Etiology.--The cause of exaggerated, prolonged grief is, in a

considerable proportion of the cases, a melancholic tendency, that is,

a failure on the {728} part of the mind to react against depression.

The weakness of mind that predisposes to this may be inherent or

acquired. Sometimes no special loss is needed to produce melancholia

in susceptible individuals, while occasionally it is precipitated by

some misfortune, inasmuch as this is a mental disease, very little can

be done directly, and yet the patient can be helped and diversion of

mind may bring a good measure of relief. More often, however, the

reason for persistent grieving is that before the disturbing loss came

into the life of the individual there had been a serious deterioration

in health. This was due to the conditions preceding the unfortunate

event. Wives sometimes have worn themselves out physically and

mentally while nursing husbands, or mothers their children, and this

has produced a lack of physical force which prevents them from

reacting with healthy mentality against the subsequent shock of loss.

Prophylaxis..--For the melancholic tendency prophylaxis cannot be

special, but must be general. We cannot prevent people from suffering

serious losses, but we can foresee the possibility of a loss proving

very depressing, and can, therefore, try to keep the individual in

reasonably good physical condition. If this is done the subsequent

depression will be much less than it otherwise would be. Very often

there is little or no recognition of the fact that there is a definite

tendency in some patients to too great an inclination toward

melancholic thoughts, and it is not until an exaggerated manifestation

of it comes that the danger is realized. It is not easy to make

patients realize the dangers, but where the physician talks with

assurance and points out definite things to do in order to prevent

serious developments, patients, or at least their friends, can be made

to appreciate the dangers.

The best demonstration that I know of the value of work as a remedy

for grief is my experience with members of religious orders. For them,

as a rule, there is no interruption in life no matter what the loss

may be. Their work goes on the day after the funeral just as before.

This is the most precious possible arrangement, time and occupation of

mind are the two factors that will dull the edge of grief and while

humanly we may resent the consolation that is thus brought by such

conventional things as the passage of time and humdrum occupations,

they represent nature's resources. Above all, patients must be given

something to do and if that something concerns other suffering human

beings, there is every reason to expect relief.

Treatment.--The most important element in the treatment of grief cases

is to prevent physical running down as far as possible and to build up

the physical condition. Depression that comes to patients who have

lost considerable weight, even though it may show some of the signs of

melancholia, is always hopeful. Where patients are twenty or thirty

pounds under weight the recovery of weight up to the normal condition

will often mean the relief of their depressed condition. The one hope

lies in this physical improvement. Mental treatment by diversion of

mind must, of course, be practiced. This does not mean getting the

patients interested once more in trivial things, but to be successful

it means arousing the deeper feelings of their nature. Above all, the

solace of tears will often save depressed and grieving persons from

themselves. An interest in the sufferings of other people that awaken

their sympathy will do the most to end exaggerated grieving over their

own loss. The self-centeredness of their grief is the principal reason

for its exaggeration. {729} It is because of overestimation of their

own importance and of the importance of their loss that these people

suffer severely.

_Motives of Consolation_.--The main resource of the physician who

would employ psychotherapy for the treatment of those who are grieving

beyond the limit of what is normal, is to supply motives by which they

can understand the real significance of their loss. Very often,

especially in young folks, there is no proper estimation of values in

life and no recognition of the fact that human life was evidently not

meant for happiness since that comes to but few, while suffering and

partings are inevitable. They come to all, and apparently will always

continue to do so. It is the young or, at least, those under middle

age, who are most likely to be affected by exaggerated depression over

losses and disappointments. Older folks have grown more accustomed to

such incidents. These patients must be made to see how many motives

there are to take their grief philosophically and while permitting

themselves the luxury of sorrow, not to let this interfere either with

their physical condition or their mental state to such a degree as to

prevent them from taking the proper interest in their duties in life.

The ethical motives that may be urged to keep people from grieving

over-much are many, but there is sometimes the feeling in the

physician's mind that it is scarcely his business to emphasize them in

any way. It is supposed that to the clergyman must be committed the

task of consoling people for losses in life. This has always seemed to

me a serious mistake. As physicians we know how much the mind

influences the body and since it is our duty to care for the body, we

must, above all and first of all, care for the mind as far as we can.

_Mens sana in corpore sano_ is a very old motto and is usually taken

only in the sense that to have a healthy mind one must have a healthy

body. In its Latin form, however, it might very well also be taken to

mean that to have a healthy body one must have a healthy mind. Since

grief has an untoward influence on the body, physicians are bound to

learn what to do for it in any and every possible way and to exercise

every faculty they have for its relief. This is all the more true

because in recent years many persons have no regular religious

attendant who would come to offer them consolation or to whom they

would go in their trouble. It is not at all with the idea of

infringing on the rights of the clergy or invading his territory that

I would insist not only on the right of the medical man, but even his

duty, to afford consolation to the mind as well as relief for the

body.

_The Family Physician_.--In older times the family physician was a

friend of the family to whom people turned in all troubles where he

might possibly be of aid, with just as much confidence and as promptly

as they did to their religious attendant. Unfortunately, in the

progress of medicine, though still more because of the social

vicissitudes that have taken place in recent years, this relationship

of the family physician has been largely diminished, but that

constitutes only one more reason why every physician, to whose

attention the grief of a patient for any loss is presented as a cause

of ill-health, should know all the means and be ready to employ them

for the amelioration of the condition. As a matter of fact, there is

often a feeling on the part of patients that it is more or less the

business of the clergyman to afford consolation and that the

performance of his duty in this matter is somewhat conventional, not

{730} as if he performed it less thoroughly because of this, but as if

the feeling of the routine practice detracted from its effectiveness.

Some of the motives for consolation advanced by the clergyman, then,

lose in significance, in some persons' minds at least, because of this

feeling, while motives presented by the physician rather gain in

weight because of the impression that he is a thoroughly practical

man, deeply interested in life's problems from a common-sense

standpoint, and who knows the motives for consolation because he has

realized that losses are inevitable, suffering unavoidable, and grief

sure to come, though somehow we must learn to bear up bravely under

life as we find it.

Physicians have always done this in the past, but in more recent years

either they have lost the habit, or have considered it unworthy of

their profession, or else, perhaps, only too often they themselves

have had no motives to offer that might seem sources of consolation

for those in suffering and especially those who are grieved for the

loss of friends. If life were a mere chance, if there were not an

evident purpose in it, if, as Lord Kelvin insisted, science did not

demonstrate (not "suggest" but "demonstrate" is the word he used) the

existence of a Creator and a Providence, Who, while caring for the

huge concerns of the universe, can just as well employ Himself with

the little details of human life, then there would be some reason for

physicians thinking that their science kept them from seeking

consolation from the ordinary motives. Even if they occupy an advanced

agnostic position, however, they may still find sources of consolation

that, if not so effective as those attached to the old beliefs, at

least will provide something for the forlorn to take hold of, that

will mitigate their grief and sense of loss and make the present and

the future look not all too blank.

Few men have been so thoroughly agnostic as Prof. Huxley, yet on the

death of his wife he found that some of the thoughts of the old

beliefs might prove a source of consolation. Huxley had loved his wife

very dearly and their separation by death meant very much. The epitaph

that he wrote for her sums up his doubts yet plucks out of them

something to console, expressed in old Scriptural language:

And if there be no meeting past the grave.

If all is darkness, silence, yet 'tis rest.

Be not afraid, ye waiting hearts that weep.

For God still giveth His beloved sleep;

And if an endless sleep He wills, so best.

_Attitude Toward Death_.--The ordinary attitude of people toward death

is a very curious one. Death is the one absolutely certain thing in

life after birth, yet most of us live our lives without much regard to

it, and whenever it comes and under whatever circumstances, at

whatever age, it is always a shock to us. No matter how old people are

it always comes a little before it is expected. When death comes it is

always a shock and all that can be said of it is what Hamlet resents

when the commonplace consolations for the loss of his father, who also

lost a father and so on all down the course of history, are offered to

him. Perhaps, however, as much the reason for his resentment was the

person who offered the consolation as the form of the consolation

itself, which, after all, exhausts nearly all that we can say in this

matter for grief for near and dear ones:

{731}

King.

'Tis sweet and commendable in your nature, Hamlet,

To give these mourning duties to your father:

But, you must know, your father lost a father;

That father lost, lost his; and the survivor bound

In filial obligation, for some term

To do obsequious sorrow: but to persevere

In obstinate condolement, is a course

Of impious stubbornness: 'tis unmanly grief:

. . . Fie! 'tis a fault to heaven,

A fault against the dead, a fault to nature.

To reason most absurd, whose common theme

Is death of fathers, and who still hath cried,

From the first corse, till he that died to-day,

"This must be so."

_Death and Pain_.--One of the most effective consolations in our day

for all classes of people, quite apart from religious affiliations or

beliefs, is the sociological import of death and suffering in the

world. Life, without suffering and death in it, would be a riot of

selfishness. Men, as a rule, would not care for others at all, the

weak would go to the wall, the individuals who possess less efficiency

than others would simply have to make out as best they could, and bad

as social conditions are now, they would be intolerably worse. As it

is the young and strong and vigorous have very little of true

sympathy. Nothing makes a man feel for others like having gone through

some suffering himself. On the other hand, nothing makes him feel the

impotence of struggling ceaselessly for vain success and the futile

rewards of life than to lose near and dear friends whose share in that

success and joy over the rewards would constitute their only real

value and justification. As a man grows older and has gone through

some of the sufferings and has had to bear the losses of life, he

learns more and more to feel for others, he is ready even to make

sacrifices that others may not have to suffer as he has suffered, he

has charity for them for the sake of his own suffering and that of

near and dear ones, and things are much better than they could

possibly be without suffering and death.

_Therapy by Example_.--Many men have taken losses so seriously as to

think that life held no more for them, and have foolishly given up

their occupations, yet have found that Time, the great healer, could

work his marvels in their case as well as in most others and that new

interests and, above all, their life work, could arouse them to a

sense of duty and bring them back to the old routine of life. Dr.

Mumford, in his "Sketch of Sir Astley Cooper," tells the story of how

even that veteran surgeon gave up everything at the death of his wife

and yet found, after a year of idleness, that he had to come back to

the old life again. Dr. Mumford says: "Sir Astley Cooper was an

emotional man. In 1827 his wife died, and the event prostrated him

with grief. He felt that all the interests of life were over for him.

He fell into an acute physical decline, sold his town house, threw up

his practice and other professional employments, and retired to his

country place to pass his last days. Within a year of the sad event he

had returned to town, taken another house, resumed practice with

increased vigor, and married again. He was then sixty years old, he

lived on until 1841, and died in his seventy-fourth year."

