of suicide. Recent investigations show

that quite the contrary is true. Professor Edwin T. Dexter of the

University of Illinois published a very important study of this

question in a paper entitled "Suicide and the Weather." [Footnote

55] He followed out the records of nearly 2,000 cases of suicide

reported to the police in the City of New York {717} and placed beside

them the records of the weather bureau of the same city for the days

on which these suicides occurred. According to this, which represents

the realities of the situation, the tendency to suicide is highest in

spring and summer and the deed is accomplished in the great majority

of cases on the sunniest days of these seasons.

[Footnote 55: _Popular Science Monthly_, April, 1901. ]

His conclusions are carefully drawn and there is no doubt that they

must be accepted as representing the actual facts. All the world feels

depressed on rainy days and in dark, cloudy weather, but suicides

react well, as a rule, against this physical depression, yet allow

their mental depression to get the better of them on the finest days

of the year. Prof. Dexter said:

The clear, dry days show the greatest number of suicides, and the

wet, partly cloudy days the least; and with differences too great to

be attributed to accident or chance. In fact there are thirty-one

per cent. more suicides on dry than on wet days, and twenty-one per

cent. more on clear days than on days that are partly cloudy.

What is thus brought out with regard to the influence of weather can

be still more strikingly seen from the suicide statistics of various

climates. The suicide rate is not highest in the Torrid nor in the

Frigid zones, but in the Temperate zones. In the North Temperate zone

it is much more marked than in the South Temperate zone. Civilization

and culture, diffused to a much greater extent in the North Temperate

zone than in the South, seem to be the main reason for this

difference. We make people capable of feeling pain more poignantly,

but do not add to their power to stand trials nor train character by

self-control to make the best of life under reasonably severe

conditions. With this in mind it is not surprising to find that the

least suicides occur in the month of December, when the disagreeable

changes so common produce a healthy vital reaction, though the many

damp dark days that occur would usually be presumed to make this the

most likely time for suicides. On the contrary, it is the month of

June, the pleasantest in the North Temperate zone, that has the most

suicides. It is important to remember this in estimating the role of

physical influences on the tendency to suicide.

Social Factors that Restrain Suicides.--_War_.--A most startling

limitation of suicide is brought about by war. For instance, our

Spanish-American war reduced the death rate from suicide in this

country over forty per cent. throughout the country and over fifty per

cent. in Washington itself, where there was most excitement with

regard to the war. This was true also during the Civil War. Our

minimum annual death rate from suicide from 1805 (when statistics on

this subject began to be kept) was one suicide to about 24,000 people,

which occurred in 1864 when our Civil War was in its severest phase.

There had been constant increase in our suicide rate every year until

the Civil War began, then there was a drop at once and this continued

until the end of the war. In New York City the average rate of suicide

for the five years of the Civil War was nearly forty-five per cent.

lower than the average for the five following years. In Massachusetts,

where the statistics were gathered very carefully, the number of

suicides for the five-year period before 1860 was nearly twenty per

cent. greater than for the five-year period immediately following,

which represents the preliminary excitement over the war and the

actual years of the war. This experience in America is only in

accordance {718} with what happens everywhere. Mr. George Kennan in

his article on "The Problems of Suicide" (_McClure's Magazine_, June,

1908), has a paragraph which brings this out very well. He says:

In Europe the restraining influence of war upon the suicidal impulse

is equally marked. The war between Austria and Italy in 1866

decreased the suicide rate for each country about fourteen per cent.

The Franco-German War of 1870-71 lowered the suicide rate of Saxony

8 per cent., that of Prussia 11.4 per cent. and that of France 18.7

per cent. The reduction was greatest in France, because the German

invasion of that country made the war excitement there much more

general and intense than it was in Saxony or Prussia.