{732}

A typical example of how much a strong man whose diplomatic ability

had stamped him as one of the large men of his generation may yet be

afflicted beyond measure by a loss of this kind is to be found in the

life of the second Lord Lytton. I have told it somewhat in detail in

the chapter on Periodic Depression. After the death of his boy Lord

Lytton, who for more than a week of anguish had watched unceasingly at

the death-bed of his dying son, came to the conclusion that God was

not in His world or, at least, that the arm of Providence was

shortened if such (as it seemed to him) needless suffering was

permitted. The boy had probably suffered much less than the bystanders

thought and much less than he seemed to, for in these cases nearly

always there is a merciful deadening of the senses that to a great

extent eliminates suffering, but Lord Lytton could not understand and

refused ever to look at life from the same standpoint afterwards. This

is, of course, only what happens in many cases, but it represents an

exaggeration of grief since death and suffering have always been in

the world and sometimes they will come to those near and dear to us,

much as we may resent it.

Neither profound intelligence nor the sympathetic genius of the poet

or artist is sufficient to safeguard men against the severer forms of

griefs for loss. Louis, the distinguished French physician (to whom we

in America are indebted so much as the Master of the Boston and

Philadelphia schools of diagnosis, and, above all, for his teaching of

the differentiation between typhoid and typhus fever), suffered so

much from the loss of his son that he could scarcely be consoled.

Dante Gabriel Rossetti was so much affected by the death of his wife

that he put into her coffin the only manuscript copy of his poems that

he possessed. It is interesting to learn that some years later he had

the coffin exhumed and took out his manuscript at the urging of

friends, and published the poems. Many other examples of this kind

might be given, for exaggeration of grief affects all classes and

conditions in life. They are practically always pathological, usually

on a basis of somewhat disturbed mentality, though often the real

underlying and predisposing condition is the physical exhaustion that

has preceded the loss and which makes patients unable to bear the

strain of it after weeks of care, solicitude, anxiety and neglect of

eating and sleep.

CHAPTER V

DOUBTING

In recent years the attention of physicians has been called to the

fact that many people are made profoundly miserable by an

unconquerable tendency to doubt about nearly everything that has

happened to them, or is happening, or is about to happen. This is not

a new phenomenon, but introspection has emphasized it, leisure gives

more opportunity for it, and so physicians hear more of it now than

they did in the past. This doubting tendency sometimes makes serious

inroads on the peace of mind of sufferers from it because they cannot

make up their minds to do things, even to take exercise, to eat as

{733} they should in quantity or quality, and to share the ordinary

life around them sufficiently to get such diversion of mind as will

keep their physical functions normal. The state used to be described

as a neurasthenia (nervous weakness), but in recent years has come

better to be designated as in the class of psychasthenias (lack of

mental energy). It is always a mental trouble in the sense that it is

difficult for these patients to make up their minds about things, yet

it is not a mental disease in the ordinary sense of the term, and

these people are often eminently sane and thoroughly intellectual when

their attention has been once profoundly attracted. They may even,

under favorable circumstances, be active and useful helpers in great

causes, yet there is always to be observed in them a certain

noteworthy difference in mentality from the normal. The physician can

do more for an affection of this kind than is usually thought, and he

is probably the only one who can thoroughly appreciate and sympathize

and, therefore, be helpful in the condition.

Sufferers are often laughed at by their friends and relatives and are

likely to be the subjects of at least a little ridicule if they take

their troubles to their physician. As a matter of fact, however,

doubting is a typical case for psychotherapeutics and not only can

much be done for its relief, but it can be kept from disturbing the

general health, which it is prone to do if neglected, and by mental

discipline and acquired habits of self-control, the doubting habit may

be almost completely eradicated.

Exaggeration of Ordinary State of Mind.--The first thing absolutely

necessary to impress upon the minds of these victims of their own

doubts is that their condition is by no means unique, it is not even

very singular, but is only an exaggeration of that hesitancy and

tendency to put off making decisions that practically every person

finds in a lifelong experience. This frame of mind is rather

cultivated by education and by a large accumulation of knowledge. The

less one knows the easier it is to come to decisions about difficult

problems and to form conclusions without hesitancy. The young man will

decide anything under the sun, and a few other things besides, almost

without a moment's hesitation, and after but slight consideration.

Twenty years later he looks back and wonders how he did it, and having

done it, how he succeeded in turning the practical conclusions to

which he came to advantage. The scholar is eminently a doubter and a

hesitater, and we recognize that he loses certain of the qualities

that would make him a practical man of affairs, though he gains so

much more that broadens and deepens life's significance that there can

be no doubt about the value of his liberal education.

"Hamlet" is just the story of one of these doubters and hesitaters. He

saw his duty clearly and that duty was imperative. In spite of

cumulative evidence, however, he refused to go on to the performance

of that duty, urging to himself now one and now another reason of

delay, until finally he wonders whether it would not be worth the

while to take his own life, rather than try any longer to solve the

problems that lie around him demanding solution. When he finally does

something, his hand is forced and circumstances have so arranged

themselves that instead of one clean-cut punishment for a great crime,

there is the tragedy that involves six lives, including his own. The

play seems to involve such exceptional characters and to be written

around such an unusual set of circumstances that it might be thought

{734} that it would prove uninteresting for men and women generally.

As a matter of fact, however, "Hamlet" is the most popular of

Shakespeare's plays and probably the most popular play, both for

readers and auditors, that was ever written. There are commentaries by

the hundred on it in nearly every modern language. Men have been more

interested in this figment of Shakespeare's imagination than in any

man that ever lived. Caesar and Napoleon have not attracted so much

attention. Only Homer and Dante have been perhaps more written about

than Hamlet.

Shakespeare has emphasized the condition of Hamlet by showing us an

eminently well educated man. His deep interest in literature, and

especially in dramatic literature and all that relates to the stage,

can be appreciated very readily from his speech to the players. No one

but a man of profound critical ability and deep intellectual interests

could have so summed up the actors' relation to the drama. Of course,

this is Shakespeare himself talking and unthinking people have said

that this was a purple patch fastened on the play because it gave the

author an opportunity to express his views with regard to actors and

their ways. Instead of that, it is of the very essence of the

development of Hamlet's character and shows us the scholarly amateur

who knows so much about many things that he has become quite unable to

make up his mind about the practical problems that lie before him.

James Russell Lowell says that Shakespeare sent Hamlet to Wittenberg,

though Wittenberg was not founded until centuries after Hamlet

existed--and Shakespeare probably knew that very well--because

Wittenberg in Shakespeare's time, on account of its connection with

Luther and the religious revolt in Germany, had the widespread repute

of occupying men's minds with doubts about many of the things that had

been deemed perfectly settled before, and its popular reputation

serves to give an added hint as to the character of Hamlet as the

dramatist saw it.

Once those who are perturbed by doubts learn that the reason for the

universal human interest in Hamlet is that there is a large capacity

for doubt of self in every man and woman, that we all put off making

decisions whenever possible, sometimes refuse to open letters when

they come if we fear that they will contain some disturbing news, put

off writing letters because we have to state ideas definitely,

apparently hope that the day and the night will bring us counsel and

that somehow the decision will be made for us without the trouble of

making up our minds, then they lose their sense of discouragement over

their condition and appreciate that they are suffering only from an

exaggeration, probably temporary and quite eradicable, of a state of

mind that comes to practically every human being.

This is the important thing, because on it can be founded the only

really hopeful therapy of the condition. Doubting is a habit that may

be increased by yielding to it, but that can be diminished to a very

great extent by constant discipline, which refuses to permit doubts

and hesitancy and bravely makes decisions, even though there may be

the feeling that they may prove to be wrong.

Extent of Affection.--If such discipline is not instituted, then the

lengths to which the doubting hesitant habit may go are almost

incredible. I have had patients tell me that they doubted about nearly

everything in the past. A very dear friend once confided to me that it

was always a source of bother {735} to him that he was not quite sure

whether he was married or not. His marriage I knew had been a public

ceremonial, and he had led his bride down the aisle to the strains of

the "Wedding March" in quite conventional style, but he was hesitant

of speech, especially under excitement, and he was not sure that he

had ever said "I will" to the question of the clergyman, for there was

a constriction at his throat at the moment and he could utter no

sound. The absence of any audible sound from the groom is not so

unusual as to attract attention and, of course, his intention and his

bodily presence and everything else gave the assent without the

necessity for the word, but he could not get out of his mind the

thought that possibly he was not married and at times it gave him

poignant discomfort. He was a thoroughly intelligent man, a teacher

and a writer, with no abnormalities that attracted attention, and his

tendency to doubt was only known to very near friends who laughed at

it and had no idea at all of the annoyance that it often gave its

unfortunate victim.

I have a clergyman friend who has had some serious scruples with

regard to his ordination. He is a Catholic priest and at a certain

part of the ceremonial of ordination it is considered necessary for

the candidate for orders to touch at the same moment the paten, the

small metal plate on which the Host is placed, and the chalice. This

clergyman is not sure that he had done this simultaneously. As a rule,

great care is exercised in seeing that all the details of the

ordination ceremonies are carried out very exactly and as there are a

number of attendants on the altar whose duty it is to see that the

absolutely necessary details are properly fulfilled, it is quite

improbable that any mistake in this matter was made. The young

clergyman, however, had not made an act of conscious attention at the

moment when he was supposed to do this, and consequently he could not

be sure afterwards whether he had done it or not. He thought of it as

the very essence of his ordination and he feared that all his

subsequent acts as a clergyman might be impaired by this negligence.

Trivial Doubts.--It is not alone with regard to important things,

however, that people may doubt and are disturbed by doubts, but with

regard to every trivial thing in life, if they permit the habit to

grow on them. Doubting is, after all, one of the phobias, that is to

say, it is the fear that something may happen if the decision they

make is wrong, that causes people to hesitate so much. There is a

tendency in all of us which, if undisciplined, may make us put off the

doing of things until the last moment. It is easy to resolve the night

before that we will do certain things the next day, but when the next

day comes we find excuses to put them off. I have already suggested as

a symptom that some people put off the opening of letters. There are

probably more who do this than anyone has any idea of. Delay in

answering letters is probably much more often due to hesitancy of

decision than to actual laziness. We doubt as to what we should say

about certain things, and we do not care to take the trouble of making

up our minds, and we fear if we do make up our minds it may be wrong,

so we adjourn the whole matter to another time and keep on adjourning

it. Many people are quite ready to confess that they do not do things

until they have to, though few are ready to acknowledge that it is due

to hesitancy or doubting about themselves and their decisions.

{736}

Of course, the man who doubts whether he has locked the door of his

house after he gets to bed can only satisfy himself by getting up and

actually investigating the state of affairs. Then there is the man who

doubts whether he has locked his safe at the office. He may get his

doubts just as he reaches the foot of the elevator and then if he is

wise he will go back and determine the matter. If he is wise with

experience he will also deliberately determine while he is there

whether the office window is closed and locked and will make a

conscious act when he comes out as to the locking of the office door.

If he does not do all this he will have further doubts on the way up

town and at his home during the evening which will make the doing of

anything else a matter of discomfort and he will spoil the restfulness

of his after-dinner hours. Some men conquer their first doubt, make

their way home only to be beset by so many doubts that at the end of

an hour they go back to their office and determine whether the safe is

locked or not. Finding it locked they may forget to notice other

things about the office and then they will surely have doubts about

these, and they may have to go back again and see about them.

Then there is the man who doubts whether he posted a letter or if he

did post it, who doubts whether it found its way down to the bottom of

the mail box, or whether it may not have caught on a projecting screw

or bolt or some portion of the upper part of the box and so fail of

collection; he may go back several times to determine this. Doubts

about even more trivial matters than this, however, annoy some people.

I have known widows on whom the responsibility of managing the

financial affairs of the household had been thrown for the first time

after their husbands' death, who constantly doubted whether they could

afford to spend this or that, though they were regularly saving money

from their income. Over and over again they would have to go over all

their recent expenditures to decide whether they could afford certain

expenses. Such little things as the sort of paper to use in their

correspondence, the wages they paid their servants, the amount of

waste in the food in the household, all aroused in them doubts and set

them to calculating once more just what was the relation of their

income to expenditure, all to no purpose, for they would have the same

doubts the next week or month.

Then there are people who doubt whether their friends really think

anything of them. They think that though they treat them courteously

this may be only common politeness and they may really resent their

wasting their time when they call on them. They hesitate to ask these

people to do things for them, though over and over again the friends

may have shown their willingness and, above all, by asking favors of

them in turn, may have shown that they were quite willing to put

themselves under obligations. They doubt about their charities. They

wonder whether they may really not be doing more harm than good,

though they have investigated the cases or have had them investigated

and the object of their charity may have been proved to be quite

deserving. They hesitate about the acquisition of new friends, and

doubt whether they should give them any confidence and whether the

confidences that they have received from them are not really baits.

This is, of course, a verging on suspicion as well as hesitancy and

doubt, but the stories of how these people try to conquer themselves,

yet have to make decision after decision, each one requiring time and

a certain resolution of mind, are quite {737} pitiable. It gets worse

rather than better unless a definite discipline of opposition and

control is organized.

What ordinary people do habitually and easily and without any effort

of mind, these people must waste time and mental energy over so that

it is extremely difficult for them to accomplish anything. Training of

mind, as of hand, consists in making certain actions so habitual that

they are accomplished quite automatically. If we have decided that we

are to get up at a certain hour we get up at that hour and do not have

to make up our minds about it again, though this is one of the actions

in which we all have the most lapses and the most need of renewal of

resolution and habit. We make up our mind what we are going to eat and

gradually acquire the habit of eating a certain quantity and a certain

variety at meals and then we do not have to make up our minds about it

every time. We go out, to do whatever must be done in our occupation

quite automatically and there is no need of wasting mental energy over

decisions about it. It is this that the doubter cannot do. He or she

calls every trifling act before the supreme court of last decision,

the bar of intellect, to decide whether it is worth while doing,

whether it is to be done or not, how it is to be done, and then there

is a doubt whether after it is done it may not prove to be quite the

wrong thing to have done. This adds so much to the friction of life

that all the surplus energy is used up in the settling of trivial

matters, and nothing worth while is accomplished.

Sir James Paget once expressed all the realities of the situation of

many of these people in a few terse phrases. It is probably the best

explanation of its kind that we have and it deserves to be in the

notebook and often before the mind of physicians who treat neurotic

patients. Sir James said: "The patient says 'She cannot'; her friends

say 'She will not'; the truth is she cannot will."

The expression, of course, applies to many other phases of so-called

nervous disease besides doubting and especially to the psychasthenias.

It represents, indeed, the keynote of many of these puzzling

affections. The fact that it was uttered more than half a century ago

shows how much better these affections were understood two generations

before ours than we are likely to think, and how well physicians then

got to the heart of them. From this to the re-education of will, that

mental discipline and relearning of self-control which constitutes the

essence of the treatment of them, is but a short step.

Prophylaxis.--_Serious Occupation_.--Of course, the real way out of

the trouble is to have to do certain important things that occupy the

mind and require the doing of many other things as subsidiaries which

must be accomplished in order to carry out the greater resolution. Men

who have important affairs on their hands seldom are bothered by

doubts and hesitancy. Women who have not much to do make mountains out

of the molehills of their little occupations and every trifle must be

adjudged. The larger interests must be cultivated, the smaller ones

must be turned over to the automaton which every one of us can develop

in our persons if we only set about it resolutely. Each thing that

comes up must be settled at once and action must replace

contemplation. The Hamlet in us all must be put down and resolution

must not be allowed to be sicklied over with the pale cast of thought.

We must do {738} things and not think about them too much. The

doubters can learn this lesson. They will never be entirely without

hesitancy, but they can remove many of their difficulties, and live to

accomplish much in spite of their make-up.

Physical Treatment.--The physical treatment of the doubting state

consists, of course, in bringing the individual's physical condition

as near as possible up to the normal. When the state occurs in people

who are under weight its betterment is rather easy. The special

feature of the physical condition that needs seeing to is an ample

supply of fresh air. People who live in ill-ventilated places, or who

do not get out into the air enough, are almost sure to suffer from the

tendency to avoid the making of decisions. The man of decision usually

is a vigorous outdoor-air individual. Even the perfectly healthy man

who has been in the house for some reason for days together gets into

a state of mind where the making of decisions becomes objectionable.

He wants to push things away from him. In individuals who already have

a natural tendency this way this is greatly exaggerated by

confinement. Arrangements must be made, therefore, that will ensure

getting out for some time, not once but twice every day. The regular

making of decisions for this purpose is of itself a good mental

discipline. It must not be omitted even for rain or snow, unless there

are additional reasons of some kind. An abundance of fresh air in the

sleeping-room is extremely important and must be secured.

Mental Treatment.--The mental treatment consists in diversion of mind.

Usually the doubters have no interests that appeal to them deeply and

in which they have to make prompt regular decisions. If possible,

these must be secured. They must form habits of doing things regularly

and of making up their minds to do them, and then not have to repeat

the adjudication and resolution. In recent years people realize, quite

apart from its religious significance, the value of what older

religious writers called examination of conscience. Regularly before

they go to sleep these people must be told to call up what they have

done during the day and to note their faults in the matter of putting

off doing things and making decisions slowly. They must, however, not

only realize their faults, but they must make up their mind to correct

them during the following day. They must not leave the arrangement of

what they shall do next day to chance, but must decide just how and

when they shall do things and then, as far as possible, keep to this

program. The program must, of course, be sensible and considerate.

This preliminary arrangement can be made to mean much more than might

be thought. Some people thus learn to correct entirely their tendency

to doubt whether they should do things or not and lessen greatly the

difficulties they have in making decisions.

CHAPTER VI

RESPONSIBILITY AND WILL POWER

The development of science (meaning by that term knowledge with regard

to physical nature in contradistinction to philosophy or the relation

of nature to man) in modern times has brought about in some minds a

hesitant, if {739} not frankly contradictory attitude towards the

question of free will. There are many scientists who not only doubt

the existence of free will, but insist that there cannot be such a

thing. For them, man like the animals is determined to do things from

without rather than from within. The stronger motive compels him.

There may be a weighing in the balance of motives, but that is a

question of intellect and not of will. It is true that the stronger

motive may be one that is less alluring to nature or to sense than

some of the others which clamor for a hearing, but it is eventually

the stronger motive that compels. A man may desire something that does

not belong to him very much, but the consciousness that it does not

belong to him and that to take things that do not belong to him is

unworthy of him will override his covetousness and so he remains

honest if he has been trained to regard things that way. After all,

the old maxim, "Honesty is the best policy," is founded on some such

reasoning as this, since only one who is at heart dishonest would

consider men as swayed by the thought that to be honest is the most

profitable, instead of being the right, and therefore the only proper

thing.

The argument for free will that appeals to most men is the

consciousness that we are free and that at any given moment we can do

a thing or not do it, just as suits us. If two things are presented

to us we can do that one which seems right to us to do, or we can do

both of them, or we can permit ourselves to be led into the wrong,

though always acknowledging to ourselves that it is the wrong and

feeling downcast, or at least disturbed, that we should let ourselves

be led away from higher motives. Even in this case the determinist

insists that we are determined from without by motives due to our

training, to our education along certain lines with the influence of

the environment in which we live, to the special sentiment that we

have within us as a consequence of the influences of preceding life.

Such determination, however, does not come from without us, but from

within. It is the result of the formation of our wills in a particular

direction. The argument is, therefore, a begging of the question. A

man may have formed the habit of doing evil things and then finds it

easy to do them without compunction. On the other hand, the exercise

of his will in doing what he considers right, in spite of the fact

that it may not be pleasant at the moment, is a training of the will

founded on its essential freedom. There is an essential distinction

between right and wrong, and we have it in our power, as many a man

has done, to follow the right even though it costs our life.

Bad Temper.--A typical example of supposed determinism, which proves

exactly the opposite of what is sometimes urged, may be noted with

regard to exhibitions of temper. As Clouston declares in his

"Unsoundness of Mind" (Methuen, London, 1911), "an uncontrollable

temper is in many cases very like and nearly allied to an unsoundness

of mind. It is certain that bad temper may gradually pass into

technical insanity and that a considerable number of persons who are

passing or have passed into insanity exhibit as the most marked

symptom morbidness and violence of temper. 'It's just temper. Doctor,'

is one of the most common remarks that I have heard made to me by

patients' friends. I think that it is quite certain that in most cases

much might be done in youth to establish a reasonable control over

temper where it is inclined to be uncontrolled, so preventing serious

discomforts in life both to its possessor and to others. In many cases

I am satisfied that {740} this education would have the effect of

preventing unsoundness of mind also, arising out of uncontrolled

temper." There are many examples in the literature of hagiology

particularly, from which it is clear that men have learned to control

even violent tempers and by self-discipline and training in

self-control have even become rather quiet, gentle individuals. The

truth of such examples is attested too well to be discredited. This

question of training, then, is extremely important.

It has been pointed out that the consciousness of freedom to which an

appeal is made in this argument for free will is shared with us by the

insane even in the performance of many acts that we know are compelled

in certain ways. Insane persons reason themselves into a peculiar

state of mind, in which they represent to themselves that they have

been persecuted, for instance, by a particular person and then they

become persecutors in turn and do harm. As they see their act, it is

often a species of self-defense. They themselves have no

consciousness, or, at most, a very dim and hazy realization of the

inner compulsion to which they are subjected at the time of the act

and sometimes talk quite rationally and discuss the motives which

impelled them to do things, just as if they were free. We recognize,

however, the distinction between this delusion of the insane and the

rational state of mind of the sane. We have no definition for

insanity, that is, no formula of words, which will absolutely include

all the insane and at the same time exclude all the sane, but we have

a practical working knowledge that enables us to judge rather well

between those who are compelled to do things by delusions, and those

who do them from motives that are rationally weighed and that

influence a will that is free to follow them as it pleases. We hold

the rational man responsible for his acts because he knows he was free

not to do them. We punish him partly because he should not have done

them and partly because we want him not to do them again, and we know

that punishment will help him to keep from committing crime, because

it will support his free will against his inclinations, when the time

of trial comes again.