_Great Cataclysms_.--Even more interesting than the fact that war

reduces the suicide rate is the further fact that a reduction of the

number of suicides takes place after any severe cataclysm. The

earthquake at San Francisco, for instance, had a very marked effect in

this way. Before the catastrophe suicides were occurring in that city

on an average of twelve a week. After the earthquake, when, if

physical sufferings had anything to do with suicide, it might be

expected that the self-murder rate would go up, there was so great a

reduction that only three suicides were reported in two months. Some

of this reduction was due to inadequate records, but there can be no

doubt that literally hundreds of lives were saved from suicide by the

awful catastrophe that levelled the city. Men and women were homeless,

destitute, and exposed to every kind of hardship, yet because all

those around them were suffering in the same way, everyone seemed to

be reasonably satisfied. Evidently a comparison with the conditions in

which others are has much to do with deciding the would-be suicide not

to make away with himself, for by dwelling too much on his own state

he is prone to think that he is ever so much worse off than others.

If life were always vividly interesting, as it was in San Francisco

after the earthquake, and if all men worked and suffered together as

the San Franciscans did for a few weeks, suicide would not end ten

thousand American lives every year, as it does now.

Individual Restraints.--_Religion_.--It seems worth while to call to

attention certain factors that modify the tendency to suicide and

limit it very distinctly, because it is with the limitation of it that

the physician must be mainly occupied. There seems to be no doubt that

certain religious beliefs, which affect the individual profoundly and

occupy his thoughts very much, furnishing, both by tradition and

heredity as it were, sources of consolation for evils in this life by

the thought of a future life, notably lessen the suicide rate. All

over the world the Jews who cling to their old-time belief have

perhaps the lowest suicide rate of any people. This is true in spite

of racial differences. People who retain the confidence in prayer,

that used to characterize members of all religions a century or more

ago, are likely to be able to resist the temptation to suicide. This

is true particularly for the more or less rational suicide. Oppenheim

has recalled attention to the power of prayer against depression and

in the insane asylums of England its efficiency in this way is well

recognized.

It is well-known that Roman Catholics the world over have much less

tendency to suicide than their Protestant neighbors living in the same

{719} communities. It is true that where the national suicide rate is

high many Catholics also commit suicide, but there is a distinct

disproportion between them and their neighbors. The suicide rate of

Protestants in the northern part of Ireland, as pointed by Mr. George

Kennan, is twice that of Roman Catholics in the southern part. He

discusses certain factors that would seem to modify the breadth of the

conclusion that might be drawn from this, but in the end he confesses

that their faith probably has much to do with it and that, above all,

the practice of confession must be considered as tending to lessen the

suicide rate materially. It is the securing of the confidence of these

patients that seems the physician's best hope of helping them to

combat their impulse and Mr. Kennan's opinion is worth recalling for

therapeutic purposes:

In view of the fact that the suicide rate of the Protestant cantons

in Switzerland is nearly four times that of Catholic cantons, it

seems probable that Catholicism, as a form of religious belief, does

restrain the suicidal impulse. The efficient cause may be the

Catholic practice of confessing to priests, which probably gives

much encouragement and consolation to unhappy but devout believers

and thus induces many of them to struggle on in spite of misfortune

and depression.

_Disgrace as a Restraint_.--It is curious what far-fetched motives,

that appear quite unlikely to have any such influence, sometimes prove

able to affect favorably would-be suicides and prevent their

self-destruction. Plutarch tells the story, in his treatise on "The

Virtuous Actions of Women," of the well-authenticated instance of the

young women of Milesia. Disappointed in love, they thought life not

worth living. Accordingly there was an epidemic of suicide among the

young women and it even became a sort of distinction to prefer death

to matrimony. Some perverted sense of delicacy entered into the

feeling that prompted the suicides, as if sex and its indulgence were

something belittling to the better part of their nature. The

authorities in Milesia must have been psychologists. They issued a

decree that the body of every young woman who committed suicide would

be exposed absolutely naked in the market-place for a number of days

after her death. This decree, once put into effect, immediately

stopped the suicides. The young women shrank from this exposure of

their bodies, even though it might be after death, and the suicide

fashion came to an end.