Above all, we are conscious of our own responsibility. We know that

when we do wrong we are worthy of blame. We know that when we allow

covetousness to lead us into the appropriation of what does not belong

to us we are deserving of punishment, because we need not have done

it, but we yielded to unworthy motives. We know that while anger may

be blind we can control it, at least those of us who are fully in

possession of our intellectual and voluntary powers, so as to keep

from doing violence, even in the heat of it. This dealing with

ourselves is the best proof that we have of our recognition of our

freedom of will. We are responsible, and what we genuinely do not will

to do is not accomplished. Our will may be bent by many attractions,

but we know that these motives are not compelling unless we allow them

to be. When a child tells us that he did something because he could

not help it, we either feel sorry for him because he is not yet in

possession of his full faculties or else we laugh at this excuse.

There is a tendency to admit this excuse as having a meaning, but only

by those who themselves come into court with hands assoiled in some

way and who are looking for pardon from others for offenses, and who,

above all, want to feel that they can pardon, or at least excuse,

themselves.

In recent years we have seriously impaired the idea of responsibility

in {741} the minds of the general public by a foolishly sentimental

mercifulness to criminals. If a man under indictment for murder can

show that he has ever previously in his life acted even slightly

irrationally, or if he has been peculiar in certain ways, provided, of

course, he has money enough to pay for the opinions, there will be an

abundance of expert testimony to declare that he is irresponsible and

should not be punished. As a consequence, in many cases justice fails.

We are reaping the harvest of this pseudo-scientific invasion of law.

Human life is cheaper in no country in the world than it is in

America. Our murder rate is going up by leaps and bounds, while that

of Canada remains almost stationary, and the reason is that while nine

out of ten of all our murderers do not receive the death penalty and

many of them escape serious punishment of any kind, nearly as large a

proportion of Canadian murderers are punished by death. A man may have

his responsibility somewhat impaired and yet retain sufficient free

will so that he deserves to be punished for serious crimes. It is hard

to decide in certain cases, but in most cases the decision is not

difficult if, with the right sense of justice, morbid sentimentality

is put aside.

[Footnote 59, the following lengthy citation is from an article on

"Responsibility and Punishment," in the _American Journal of

Medical Science_, 1909.]

While the doctrine of free will is so clear it is still true that

the question of responsibility for actions, and above all for

criminal actions, is not so simple as many people used to proclaim

it in the past. No two men are free to perform an act or not to

perform it in quite the same way. Familiar examples are ready to

hand: One man finds no difficulty at all in resisting the

inclination to take spirituous liquor to excess; another finds it a

most difficult feat, often apparently impossible for him to refrain

from indulging to excess almost whenever the opportunity offers, or

at least whenever he gets a taste of liquor. This difference between

the two men is founded in their very nature. It would be utterly a

mistake to praise the one for his abstinence or to blame the other

under certain circumstances for his indulgence. Between these two

classes there are others quite different individually. Some of them

have a slight tendency, and, fearing the worst, do not indulge in

it; some of them have a marked tendency which they are able to

resist under most circumstances without very much difficulty once

they have made up their minds; some are sorely tempted, fall

occasionally, yet never become habitual drunkards. For each of these

men there is a different responsibility, and so far as they are to

be punished a different punishment must be meted out, for it is our

effort in the modern time to make the punishment fit the criminal

and not the crime.

This same thing holds true for many other forms of crime. Some men

readily lose sight of the distinction between mine and thine, and

possess themselves of their neighbors' goods almost without

realizing that they have done wrong. They are rare, and we have been

accustomed to call these people kleptomaniacs. Between these and the

man who hesitates to steal, even when starving or for his starving

children, there are many degrees of inclination and disinclination

toward stealing. The same thing is true to a more noteworthy degree

with regard to anger. Anger, the old saw says, is a brief madness.

In America we say very frankly that a man who is very angry is mad.

In this brief madness he may be led to do things which he would not

do at all in his sober senses. Some men easily get into one of these

awful fits of anger in which their responsibility is lessened, while

others have a calm phlegmatic disposition from which they are

scarcely aroused even by the worst forms of abuse or injury, or even

physical suffering.

It is evident in all these cases that in order to measure how much

of punishment ought to be meted out for acts committed it is more

necessary to know the individual than his act. This often becomes an

extremely difficult matter, for {742} after the commission of crime

every effort is made to make out as little responsibility as

possible for the criminal. The easiest way to do this has been to

use the insanity plea. As already stated, we have no definition of

insanity. It is easy to understand then that there will be a

disagreement among physicians as to who is or is not insane, and the

result is almost sure to create doubt which tends to obscure the

principles on which are based the proper punishment of crime. Now

this system is founded on certain wrong principles as regards the

administration of Justice. While it is difficult to decide with

regard to a man's insanity or sanity, it is not difficult to decide

with regard to his punishment when the ordinary purposes of

punishment are kept well in view.

The old idea of punishment used to be that of revenge. A man had

done a wrong, and what would ordinarily be held a wrong had to be

done to him in order that the scales of Justice should be maintained

level. At the present time we have no such idea at all. Punishment

has two main purposes--the prevention of further disturbance of

social order by the particular criminal, and the deterrence of

others from like acts. If a man takes away the life of another we do

not take away his because thus Justice will be obtained, but we take

it away to prevent him from ever doing anything of the same kind

again. A man who has committed murder is more likely to do it again

than another. He has committed one breach of social order; we shall

prevent him forever from committing another of the same kind. This

is the very best deterrent to such crimes that there is. It will be

said, of course, that these men could not refrain from doing their

acts. It is doubtful, however, whether this contention is true in

the great majority of cases, and the proper punishment of such as

occur furnishes the best possible motive to help others from the

commission of like acts.

This holds true for children at a time when their sense of

responsibility for their acts is as yet undeveloped. They can be

taught, even very early in life, by properly applied punishment,

that need not be severe, that they must not do certain things, and

then they will not do them, or at least, will do them much less.

This is true not only for perfectly rational children, but also for

those that are to some degree irrational. Punishment is of great

importance in the training of children of low grade intelligence,

and there is scarcely any child, however wanting it may be in

intellect, that cannot be disciplined into conduct that makes it

much less bothersome than would ordinarily be the case. This is well

known and it is also well known that the attempt to manage such

children without punishment would be extremely difficult, not to say

impossible. They do not reason about the thing, they are not quite

responsible for their acts; but they do connect punishment with what

they have done, and are in many cases deterred from doing it again,

especially while they realize that authority is near them and that

punishment is inevitable. These are the principles on which the

adjudication of punishment for crime must be measured. There is

nothing else that can be done if society would preserve itself and

its members from those who are irresponsible even in minor degrees.

In this matter practical experience is well worth the while. The

lower order of creatures, the animals, we do not consider

responsible for their acts in the same way as human beings. We know

the value, however, of punishment in deterring them. A dog, for

instance, by being whipped a few times when he is young, can be

taught not to steal things to eat, and taught that there is an

inevitable connection between the taking of such things and the

infliction of such punishment. I shall not soon forget my first

lesson in philosophy from a dear old professor, who, talking of the

memory of animals, demonstrated that they had a memory, from the

ordinary experience of mankind with regard to them. "If a cat does

something naughty in your room," he said, "you rub its nose in it,

and it will not do it again." The cat had no idea that it was doing

wrong. According to its way of life it was not doing wrong. It

learned, however, from sensory experience that it must not do this

sort of thing under special circumstances, and after the lesson has

been once thoroughly learned there is no more trouble of this kind.

Individuals who are of less mental stability than normal require,

indeed, more careful discipline than average men. The rational may

be managed by sweet reasonableness. The defective child must be made

to realize that certain actions {743} will surely be followed by

painful punishment, though, of course, the main purpose of modern

care for such children is to watch over them so diligently as to

prevent them getting into mischief. This is after all what we do

with the animals, and we realize the necessity for it. Defective

human beings approach the animal in their lessened power to resist

impulses, and they must be treated in the same way. If we were to

save the animals in an excess of tenderness toward them, because we

held to the notion either that they did not know any better or else

could not resist their impulses, and then permitted them to do

things without punishment, we should either have to get rid of

animals entirely, or else life would be one continuous readjustment

of things to animal ways. Since defectives occur in the general

population, it must be realized that far from being less rigid with

them in the matter of meting out punishment for things they do that

are harmful to others, we must be even more strict with them.

Otherwise, we will have to take the bitter consequences of our own

foolishness.

It does not make so much difference if the thoroughly rational

individual occasionally escapes punishment for something done, but

whenever the subrational escapes, he is encouraged to do it again.

More than that, the example of his punishment is needed for others.

So far as possible, punishment must inevitably follow crime in the

world, in order to impress the subrational and deter them from

yielding to impulses. Far from being less deserving of punishment in

every sense in which a modern penologist cares to inflict

punishment, these individuals are more impressed by it, and, above

all, need to be more impressed by it. When the subrational know that

they can do things without being severely punished for them, they

will always abuse that state of affairs. The thoroughly rational man

may be depended on to do his duty as a rule without the need of

punishment hanging over him. This is not true for the others, and

hence the greater increase in crime, and above all in murder, which

has made human life cheaper in this than in any other country in the

world, as the direct consequence of recent abuses in our penal

system.

It has become very clear now that in recent years we have come to

take entirely too lenient a view in these matters, and that many

criminals who deserved to be punished, both because in this way they

would be prevented from future crime and others deterred by the

knowledge of their punishment, have been allowed to escape Justice.

The tendency is toward too great mercifulness, which spoils the

character of the nation, just as leniency to the developing child

spoils individual character. Men may very well be insane, in the

broad meaning of that term, in the sense that they have done

irrational things, but then there is almost no one who has not. The

responsibility of most men for a definite action is quite clear in

the sense that if they are punished they will not do it again, or

will be less likely to do it again, while if they are not punished

their escape becomes a suggestion to themselves and to others to

repeat such acts. It is for the subrational that we most need to

insist on punishment. The cunning of the insane is proverbial, and

this extends also to the subrational, and many of these folk realize

that their difference from others, their queerness, as their folks

call it, is quite enough to make a verdict of insanity in their case

assured with the present lax enforcement of law. If the present

state of affairs continues in this matter, we are simply allowing

ourselves to be led by the nose by these cunning people into the

perpetuation of a state of affairs in which they may do what they

like because we have become foolishly oversensitive in the matter of

inflicting punishment.

On the principle that punishment deters, a man who has killed

another man, even under conditions that seriously impaired his

responsibility for the act and with evidence of previous lowered

mentality, must never again be free to live the ordinary life of

men. He must be under surveillance, and should be confined for life

in an institution for the criminally insane. For the subrational

such a sentence, if known to be inevitable, would usually be more

deterrent than even imprisonment in an ordinary prison for life with

all the possibilities for freedom which are presented by executive

clemency, pardoning boards, and the like. It is absurd to say that a

man may have such an attack of mental unsoundness as will lead him

to do so serious an act as taking away human life, and then be

expected to get over his mental condition so as not to be likely to

do the same thing again. {744} Every alienist knows that this is not

true. Such acts, when really due to mental instability, occur either

in depressed or maniacal conditions, and these, as is now well known

from carefully collected statistics, inevitably recur, or in

weakened toxic conditions in susceptible subjects, and a return to

the old mode of life may at any time bring recurrences.