It might be thought perhaps that this incident represented ancient

feeling and that a similar condition in the modern times would not

have a corresponding effect. It so happens that something similar has

been tried. In some of the cities of South Central Europe in which the

suicide rate is almost the highest in the world, it was decided about

a generation ago by the Church authorities of the towns that suicides

would not thereafter be buried in the cemeteries near the bodies of

those who died in the regular course of nature, but must be interred

in a separate portion reserved for themselves. Strange as it may seem,

just as in the case of the young women of Milesia, this proved a great

deterrent to suicide. The suicide rate was reduced one-half the next

year.

As a matter of fact, it only takes some reasonably forceful

countervailing notion to set a train of suggestions at work that will

prevent suicide. If those contemplating suicide are made acquainted

with some of these curious facts we know, then the notion of suicide

loses more than half its terrible {720} attraction by being stripped

of all of its supposed inevitableness. Almost any motive that attracts

attention, even apparently so small a thing as disgrace after death,

makes these people realize the littleness and the cowardice of the

act.

Favoring Factors.--_Psychic Contagion_.--A prominent factor in

suicides that must constantly be borne in mind is the influence of

example or, as we have come to call it learnedly in recent years,

psychic contagion. It is discussed more in detail in the chapter on

Psychic Contagion, but its place here must be emphasized. It has often

been noted that certain peculiar suicides are followed by others of

the same kind. If a special poison has been used, others obtain it and

put an end to their lives in that way. Even such horrible modes of

death as eroding the jugular vein by drawing the neck backward and

forward across a barbed-wire fence have been imitated. If the story of

jumping off a high building is told with lurid details, special care

has to be taken in permitting unknown people to go up to the same

place for some time afterwards. The imitative tendency is evidently a

strong factor. Plutarch's story of the young women of Milesia brings

this out, and it has been noted all down the centuries.

In any discussion of the prophylaxis of suicide the effect of

newspaper descriptions of previous suicides must be looked upon as

very important. The influence of suggestion of this kind on people who

have been thinking for some time of suicide is very strong. There

comes to them the impelling thought that the suicide's miseries are

over and they wish they were with him. From the wish to the resolve

and then to the deed itself are only successive steps when suggestion

is constantly prodding the unfortunate individual. If we are going to

reduce the suicide rate materially or, indeed, keep it from increasing

beyond all bounds, this question must be squarely faced. Accounts of

suicides are not news in the ordinary sense of the word and while they

might find a place for legal and other purposes in a few lines of an

obituary column, the present exploitation of them by the papers makes

them a constantly recurring source of strong suggestion to go and do

likewise. These suggestions come to persons already tottering on the

edge of disequilibration in this matter, and it is like tempting

children to do things that they know are wrong, but that look

irresistibly inviting when presented under certain lights. The very

fact that their death will produce a sensation and will give them so

much space in the newspapers attracts many morbidly sensation-loving

people. Physicians must work as much for this prophylaxis as we have

for the prevention of infectious diseases.

Child Suicides.--Probably the worst feature of the suicide statistics

of recent times in all countries is the great increase of self-murder

among children. Arthur MacDonald in discussing the "Statistics of

Child Suicide" [Footnote 56] has shown that there is a special

increase of young suicides everywhere. In France there are nearly five

times as many suicides at the end of the nineteenth century as there

were at the beginning of it. In England there is almost as startling

an increase. Though the statistics are not as well kept, child suicide

has increased not only in proportion to the increase of suicide among

adults, but ever so much more. In Prussia the condition is even worse.

[Footnote 56: "Statistics of Child Suicide," _Transactions of American

Statistical Association_, Vol. X., pp. 1906-1907. ]

{721}

The French child suicide rate is especially interesting and

disheartening. In the Paris Thesis for 1906 Dr. Moreau discusses the

subject of suicide among young people and shows how rapid has been the

growth of the number of such suicides in the last 100 years. The first

statistics available for the purpose that, in his opinion, are exact

enough to furnish a basis for scientific conclusions, are from 1836 to

1840. Altogether during that period in France there were 92 suicides

under the age of seventeen years, 69 of whom were boys and 23 girls.

In 1895 this number had increased to such a degree that in a single

year there were almost as many suicides (90) as there had been in five

years, only fifty years before. In 1895 the proportion of suicides

less than ten years of age was a little more than one in twenty of the

total number of suicides in France. There are countries in Europe in

which the suicide rate among such children is even higher than it is

in France. In every country it has gone on increasing and the awful

thing is that the suicide rate is increasing more rapidly among

children than it is among adults, though among adults it doubles every

twenty years.

_Causes at Work_.--The causes for the increase in suicide among

children were pointed out even by Esquirol, the great French

psychiatrist, nearly a century ago. They are the same to-day, only

emphasized by the conditions of our civilization. He attributed it to

a false education which emphasizes all the vicious side of life, makes

worldly success the one object of life, does not properly prepare the

child for constancy in the midst of hardships, nor make it appreciate

that suffering is a precious heritage to the race, that has its reward

in forming character and fixing purpose. He thought that there were

two very serious factors for the increase of suicide among children

not usually realized. They were in his time literature and the

theater. He said: "When the theater presents only the triumphs of

crime, the misfortunes of virtue, when the books that are in common

circulation because of the low price at which they are issued, contain

only declarations against religion, against family ties and duties

towards our neighbor and society, then they inspire a disdain of life

and it is no wonder that suicide rapidly increases even among the very

young." He was commenting on the case of a child of thirteen who had

hanged himself, leaving this written message: "I bequeath my soul to

Rousseau and my body to the earth."

Cowardice of Suicide.--Of course, the strongest motive for dissuasion

from suicide is the utter cowardice of the act. As a rule, the man who

contemplates suicide is not a sufferer from inevitable natural causes,

but one who for some foolish act has put himself into what seems to

him an intolerable position out of which escape without disgrace is

impossible, and he is afraid to face the consequences of his own acts.

It is from the fear of mental worry and of the condemnation of others

rather than from any dread of physical suffering and pain that men

commit suicide. The suicide leaves those who are nearest and dearest

to him to face the battle of life alone, with all the handicaps that

have been created by their foolishness. Running away in battle is as

nothing compared to the cowardice of the suicide. The deserter is

deservedly held in deepest dishonor, and if there is some little pity

for the suicide, it is because of the supreme foolishness of his act

and the feeling that it only can have been dictated by some defect of

mental equilibrium. A frank recognition of these conditions in their

real significance probably will do more than anything {722} else to

make the prospective suicide realize the true status of his act better

than anything else.

Men sometimes seem to persuade themselves that it is a brave thing

thus to face death. The shadowy terrors of what may come after death

are too little realized to deter a man from his act when compared with

the real disgrace that he is so familiar with and that he has often

witnessed in actual life. It is the man, as a rule, who has most

condemned others when something has gone wrong, who has found no

sympathy in his heart for the slips of his fellows, who discovers no

courage in himself when he has to face disgrace. He does not realize

that for most men there are so many extenuations of any evil that a

man may do, that the large-minded man is ready to forgive and

eventually to forget almost anything that happens. "To know all is to

forgive all," and the more we know of men the readier we are to

forgive them. Little men do not forgive and cannot forget the failings

of their fellows and they think that everyone else looks upon men's

failings in the same way. It is only the small, narrow man who

contemplates suicide as a refuge from disgrace, and the fact that he

can complacently plan the abandonment of others not only to the

disgrace which he himself is not ready to face, but to all the

suffering consequent upon it, is the best proof of his littleness of

soul. The utter pusillanimity of suicide is the best mental antidote

for the temptation to it.