It is in the treatment of disorders of the will of various kinds that

the physician is brought to realize how much harm is done by the

teaching that determinism and not free will rules life. It is true

that we often find cases in which men and women cannot use their wills

or at least seem not to be able to use them. They are lacking in some

essential quality of human mentality. We find many human beings,

however, doing things that are harmful for them and that are so

inveterated by habit that it is extremely difficult to get away from

them. In every case the sane person can conquer and break the habit,

no matter how much of a hold it may have obtained.

We have heard much of the born criminal and of the degenerate and his

inevitable tendencies, but most of the theories founded on this phase

of criminal anthropology have gradually been given up as a consequence

of more careful and, above all, more detailed observation. Many

criminals bear the stigmata of so-called degeneration. Many of them

have irregular heads, uneven ears, some fastened directly to the cheek

and some with the animal peak, many have misshapen mouths and noses,

but, on the other hand, many people having these physical qualities

are good men and women, perfectly capable of self-control, honest,

efficient members of society, and it is evident that the original

observations were founded too exclusively on the criminal classes,

instead of on the whole population. It is important, then, to get away

from the notion of irresponsibility in these cases.

While men are free, yet each in a different way and the freedom of

their wills is as individual as their countenances, it must not be

forgotten that the freedom of the will is a function of the human

being, and, like all other functions, can be increased or decreased by

exercise or the lack of it. The old idea of "breaking the will" was as

much of a mistake as that other old-fashioned notion contemporary with

it of "hardening" children by exposing them to inclement weather and

severe physical trials. The will may be strengthened, however, by the

exercise of it and if not exercised it may not be expected, by

analogy, at least, to be as weak and flabby as muscles would be under

similar circumstances. The training of the will by self-denial and

self-control is extremely important. When there is an hereditary

influence, a family trait and not merely an acquired character, by

which the will rather easily passes out of control, there is all the

more need for the training of it in early youth. Without such training

men may find it impossible to make up their minds to deny themselves

indulgence of many kinds, but this is not because they have not free

will, but because this function has never been exercised sufficiently

to enable them to use it properly. A man who attempts to do gymnastic

feats without training comes a cropper. A man who is placed in

circumstances requiring hard muscle exertion will fail if his muscles

have not been trained to bear it. The same thing will happen with the

will.

Unfortunately this training of the will has been neglected to a

considerable extent in modern education, and, above all, in modern

families, where the presence of but one or two children concentrates

attention on them, {745} over-stimulating them when young, leading to

self-centeredness and, above all, discouraging self-denial in any way

and preventing that development of thorough self-control which comes

in the well-regulated large family. Besides, unfortunately it is just

the neurotic individuals who most need thorough training in

self-control and whose parents suffer from the same nervous condition

(for, while disease is not inherited, defects are inherited), that are

deprived of such regular training in self-control because of the

inability of their parents to regulate either themselves or others

properly. Here is the secret of the more frequent development of

neurotic symptoms in recent years. It is not so much the strenuous

life as the lack of training of the will so that the faculty of free

will can be used properly. Lacking this, hysterical symptoms,

unethical tendencies, lack of self-control become easily manifest. The

training that would prevent these should come early in life, and when

it does not it is very difficult to make up for it later. Just as far

as possible, however, it is the duty of the psychotherapeutist to

supply by suggestions as to training and discipline for the education

of the will that has unfortunately been missed.

{746}

SECTION XX

_PSYCHOTHERAPY IN SURGERY_

CHAPTER I

PSYCHOTHERAPY IN OLD-TIME SURGERY

Surgery, a name derived from chirurgy--handwork--might seem to be

dependent almost entirely on mechanical and technical skill, yet there

has always been the conviction that the patient's attitude of mind

towards an operation is almost as important a factor in the success of

surgery as the surgeon's skill.

Astrology in Surgery.--From the earliest history of surgery we, find

that astrology was mainly employed in order to determine what days

were likely to be favorable, and what unfavorable, for the practice of

such surgical procedures as were in vogue at that time. Certain

conjunctions of the planets were declared to be particularly

unfavorable, and some of them, indeed, were declared almost absolutely

fatal; others were said to be especially favorable. As astronomical

and anatomical knowledge grew, more and more details were added in

this matter. Definite portions of the body were supposed to be under

the occult influence of certain constellations. It was only with

careful reference to these constellations then that surgical

procedures or, indeed, the application of remedies of any kind, might

be undertaken. All remember the picture in old almanacs of a man with

the signs of the zodiac around him, and the indications that referred

certain of these signs and the corresponding constellations to the

different parts of the body.

_Venesection and the Stars_.--When venesection became a frequently

used remedy, the question of the favorable and unfavorable influence

of the stars was an important element in it. In old Babylonia, noted

for its knowledge of astronomy, which was then called astrology

without any of our derogatory meaning in the word, certain positions

of the planets were absolute contraindications for the performance of

venesection. Indeed, astrology often furnished the best possible

excuses for the failure of what were thought to be absolutely specific

remedies. When the remedies did not succeed, their failure was

attributed to their being taken at unfavorable times and not to the

remedies themselves. These astrological ideas continued to influence

medicine, and, above all, surgery, down almost to our own time.

Galileo and Kepler made horoscopes, and Mesmer wrote a thesis on the

influence of the stars on human constitutions. In fact, very few

important patients of the seventeenth and even eighteenth centuries

were treated medically or surgically without due reference to the

stars at the time. All this had a profound influence on {747} the

patient's mind. He felt that every precaution was being taken to

preclude the possibility of failure and assure favorable results, and

he, therefore, submitted to the operation absolutely confident that so

far as human knowledge could go, everything was favorably disposed in

his regard.

Mental Influence in Old Hospitals.--It is rather interesting to

realize how much the history of medicine illustrates the profound

attention that was given in the old times to the question of the

occupation of patients' minds as an eminently helpful factor in the

treatment of disease and, above all, in convalescence. In the great

health resorts, the temple hospitals like that at Epidaurus, or even

the city hospital, the AEsculapeum at Athens, the question of

recreation of mind was evidently considered very important. At Athens,

the two city theaters, the larger one seating perhaps 50,000, and the

smaller, Odeon, were not far from the hospital. At Epidaurus, a

theater seating probably 12,000, in which the great Greek classic

plays were given; a Stadium, seating nearly 10,000, in which athletic

contests were conducted, and a Hippodrome, seating 6,000, in which

animal performances might be witnessed, were all in connection with

the temple hospital. Outdoor sleeping apartments were provided; that

is, the patients slept under a colonnade, and, in general, the mental

and physical hygiene of modern times was thoroughly anticipated. All

of this was considered particularly important for convalescents.

Patients were occupied, while in bed, with various interests. Just as

soon as they could be moved, their minds were occupied with all sorts

of interests external to themselves, and especially such as had the

readiest appeal to humanity. (See bird's-eye view, facing p. 9.)

Medieval Hospitals and the Mind.--It is not difficult to trace the

development of similar conditions in the hospitals of the Middle Ages.

While we are inclined to think of these older hospitals as surely

lacking in everything that we have developed in our modern hospitals,

they prove, on the contrary, to have anticipated most of our hospital

improvements. They were of single story construction, with large

windows high up in the wall so that there could be no drafts, with a

balcony on which patients could sit in the sun, with arrangements for

procuring privacy rather easily by means of sliding partitions, with

tiled floors, and, above all, with pictures on the walls, some of them

the products of the brush of the great artists of the old time and

which would serve to occupy patients' minds. Probably nothing is worse

for patients who are convalescing from illness or operation than to be

left to their own thoughts. Often they must not be talked to overmuch,

or permitted the exertion of conversation or of reading, yet they must

have some occupation of mind. The frescoes painted directly on the

walls of the old hospitals were eminently psychotherapeutic in this

respect, and we shall probably have to imitate them. Besides, the

patients had the opportunity every morning to hear Mass, which was

said at an altar at an end of the ward, and certain religious

exercises were conducted by the sister nurses each afternoon. How much

of consolation this was to believing patients at a time when all were

believers is rather easy to understand.

Medieval Surgeons and Mental Influence.--Some of the insistence on

this favorable state of mind for operations during the Middle Ages is

extremely interesting. One of the great surgeons of the fourteenth

century was Mondeville, whose text-book has recently been published in

both France and {748} Germany. I have translated in "Old-time Makers

of Medicine" [Footnote 60] some of his emphatic expressions, which

show how important he deemed it to keep the patient in as favorable a

state of mind as possible before and after operations. He went so far

as to suggest that someone should be deliberately called in to tell

him jokes. He said, "Let the surgeon take care to regulate the whole

regimen of the patient's life for joy and happiness by promising that

he will soon be well, by allowing his relatives and special friends to

cheer him, and by having someone to tell him jokes, and let him be

solaced also by music on the viol or psaltery. The surgeon must forbid

anger, hatred, and sadness in the patient, and remind him that the

body grows fat from joy and thin from sadness. He must insist on the

patient obeying him faithfully in all things." He repeats with

approval the expression of Avicenna that "often the confidence of the

patient in his physician does more for the cure of his disease than

the physician with all his remedies."

[Footnote 60: Fordham University Press, 1911.]

Mondeville was but one of the great surgeons of the medieval period

who dwelt on this. It would not be hard to find corresponding

expressions in the books of such men as Guy de Chauliac, Hugh of

Lucca, Theodoric, or even earlier among the great Arabian physicians

and surgeons. Rhazes, for instance, declared that "physicians ought to

console their patients even if the signs of impending death seem to be

present, for the bodies of men are dependent on their spirits." He

considered that the most valuable thing for the physician to do was to

increase the patient's natural vitality. Hence his advice: "In

treating a patient, let your first thought be to strengthen his

natural vitality. If you strengthen that, you remove ever so many ills

without more ado. If you weaken it, however, by the remedies that you

use, you always work harm." Another of his aphorisms seems worth while

quoting: "The patient who consults a great many physicians is likely

to have a very confused state of mind." For him a confused state of

mind evidently meant a lessened tendency to recovery.

Surgical Lesions Influenced.--The King's touch in England, which so

often proved beneficial for scrofulous patients, illustrates very well

how much strong mental influence may avail even in cases where surgery

seems surely indicated. Many cases of epilepsy were also greatly

benefited by the King's touch, and, indeed, in this matter there are

probably many more cases of the cure of epilepsy, or at least relief

of the worst symptoms of the affection, reported as following the

King's touch than after operation in the modern time. In both sets of

cases we are now confident that the good effects produced came through

the minds of the patients. When, during the eighteenth century,

Mesmerism began to attract attention, investigators and experimenters

on the subject were able to show that many pains and aches could be

greatly benefited by psychic treatment. The painful conditions

following fractures and sprains proved to be particularly amenable to

mental influence exerted in this special way. As we approach the

modern time, there comes to be a definite recognition of the fact that

the mind may produce many pains and aches which seem due to purely

physical conditions that might be expected to yield only to physical

treatment. A corresponding recognition of the power of the mind to

lessen and even suppress actual physical pain is almost a corrollary

of this.