Besides, the thought that deterred Hamlet may well be urged:

There's the rub;

For in that sleep of death what dreams may come.

When we have shuffled off this mortal coil,

Must give us pause;

. . . who would fardels bear,

To grunt and sweat under a weary life;

Cut that the dread of something after death.--

The undiscovered country, from whose bourn

No traveller returns.--puzzles the will;

And makes us rather bear those ills we have.

Than fly to others we know not of?

It is sometimes said that this is the argument of a coward, but such

cowardice is as reasonable as the dread of touching a wire that may be

carrying a high charge of electricity. Besides it is only such an

argument that will properly suit the man who, in his cowardice, is

ready to let others bear the brunt of his disgrace, flying from it

himself. [Footnote 57]

[Footnote 57: Is life worth living? How old this argument as to

suicide is can perhaps best be appreciated from the fact that it is

discussed very suggestively in a papyrus of the Middle Kingdom the

date of which is probably not later than 2500 B. C, which is now in

the Berlin Museum and is recognized to be the most ancient text of

its kind that has been preserved in the Nile Valley. I have referred

to this in the initial historical chapter. I think that I have more

than once turned men's thoughts from the serious contemplation of

suicide--always a dangerous thing--by discussing with them this

fact that men have at all times in the world's history argued just

the same way on these subjects. Men prefer not to resemble the dead

ones, and a motive is all that is needed. ]

There has sometimes been an erroneous tendency to confuse suicide and

heroism, but Chesterton, in "Orthodoxy," [Footnote 58]

has well expressed the difference:

[Footnote 58: "Orthodoxy" by Gilbert K. Chesterton, New York, John

Lane Co., 1909. https://www.gutenberg.org/ebooks/130]

{723}

A soldier surrounded by enemies, if he is to cut his way out, needs

to combine a strong desire for living with a strange carelessness

about dying. He must not merely cling to life, for then he will be a

coward, and will not escape. He must not merely wait for death, for

then he will be a suicide, and will not escape. He must seek his

life in a spirit of furious indifference to it; he must desire life

like water and yet drink death like wine. No philosopher, I fancy,

has ever expressed this romantic riddle with adequate lucidity, and

I certainly have not done so. But Christianity has done more: it has

marked the limits of it in the awful graves of the suicide and the

hero, showing the distance between him who dies for a great cause

and him who dies for the sake of dying. And it has held up ever

since above the European lances the banner of the mystery of

chivalry: the Christian courage, which is a disdain of death; not

the Chinese courage, which is a disdain of life.

The feature of incidents in life that bring with them disgrace and

punishment which needs to be insisted on for those to whom the thought

of suicide comes, is that the sensation which the revelation of such

acts causes is but a passing phase of present-day publicity, and that

after all it is not even a nine-days' wonder, but a two- or

three-days' wonder, and then it is forgotten and replaced by something

else. The facing of the condemnation for the moment may seem an

extremely severe trial. The world's blame, however, is largely a

bogey, a dread that is phantom-like and that disappears, or at least

diminishes, to a great degree as soon as it is bravely faced. Besides,

as practically every man who has been carrying around a guilty secret

with him for years is free to confess, there is an immense sense of

relief once the worst is known. At last the effort at concealment, the

nervous tension, the fear of the moment of exposure are all past and a

new set of thoughts can be allowed to come. Those may be unpleasant

and yet they are not so bad as the dread of discovery that hung over

the unfortunate. If a man can be braced up to meet exposure, usually

he will find in a very few days that there are sources of consolation

that make it much easier for him to live than he thought possible

before.