{749}

Sir Benjamin Brodie declared, as I have quoted in the section on

"Diseases of the Muscular and Articular System" that a large

proportion of the painful joint conditions that he saw among his

better-to-do patients were of the hysterical or neurotic type. Sir

James Paget thought this expression of Brodie an exaggeration, but

acknowledged that one-fifth to one-fourth of all his cases in both

hospital and private practice were due to hysteria. In those days most

of the painful conditions were considered to belong rather to surgery

than to medicine, so that these opinions represent very well the

practice of medicine in these cases during the early nineteenth

century.

During the nineteenth century great practical surgeons, and especially

those who have taught us how to treat individual patients rather than

their diseases--for it is quite as true in surgery as in medicine that

the patient is more than his disease--have made distinct contributions

to the department of psychotherapy in surgery. Dr. Hilton's great book

on "Rest and Pain" is full of psychotherapy. His cases illustrate the

fact that when patients' minds and bodies are set at rest, all sorts

of serious conditions proceed to get better. The rest of mind, the

cessation of worry, the presence of a feeling of confidence in

recovery, is quite as important as the physical measures. Young

surgeons particularly probably could not do better than follow the

advice of the old Scotch surgical professor at Edinburgh who suggests

to his pupils that they should read Hilton's "Rest and Pain" at least

once a year.

CHAPTER II

MENTAL INFLUENCE BEFORE OPERATION

Much may be done during the preparation for operation to put the

patient in the most suitable condition for the manifestation of

healthy reaction of tissue and of normal convalescence. Many patients

do not come for operation until their health has been somewhat

impaired at least by the condition requiring operation. Not

infrequently a good proportion of this impairment of health is due not

so much to the lesion that is present as to the worry over it and the

anxiety and solicitude which its development has occasioned. If the

lesion is in connection with the digestive tract, this is particularly

likely to be true, and nutrition will often have been sadly interfered

with, not so much by direct influence of the pathological condition as

by the unfavorable mental influence developing in connection with it.

We know now that it is perfectly possible for an indigestion which is

entirely above the neck to make rather serious inroads upon the health

of the patient, by producing dislike for food or at least such loss of

appetite as leads to considerable reduction in weight. In such cases

there are often complications, such as tendencies to constipation,

that still further impair health or at least reduce vitality and

therefore hamper that healthy reaction which should occur after

operation in order to assure normal convalescence.

Accessory Neuroses.--In many of these cases, even where there is a

definite lesion present, the patient can be brought up to normal

weight, or at least his condition can be greatly improved by medical

treatment accompanied {750} by such attention to his state of mind as

will neutralize its unfavorable influence. If he can be made to

understand that a definite effort to increase weight and to bring back

his strength will be of assistance in recovery from the operation, and

that the reestablishment of certain habits of eating and caring for

himself will do much to help in this, very desirable changes for the

better in his general health may be brought about. This is illustrated

very well by what happens in certain incurable cancer cases. The

patients often have lost considerable weight, even thirty to forty

pounds, before an operation is decided on, and then when the operation

is performed their cancer is found to be inoperable. After the

exploration the patient is not told this, but is mercifully spared and

is assured that now he ought to get better, since an operation has

been performed. Such patients have been known to gain twenty, thirty,

and in one case I believe over forty pounds as the result of the

mental influence of this suggestion and the resumption of former

habits of life to some extent at least, consequent upon the

neutralization of the unfavorable state of mind into which they had

sunk before through over-solicitude about themselves. If even the

depressing effect of the toxins of cancer can thus be overcome, it is

easy to understand how much can be accomplished when there is no such

physical factor at work.

Dominant Ideas.--As a general rule, it must be recognized that

patients may be, and indeed frequently are, besides their definite

pathological conditions, under the influence of dominant ideas which

must be recognized and as far as possible neutralized. Some of them

have persuasions with regard to food and the amount that they can eat,

others have removed many important nutritious articles from their diet

and are quite sure that any attempt on their part to take such

articles is sure to be followed by indigestion, and still others have

habits with regard to the amount and the kind of fluids that they take

at meals and between meals and, above all, the lack of fluids in their

diet which need to be overcome. Unless such ideas are counteracted

there is difficulty even in convalescence, and very often they have

brought patients into physical conditions in which whatever

pathological condition is present is emphasized by that over-attention

which the nervous system is so prone to give to even slight sensations

when the organism is in a state of lowered nutrition.

In not a few of these cases the bringing of the patient up to the

normal condition of weight and health, and the removal of the

influence of dominant ideas, will perhaps also remove many of the

indications for operation. There are many patients, and especially

such as are reasonably educated and have some leisure, who get certain

of their organs on their minds and produce symptoms or emphasize such

symptoms as are present until it seems as though an operation is the

only thing that can lift their burden of discomfort and permit them to

go on again with their work. We have all known of physicians who felt

sure that they ought to be operated on for such conditions as gastric

ulcer or duodenal ulcer, though subsequent developments in the case,

when they were persuaded to put off operation and made to reform

certain ill-advised habits, proved that no such lesion as they

suspected had ever been present. Indeed, some of these physicians and

even surgeons have insisted so much that surgical friends occasionally

have operated on them and have found nothing to justify the operation.

{751}

Some of these states in connection with discomfort of various kinds in

the abdomen have been discussed in the chapter on Abdominal

Discomfort, and some illustrations of useless operations given. We

must not forget that there is a constant stream of pathological

suggestion in the air at the present time, not only in medical

journals, but even in the secular press, and that this concentrates

the attention of patients on comparatively slight discomforts and

leads to the exaggeration of them until even an operation seems a

welcome relief for them.

Operative Persuasions.--While surgical operations are in practically

all cases mutilations, they are absolutely necessary under certain

circumstances, are often, indeed, life-saving, and there is no doubt

that they have saved mankind a great deal of discomfort. Surgeons are

agreed, however, that they are not to be performed unless they hold

out a definite promise of physical relief. It is extremely important,

then, that patients must not become persuaded of the need of an

operation in their cases unless surgical intervention is really

necessary. This is as true for physicians and even surgeons

themselves, as I have said, as it is for the general public. Women are

much more susceptible than men to operation suggestions, and since it

has become fashionable to talk about _their_ operations, not only has

the deterrent idea of surgical mutilation been greatly lessened, but

there has actually developed in many of them a morbid fascination for

a similar experience with all its attraction of attention and promised

occupation of mind for the woman of leisure.

This phase of the necessity for favorable mental influence has been

especially emphasized in the chapters on Gynecology. Unless,

therefore, there are very definite indications, operations must not be

performed, for they will relieve, as a rule, only for the time being,

and further operations may have to be done to no purpose. Any

physician of reasonably large experience has seen such cases. Patients

get the idea of an operation as their one hope, and then nothing less

than that will produce such diversion of mind as will bring relief of

symptoms. It is important in these cases that such patients should not

have operations suggested to them. Once the suggestion takes hold,

they do not use their reserve energy in such a way as to help out

effectively other remedies that may be given. They distrust all

remedial measures, think that at most they can be only palliative, and

so do not add to other forms of therapeutics the power of

psychotherapy to cure them.

Besides the abdominal conditions, there are certain tuberculous

conditions with regard to which this seems to be particularly true. I

have seen enlarged cervical glands disappear without discharge when

patients have taken up the outdoor life, and, above all, when they

have gone out of the city and have lived the regime proper for those

in whom tubercle bacilli are growing. If such patients, however, once

become persuaded that their glands must be operated on, they are

likely to need, if not active intervention, at least the discharge of

material from their tuberculous lesions before they get well.

Operations of a radical character for tuberculosis used to be much

more popular than they are now, when we are likely to think that

nature can do more for tuberculous lesions in nearly all cases than

the most skillful surgery.

Fractures and the Mind.--In such surgical conditions as fractures and

dislocations, a change has come about in the mode of treatment, at

least in many hands, that seems entirely physical in its effect, yet

has undoubtedly {752} exerted important psychic influences favorable

to recovery which deserve to be noted. In dislocations and fractures,

and particularly the latter, it was the custom in the past to do the

fractured limb up in bandages and then leave it until knitting of the

bones, or, in dislocations, healing of the soft tissues, had taken

place. Apparently it was forgotten that this eminently artificial

condition was not conducive to that healthy reaction of tissues for

reparative purposes which must be expected in these cases. Circulation

was not so good because of the constrictive effect of the bandages;

vitality not so high because of failure of nervous activity in

absolute immobility; the return venous circulation was somewhat

hampered because there were no contractions of muscles; and all the

conditions were distinctly unfavorable, though nature was expected not

only to maintain the health of the part, but bring about the added

functions of repair. In spite of the more or less unfavorable

conditions, nature was able, as a rule, to do so. Prof. Lucas

Championere reintroduced the older method of treating fractures and

dislocations more openly and of even using certain manipulations,

passive movements, and massage in order to encourage the circulation

and the natural vitality of the limb.

There is another phase of the influence of this mode of treatment that

deserves to be recalled. When the fracture is hidden away for many

days and the patient is not absolutely sure whether it is getting on

well or not, solicitude or anxiety is awakened in some minds that

prevents, or at least delays, normal healthy repair. It is well known

by surgeons that fractures do not heal so well after accidents in

which there has been considerable shock, or in which the simultaneous

death of a friend seriously disturbs the patient's mind. Nor do

fractures heal so well if the patient is worried about business

affairs or seriously disturbed over family matters. Among sensitive

patients, a state of mind not unlike that produced by worry or shock

may develop as a consequence of the dread that the fracture may not

heal properly, or that there may be deformity, or that when the

surgeon removes the bandages he may find it necessary either to break

it again or do something that would involve considerable discomfort.

These patients need reassurance. If the surgeon sees the broken limb

occasionally, and, by manipulation and passive movements such as may

properly be used, assures himself as to its condition, the patient's

mind is much better satisfied and that inhibition of trophic processes

which otherwise sometimes occurs is prevented.

Incisions and Suggestion.--Something of this same psychotherapeutic

influence is noted with regard to the healing of incisions when these

are not left without inspection too long. The newer surgical customs

of comparatively few dressings, so that the wound may easily be

inspected and the patient may be completely assured with regard to it,

has undoubtedly had a good influence in bringing about more rapid

repair. Air is the best environment for a healing as well as a healthy

skin, and mental trust is best for the patient's power of repair. In

vigorous individuals such repair will occur anyhow. It is in those of

delicate health, neurotic disposition, and psychoneurotic tendencies,

that reassurances are needed. Often their physical condition is such

that they need every possible aid in bringing about complete repair.