Real Suffering a Tonic.--Probably the best remedy for a man or a woman

who talks of suicide and seems to fear lest the temptation should

overcome them is, if possible, to give them an opportunity to see some

real suffering. I have on a number of occasions had the opportunity to

note the effect on a discouraged man or woman of the sight of a cancer

patient suffering severely, yet bearing the suffering patiently,

wishing that the end might come, yet ready to wait until it shall come

in the appointed order of nature. Suffering, like everything else,

becomes much more bearable with inurement to it. The old have learned

the lesson of not only not looking for pleasure in life, but of being

quite satisfied with their lot if no pain comes to them, and they even

grow to consider that they have not much right to murmur if their pain

is not too severe. It is not among those who have to suffer severe

pain that one finds suicides as a rule. It is true that young, strong,

healthy persons who suddenly find that pain is to be their lot for a

prolonged period may grow so discouraged and moody over it as to take

their lives. The patients that I have seen suffering from incurable

diseases have expressed no desire at all that their life should be

shortened, except during the paroxysms of their pain, unless they feel

that they are a serious burden on others when they may express the

wish to be no more.

Euthanasia.--Every now and then there is a discussion in the

newspapers {724} of the justifiableness of euthanasia, that is, the

giving of a pleasant death to those who are known to be incurably ill

and who are doomed to suffer pain for most of what is left of their

existence. The question usually discussed is whether patients have the

right to shorten their own existence and then, also, whether their

physician might have the right or, even as some people say, the duty,

to lessen human suffering by abbreviating existence for such incurable

cases. The discussion has always seemed to me beside the realities of

things, because physicians do not see many patients, I might almost

say any patients, who really want to shorten their lives or would want

to have them shortened. I have known many physicians die of cancer,

but very seldom is it that one tries to shorten his own existence, or

that even his best friend in the profession would consider that he was

justified in doing this for him. This, it seems to me, should be the

test of the problem. It is true that not infrequently, in the midst of

their paroxysms of pain, patients wish they were dead, but there come

intervals of surcease from discomfort to some degree at least that

make life quite livable for a time again and even occasionally there

is real happiness in these intervals, deep, human, natural happiness

in heroic forbearance and example.

We can recall AEsop's fable of the old man who, gathering wood for the

fire in the winter that he needed so much, finds the burden of his

labor and the wood too much for him and calls loudly for death to come

to him. Promptly Death makes his appearance and asks what the old man

wants. "Oh! nothing," is the reply; "only I would like you to help me

to carry this bundle of sticks." This is the attitude of mind of

practically all who have grown old in suffering. They have learned to

bear with patience, and that patience gives even something of

satisfaction. After all, it is not so often the pleasant things in

life that we look back on and recall with most satisfaction as the

difficulties and trials. Virgil said long ago, _"Forsan et hoc olim

meminisse juvabit"_--perhaps at some future time we shall recall

these, our trials and pains, with pleasure. It is the conquering of

difficulty that means most for men and even the standing of pain is

not without an aftermath, if not of pleasure, at least of broad human

satisfaction. When we talk about euthanasia, then, it would be well to

ask some of these old people whether they want it or not. Seldom will

the answer be found to be that which is so often presumed, by those in

good health and strength, to be inevitable under such conditions.

Physicians have all seen incurable cancer patients who were

approaching their end inevitably and with the fatal termination not

far off, have hours and days of alleviation of suffering and even of

enjoyment that made up for the prolongation of life almost in the

midst of constant agony. The distinguished New York surgeon who had

the pleasure a few years ago of listening once more to his favorite

singer and fairly seemed to get renewed life from the inspiration of

her voice and who for days after had the pleasant consciousness of

smooth running life in improvement so characteristic of convalescence,

is a typical example of what may happen under such circumstances. I

shall not soon forget Dr. Thomas Dunn English, the well-known author

of "Sweet Alice, Ben Bolt," saying at an Alumni dinner of the

University of Pennsylvania, that, like Bismarck, he used to think that

all the joys of life's existence were in the first eighty years of

life, but of late years he had found {725} that many of them were also

in the second eighty years of life. He was at the time 83. He made the

most joyous and happiest speech on that occasion. He was quite blind,

was almost deaf, had been reported dying some months before, and had

gone through prolonged suffering, yet he was by his cheeriness and

whole-hearted gaiety on that occasion a joy and inspiration to all the

younger men at the table.

Dread of Suicide.--There are patients who come to the physician worked

up because they fear they may commit suicide. Every now and then the

thought comes to them that some time or other they will perhaps throw

themselves out of a window, or be tempted to drop in front of a

passing train, or over the side of a steamboat, or impulsively take

poison. Some nervous people become quite disturbed by these thoughts.

Every physician is sure to have some patients who must be reassured,

every now and then, that they are not likely to commit suicide. Their

nervousness over the fear of this may serve to make them supremely

miserable and it evidently becomes the doctor's duty to reassure them.

It is not difficult to do this, as a rule, provided the physician will

be absolutely confident and unhesitating in his declaration that there

is no danger that they will commit suicide, since it has almost never

been known that patients who dread it very much and, above all, those

who dread it so much that they take others into their confidence in

the matter, take their own lives. The very fact that the thought

produces so much horror and disturbance in them is the best proof that

they will not impulsively do anything irretrievable in this way.

Prof. Dubois has discussed this subject in his usual thoroughly

practical way and his words serve as an authoritative confirmation of

what has been already said, though as a matter of fact the expressions

and experience of nearly every nervous specialist thoroughly justify

the position here assumed. Besides, it must be realized that this

confident assurance is the best possible prop that doubting patients

can have with regard to the actions they dread, and by positive

declarations the physician will accomplish more than in any other way.

There are patients who are subject to strange obsessions. They are

afraid that they will throw themselves out of the door of a car, or

climb over the parapet of a bridge. They are afraid that they will

throw their relatives out of a window, or will wound somebody with a

knife or a gun. There are some with a strong impulse to open their

veins. But if there is a certain attraction in such things, it is

really a phobia. It tends to make one shrink back and not to act.

Nothing quiets these patients like the frequently repeated statement

that they will not do anything. It is necessary to show them the

vast distance there is between the impulse toward suicide and murder

and the phobia which, however distressing it may be, is a safeguard.

One must keep at this education of the mind with imperturbable

persistence and use the most forceful and convincing arguments that

one can think of to correct the judgment of his patient, in order to

make the strings of moral feeling and reason vibrate in unison.

It is through lack of courage and perseverance that we err in the

treatment of these psychoneuroses. We wait too long to distinguish

the morbid entities that bear on a certain etiology or a different

prognosis. We do not see clearly enough the bond which unites these

different affections.

It may seem to some physicians as though they would be assuming too

much responsibility in giving patients such positive assurance that

their dreads {726} will not be fulfilled, but as a matter of fact the

experience of physicians is quite sufficient to justify the confident

statements here suggested. It is true that occasionally a person who

afterwards commits suicide talks the matter over and hints at the

possibility of taking his own life. He does not, as a rule, speak of

it with dread, however, but as one of the alluring solutions of his

difficulties that he sees ahead of him. He is much more likely to

write a letter to his physician telling him that all his arrangements

are made and that by the time this letter reaches him he will be

already dead. The prospective suicide is usually quite secretive about

this purpose, not only to friends, lest he should be prevented from

accomplishing it, but even with his physician, in whom he has had

absolute confidence and to whom he has told practically everything

else. The patients who fear the possibility of committing suicide, who

tell how much they dread the horror of it, and who rush to consult the

physician to help them against themselves, show by the very fact the

unlikelihood of action on their part.