Their state of mind, then, must be noted carefully, and any inhibitory

ideas that may be present because of over-anxiety as to how the

incision is getting on must be removed. This does not mean that

patients' whims should be yielded {753} to in the matter of

over-solicitude about their condition, but that proper care should be

taken to prevent inhibition of trophic influences through unfavorable

mental states just as far as is possible. Most surgeons of experience

do these things in the proper way by instinct from the beginning, or

by a tactful habit, which develops in their surgical experience of

adapting themselves to individual patients. It is well to realize,

however, that such mental attitudes are extremely important and must

be deliberately treated by the surgeon.

Pseudo-rabies.--Certain conditions usually treated of as surgical have

mental relations that are very interesting. There seems no doubt that

in a certain number of cases pseudo-rabies occurs; that is, persons

are bitten by a dog, become seriously disturbed over the possibility

of rabies developing, and after brooding over this for a time their

mind gives way and there is either a neurosis simulating many symptoms

of true rabies, or a state of collapse from fright in which even death

may take place. These cases are not frequent. Their occurrence is

taken by some of those who are opposed to animal experimentation as a

proof that rabies is always some such delusion, and that it is due to

the exaggeration of the significance of dog-bites by the medical

profession that the symptom complex known as rabies has come into

existence. This is, of course, nonsense, and many true cases of rabies

occur. Since, however, these other cases provide the opportunity for

argument in the matter, it is all the more necessary that they should

be recognized for what they are. When a patient has been bitten by a

dog that has not died from rabies within three weeks after the bite,

there is practical certainty that the animal did not have and could

not communicate rabies. The cases of hydrophobia with long incubation

periods are rather dubious, and the general impression now is that

there has been subsequent infection. Patients who are in the midst of

overwhelming dread of the development of rabies must be taken

seriously and their cases treated by mental influence. Suggestion,

instruction, and the neutralization of wrong ideas by reference to

authorities in the matter, must be used to overcome the unfortunate

state of mind which may, if allowed to continue and, above all, to

develop, prove serious for the individual.

Pseudo-rabies is but a type, though the most serious and perhaps most

frequent of what may be called surgical psycho-neuroses. There are

others. Imaginary syphilis is an affection that often causes worry and

trouble to patient and physician. _Herpes preputialis_ with mental

symptoms is almost as bad. These are mental infections of various

kinds. There are many neoplastic persuasions and toxic suggestions

that must be treated with tact and firmness.

CHAPTER III

MENTAL INFLUENCE IN ANESTHESIA

Nowhere in the domain of surgery is the influence of the mind more

important than in the production of anesthesia for surgical purposes.

It is well known that intense preoccupation of mind will make an

individual completely anesthetic even for very severe injuries. In

battle men frequently are severely wounded, yet do not know it, or at

least have no idea of the extent of the wound and of the pain that

ordinarily would be inflicted by it. In the {754} midst of panics, as

during fires, or when crowds are trying to get out of buildings

rapidly, people often suffer severe injuries and know nothing about

them. The story of the woman who lost her ear in the theater panic and

was quite unaware of it until her attention was called to it, is only

one of many striking examples. Men have been known to walk round even

with a broken leg, or with a dislocation with which it proved quite

impossible for them to move, once their mental preoccupation for

others ceased and they had time to think about themselves. Anesthetic

incidents under conditions in which great pain might well be expected

are not uncommon. It is evidently possible so completely to occupy the

mind that pain sensations cannot find their way into the

consciousness.

Pain and Diversion of Mind.--From very old times, attempts have been

made to use this power of the mind to prevent pain, and often with

some results. In preanesthetic surgery, minor operations were

performed rapidly, beginning just after the patient's attention had

been attracted to something else besides the thought of the operation.

Pain is, of course, much less tolerable and seems to the sufferer at

least to be much more severe whenever the attention is concentrated on

it. Specialists in nervous diseases, during the process of eliciting

complaints of pain or tenderness while employing movements or

manipulations, usually try to attract the patient's attention as much

as possible to something else, in order to determine just how much

genuine pain or tenderness is present. Often it is found that, while a

part of the body is complained of as exquisitely tender or it is

averred that a joint cannot, be touched or a limb moved without severe

pain, when the patient's attention is attracted strongly to something

else, deep palpations may be practiced and rather extensive

manipulations can be made without complaint. In these cases very often

the pain is not imaginary, but is slight, due to some physical basis,

and has been very much increased by the concentration of attention on

it. This part, at least of the pain, may be removed by an appeal to

the mind. The principle is valuable when there is question of minor

operations.

Surgeons have often taken advantage of this power of distraction of

attention to relieve pain in surgical manipulations. The story is told

of the French surgeon, Dupuytren, that he was called one day to see a

lady whom he knew very well in order to determine the form of injury

from which she was suffering. He found that she had a dislocation of

the shoulder, and during the manipulations, in order to make his

diagnosis, he almost inevitably inflicted considerable pain. She

complained very bitterly and told him that she understood that he was

very rough with his hospital patients, but he must not be rough with

her. He had hold of her hand at the moment, and, just before grasping

the arm in such a way as to make the manipulations necessary to reduce

the dislocation, he slapped her face and told her that she must not

talk to him while he was treating her. Needless to say, she was deeply

shocked. Before her shock had passed away, Dupuytren had completed the

reduction of the dislocation, and in her preoccupation of mind she

felt almost no pain. She remarked afterwards, however, that she had

suffered so much mental anguish from his unexpected roughness that she

was not sure whether, after all, she had been really spared in her

feelings.

Hypnotic Anesthesia.--When, in the first half of the nineteenth

century, {755} scientific attention was seriously attracted to

hypnotism, it was hoped that this would prove an effective means of

producing anesthesia during surgical operations or at least of greatly

lessening pain. The hope was not disappointed. There was a discussion

on the subject before the Medical Chirurgical Society of London in

1840, and in 1843 Dr. Eliotson wrote a work with the title, "Numerous

Cases of Surgical Operations Without Pain in the Mesmeric State." In

1846 Sir John Forbes wrote in his Review that "the testimony as to the

value of hypnotism as an anesthetic is now of so varied and extensive

a kind as to require an immediate and complete trial of the practice

in surgical cases." At the end of that same year, ether as an

anesthetic was introduced into England, and the first case was

reported under the caption "Animal Magnetism Superseded," which shows

how much attention the previous attempts at hypnotic anesthesia had

attracted. After this, hypnotism was given up for anesthetic purposes

except by a few enthusiastic students of it. These, however, succeeded

in accomplishing much with it. Dr. Esdaile, in India, succeeded in

doing all sorts of operations under hypnotism. Dr. Milne Bramwell, in

"Hypnotism, Its History, Practice and Theory" (London, 1906), lays

down the rules for hypnosis for anesthetic purposes. They are

eminently practical.

While hypnotism can be used to produce anesthesia, it has many

disadvantages. The length of the hypnosis cannot always be arranged so

as to assure anesthesia during the whole of an operation, while in

some cases it will continue after the operation for some time in spite

of every effort on the part of the hypnotist to bring the patient to

himself. Besides, the depth of the hypnosis cannot always be assured,

and sometimes some sensation remains. Patients will groan and wince

and move, though, of course, under ether or chloroform such

manifestations may take place, yet the patient afterwards will give

every assurance that not the slightest pain was felt. In some cases,

however, even where the pain sensation is not severe during an

operation under hypnosis, it may, nevertheless, prove sufficient, when

continued for some time, to bring the patient out of the hypnotic

state.

For short operations of minor character, undoubtedly hypnosis can be

employed successfully. As we explain in the chapter on Hypnotism,

anyone can produce hypnosis who has confidence in his own power and in

whom the patient has trust. There is no need of a special hypnotist,

and there is no special faculty required. There should be some

familiarity with procedures, but any man has just as much hypnotic

power as another. The influence does not pass from the operator to the

subject, but is due to the subject's concentration of his attention so

that there is a short circuiting of association tracts within the

brain very probably, which does not permit the entrance into

consciousness of sensations through any path except one or two,

usually that of hearing, and sometimes of sight, less frequently of

other sensations.

Concentration of Attention.--In a great many cases of minor

operations, such as the opening of a boil of a small abscess, the

pulling of a tooth, the lancing of a gum, or other such procedures, a

surgeon who is confident in his own mental power over his patient can

rather easily produce a state of mind in which the discomfort of the

surgical procedure is greatly minimized. There are certain physical

helps for this. For instance, if patients are asked to breathe rapidly

and deeply for a few minutes, there is a hyperoxygenation {756} of the

blood which seems to obtund sensibility. If patients are told of this,

and then made to breathe rapidly for a half a minute in order that

they may continue consciously their deep, rapid breathing even when

pain is noted, a state of mind is produced from concentration of

attention on their breathing in which painful sensations are greatly

obtunded. The effect is probably more mental than physical, and is

well worth while trying because of the amount of pain it often saves.

Waking Suggestion.--Without resort to hypnotism, much can be

accomplished by mental suggestion in the waking state to lessen the

pain of surgical operations and maneuvers. This is particularly true

as regards nervous persons, who will otherwise emphasize their

discomfort, and for those of lesser intelligence, children, and the

like. Esdaile's experiences in India show how much can be done in this

way. Often the hypnosis was so slight that the patients were perfectly

cognizant of everything that went on around them, yet under the

compelling influence of the assurance of Dr. Esdaile, whom they

trusted completely, they did not complain of pain nor wince even when

considerable surgical intervention was practiced, and they always

assured their friends afterwards that they had felt nothing. I know an

American physician who has an almost similar power over negroes.

Ordinarily it requires more of an anesthetic to produce

insensitiveness to pain in the negro than in a white person. By

personal assurance, by the absolute securing of their confidence, and

through their trust in him, this man is able to produce anesthesia

without the use of more than a minimum quantity of the anesthetic. He

is able to do the same thing with children, and, of course, it is well

known that mental influence over them is extremely important in

limiting the amount of anesthetic that will be necessary.

Personality of Anesthetist.--Some anesthetists by their personal

influence are able to bring patients under the influence of an

anesthetic with much less excitement and, as a consequence, with the

use of much less of the anesthetic than others. It is the same

question of personal influence that extends through all medicine. Some

men seem to have it naturally, and others not, though to some extent,

at least, it may be cultivated. Of course, it is now well understood

that, under no circumstances, should a patient be forced to take an

anesthetic. This is as true for a child as for any other patient. Only

a little management is required to secure the cooperation of even a

young child. Above all, there must be no struggling, and while there

may be a passing stage of excitement, which cannot be entirely

controlled, this can be eliminated by those who are skillful. It may

be necessary, especially in the case of children, for the little

patients to become familiar with the anesthetist. They should see him

on several occasions and should be made to feel that they know him.

The presence of a stranger is enough of itself to excite children and

make them suspicious and resentful of any manipulations. It may be

well for them to have breathed through the cone on several occasions

and to play a sort of game with it. In this way children will often go

under an anesthetic without any struggle or excitement.