The Physician and Suicide.--By mental influence, then, the physician

may lessen the tendency to suicide in the individual and in the

community. To do this is to save suffering and to help in the solution

of one of the most serious social problems in modern times. It can

only be accomplished by a sympathetic attitude towards the whole

subject and a tactful understanding of each individual case. Every

effort in the matter, however, is well worth while, for there is no

more hideous blot on our modern civilization than the startling

increase of suicide. It is particularly important to bring about

improvement in this regard among young suicides, and fortunately it is

here that the influence of the physician for good is likely to be most

felt. The saving of life is the noblest part of the mission of the

physician and nowhere, perhaps, can this be accomplished more

successfully than with regard to some of these patients whom a rash

resolution, due to a momentary fit of depression and a sense of

suffering exaggerated out of all proportion to their actual pain, is

hurrying out of life.

CHAPTER IV

GRIEF

Grieving would seem at first glance to be one of the conditions for

which the physician, especially if the etymology of the name of his

profession be taken strictly, should not be called upon to minister,

nor his remedies be expected to relieve. Grief is usually supposed to

be due to moral ills and, therefore, at most to come under the care of

the alienist, with the feeling that even he can accomplish very little

for what is an affective rather than a true mental disorder. There is

no doubt at all, however, that grieving, especially in the excess that

shows it to be pathological, is always associated with certain

physical and mental conditions for which the physician can accomplish

much. Indeed more often than not the physical condition of the

grief-stricken person is a prominent factor in the production of the

state of feeling which causes grief to be exaggerated, while, on the

other hand, this state of mind {727} itself reacts upon the physical

being so as to make it more sluggish in all its functions, and as a

consequence a vicious circle of cause and effect is formed affecting

unfavorably both the mental and physical conditions. It is when

patients are run down in health that grief becomes extremely difficult

or apparently impossible to bear and grief itself still further brings

about a deterioration of health that makes the mind's reactionary

power against its gloomy feelings still weaker than they were.

Viewed in this way, grief is an ailment that should properly come to

the physician for treatment and with regard to which that important

principle is eminently true that the physician cannot always cure, but

he can nearly always relieve, and he can always console his patients.

On the one hand, an improvement in the general health always make

grief easier to bear because it increases the resistive vitality of

both mind and body. On the other, any diversion of mind that lifts the

burden of grief even to some degree, releases new stimuli and physical

powers for the restoration of bodily function to the normal and this

brings about an immediate lessening of the depressive condition. In a

word, for the vicious circle of unfavorable influences ever pushing

the victim farther into depression, a virtuous circle, in the Latin

sense of the word virtue, meaning courage, favoring strength, must be

formed, that brings about an immediate improvement in the patient's

mental and physical well-being. This is not a pretty bit of theory but

is the result of the experience of every physician who has ever taken

seriously the problems of caring for the grief-stricken.

Natural and Pathological Grief.--It is, of course, not easy to

distinguish between grief that may be called morbid in the sense of a

melancholy, that is, more than natural--a true mental disease--and

that which represents only an affective state accompanied by

depression from which there will be complete reaction. A mother loses

a favorite, it may be an only son, and is plunged into grief. For

days, even weeks, she refuses to take any interest in life, she thinks

moodily about the awful affliction that has come to her and how blank

the future is, and she cannot be aroused to attend either to her own

affairs or to the duties of life around her. Such a grief is, in many

cases, not more than the normal depression incident to such a loss. If

after months, however, the mother still continues to refuse to take

interest in life and the things around her, especially if, besides,

she now talks of having been visited with this punishment because of

some unpardonable sin in her own life, or because the Deity has been

offended beyond all hope of propitiation, then the case verges over

into one of true melancholy in which the mental depression is not

merely a symptom of a passing condition, but partakes of the nature of

a mental disease, or is the consequence of a profound neurotic

condition.

It must not be forgotten that there is always the danger that

exaggerated grief, as it seems for the moment to be, may be only the

first symptom of a true melancholic condition. Only too often friends

and physicians have been deceived by this. Some of the sad cases of

self-destruction and a few cases of homicide and suicide have followed

a condition that seemed to be only abnormal grief for the loss of a

relative.