It seems a little childish to suggest similar procedures with grown

patients, but even surgeons of long experience with the older methods

who have insisted on the trial being made on their patients have found

much benefit from it. Familiarity with the anesthetist and even with

the inhaler {757} and the breathing through it on several occasions

beforehand, when no anesthetic is being administered, helps many

patients not a little. This preliminary is particularly of help with

regard to nervous patients and especially women. It is very seldom

necessary to use nitrous oxide as a preliminary to ether if this mode

of procedure is practiced.

Mental Diversion.--It is well to concentrate the mind of the patient

on something else besides his sensations. One element that is

extremely important for anesthesia is deep breathing. The patient must

then have his attention called to the necessity for deep breathing and

should frequently have the suggestion to this effect repeated in his

ear as he comes under the anesthetic. There should be some practice in

deep breathing deliberately beforehand, with the idea of accustoming

the respiratory mechanism to take deep breaths by habit even when not

entirely under the control of the will. This may be done with the

inhaler on a few occasions at least. The occupation of attention

necessary for deep breathing during the taking of the anesthetic

lessens the concentration of mind on the feelings, and actually makes

the discomfort much less. Besides, deep breathing distributes the

anesthetic over the lungs, leads to its absorption more rapidly, and

makes the irritation of the anesthetic less by diffusing it over a

larger surface. On the contrary, short, rapid breaths lead to an

intensity of irritation and much slower absorption.

Skilled anesthetists have found it of decided advantage to keep the

patient's mind fixed on something else besides the breathing. Perhaps

the easiest recommendation is that of locking the hands over the

abdomen just above the umbilicus and asking the patient to hold tight.

This gives something very definite to think about and to occupy the

mind with. I have seen patients of rather nervous organizations go

under the influence of even a very small quantity of an anesthetic

when required to hold their hands thus and when the command was

constantly repeated, "Hold your hands tight," whenever there was the

slightest sign of struggle or excitement. Where this was done

tactfully and regularly, I have seen patient after patient go into

anaesthesia without struggle or excitement and usually without any

noise or even a loud word. I realize how much the personality of the

anaesthetist means in such cases, and I feel sure that anyone who is

confident in his own power in the matter will produce a corresponding

feeling of confidence in the patients.

Fright in Anesthesia.--There seems good reason to think that

occasionally the deaths reported from anesthesia have really occurred

from fright or at least have been greatly influenced by emotional

factors. It has often been noted that these deaths occurred

particularly at the beginning of the administration of an anesthetic

and before anything like a sufficient quantity to produce a toxic

effect had been administered. In other cases it has been noted that

patients were allowed to come out partially from under the anesthetic,

and as they recovered consciousness were disturbed by some incident.

Sometimes the pain seems to act as an inhibitory agent on the heart.

In more than one reported case the patient told afterwards of hearing

very distinctly some remark that seemed to be of bad omen. In one case

in my own experience the breathing and heart stopped (though the

patient fortunately was resuscitated) as a consequence of hearing a

series of rather loud goodbyes said at the door of the elevator

leading to the operating room during the {758} course of an operation

just at a moment when the anaesthetic influence was very much lessened

for a while. In some cases where there has been great fear of the

anesthetic which has been talked over beforehand by the patient, even

a few whiffs of the ether or chloroform have given rise to serious

symptoms from stoppage of the heart. It is evident that it is

extremely important properly to predispose such patients.

The well-known surgical warning not to make remarks during the course

of an operation that might prove disturbing to the patient, needs to

be emphasized. By a very curious psychological anomaly some patients,

though thoroughly anesthetic as regards pain, are able to hear and

understand very well remarks that are made near them. Fortunately,

such patients are few in number, but they are sometimes rather

seriously disturbed by chance observations that for the moment at

least seem to have an unfavorable bearing on their case. Besides,

certain patients sometimes have their special senses come out from

under the influence of the anesthetic before their sense of pain. They

may also hear and be disturbed. These cases illustrate very well the

place of mental influence and how much deliberate attention should be

given to this phase of the treatment of surgical cases coming out of

anesthesia, as well as while more or less under its influence.

Local Anesthesia.--In local anesthesia it has come to be generally

recognized in recent years that the personality of the operator is one

of the most important factors for success. A number of local

anesthetics have been introduced, and in some hands only comparatively

small quantities of them are needed in order to produce complete

absence of pain during operations. In other hands, however,

considerable and even toxic quantities may have to be employed and

sometimes without entire satisfaction. Infiltration anesthesia depends

for its success largely on the personal influence of the administrator

over the patient. It is extremely important that the patient should

have complete confidence and not have that confidence disturbed in any

way. For instance, he needs to be warned that he will feel the slight

prick of the needle when it is first introduced, for otherwise he will

be disturbed by even so slight a pain at the very beginning and will

magnify subsequent feelings until satisfactory local anesthesia

becomes impossible. Without thorough command over the patient and

complete trust, local anesthesia never succeeds except in very minor

operations. There are some men, however, who can do even severe and

extensive operations with comparatively small amounts of local

anesthesia. Others cannot perform satisfactorily even minor operations

with large amounts. It is the operator, his personality, and mental

influence over the patient that counts.

Vomiting After Anesthesia.--The vomiting that comes after anesthesia,

especially with ether, often constitutes not only an annoying but

sometimes a seriously disturbing complication. It must not be

forgotten that vomiting in neurotic individuals, and especially women,

may be largely due to a neurosis. In the section on Psychotherapy in

Obstetrics we discuss the vomiting that occurs in connection with

pregnancy and suggest that it is nearly always neurotic in character.

The best-known European obstetricians are now agreed in this. While

ether produces a tendency to vomit in everyone, in some the actual

vomiting is very slight or completely absent. If patients expect that

there is to be vomiting, if they are of the neurotic temperament that

not only {759} vomits easily but has a tendency to secure sympathy by

fostering this symptom unconsciously perhaps, then the vomiting may

become even a dangerous complication. If there is no expectancy in the

matter, however, but if, on the contrary, it is made clear to these

patients before the anesthetic is administered that, while there may

be some nausea, there need be no vomiting unless they yield too

readily to their feelings, much can be done to lessen the vomiting. A

single suggestion may not mean much in this matter, but a series of

suggestions properly given beforehand, especially if the patient has

seen others vomiting after operations and is worrying about it, may

prove of excellent contrary suggestive value.

If there is no expectancy, the physician must be careful not to arouse

it by over-solicitous anxiety in the matter. A plain statement should

be made on several occasions, however, so that the patient will have

in mind a good basis for contrary suggestion when coming out of the

anesthetic. Many remedies have been suggested for this post-anesthetic

vomiting, but, just as with regard to the vomiting of pregnancy, the

most important element in all the cures that have been reported has

been the influence upon the patient's mind. Whenever we have a number

of remedies for an affection, it is almost sure that it is not their

physical but their psychic effect that is of most importance.

CHAPTER IV

MENTAL INFLUENCE AFTER OPERATION

Every surgeon feels the necessity of having his patients as quiet and

restful as possible after operation. Any unfavorable mental influence

will surely hamper the curative reaction of tissues and delay

convalescence. We all know how fear blanches tissues, and anxiety

causes hyperemia, and how solicitude with regard to any part of the

body interferes with the normal control of the sympathetic nervous

system and sets up vasomotor disturbances. Either a lessening or

surplus of blood in a particular part interferes with the normal and

healthy curative reaction of tissues. The patient's mind should

therefore be as much as possible diverted from attention to the part

that has been operated on in order to leave nature to pursue its

purposes without disturbance. For this, of course, pain must be

relieved and every possible measure taken that will add to the comfort

of the patient. In spite of the fact that opium may interfere with

certain natural processes, it is always useful after severe

operations, because it represents the lesser of two evils. The pain of

itself would produce more detriment than does the opium which relieves

the pain. There are, of course, other anodynes which may be used and

that have less disturbing sequelae. In this matter, routine is

unfortunate, for individual patients react very differently to opium

and its derivatives, the disturbing effect upon the mind being greater

than the quieting effect on the body. Many patients stand the coal-tar

derivatives much better because of their lack of effect on the mind.

Removal of Worries.--Worries of all kinds not associated with the

operation must have been thoroughly removed beforehand and must not be

allowed {760} to obtrude themselves afterwards until convalescence is

well established. Business is quite another matter. Whenever it does

not imply worry but only means occupation of mind and distraction of

the attention of the patient from himself, it may very well be

permitted, after only a comparatively brief interval after operation.

Within a few days a business man may certainly be allowed to dictate

letters for an hour or so, and an author may even be allowed to

dictate notes of some of the fancies that came to him during

anesthesia. When a man has the opportunity to look forward to even a

short interval during the day when he can do something that is useful,

it serves as an excellent distraction for many hours beforehand and as

a satisfactory memory for hours afterwards.

Pleasant Visits.--It used to be the custom to keep visitors from

patients after operation much longer than is at present the custom.

There has come the realization, however, that short visits from

pleasant friends may mean much for the patient. It is hard to make the

selection, for certain friends and especially relatives disturb and

annoy rather than help the patient. Anyone who shows much solicitude

and, above all, fussy over-anxiety, must be excluded, no matter how

nearly related he or she may be.

Psychic Conditions of Hospitals.--The atmosphere of the hospital must

all conduce to peace and quiet of mind. It is surprising the

differences that may be noted in this respect. I have been in a

hospital where only a dozen of operations were done a week and have

scarcely ever been there without hearing complaints of pain and

discomfort that were surely disturbing to others. On the other hand, I

have been in a hospital where twenty capital operations a day were

done, and have heard no complaint, and at nine o'clock at night have

found in it the peace of a religious community. I knew that it was all

due to the personality of the surgeons and their lack of power in one

case to impress their patients' minds and a very marvelous power in

the other of impressing patients favorably. The success of many a

surgeon in a material way depends on this power to impress his

patients. It is they who send others to him, and in general there is a

feeling that if he cannot cure them no one can.

Of course, it is extremely important that circumspection should be

employed as regards chance remarks that may be seriously

misinterpreted and prove unfavorably suggestive. Patients should not,

as a rule, be allowed to see their own charts whenever there are

disturbing developments in pulse and temperature. During dressings the

conversation should be cheerful, distracting to the patient, and

should not contain remarks that may be disturbing. The surgeon and his

assistants must know how to control their expressions so as not to

reveal any solicitude that may be occasioned by the patient's progress

or by the state of his wound when these are not satisfactory.

Surgeon's Visits.--Practically every time that a surgeon visits a

patient after operation there is something that the patient has to ask

or have explained. A good deal depends, as far as regards the comfort

and peace of mind during the interval until the coming of the surgeon

again, on the satisfaction derived from the surgeon's explanation. He

should be prepared, therefore, to answer in such a way as will leave

no haunting doubts in the patient's mind. Some patients are very prone

to find unfavorable suggestions in even simple expressions of the

physician. He must be prepared for {761} this, therefore, and be sure

to say nothing that can possibly be misunderstood. In spite of this,

at times patients will draw unfavorable inferences and then the nurse

should have the confidence of the patient sufficiently to set the

matter right or at least to give reassurance that will keep the

patient's anxiety from disturbing until the next visit of the surgeon.

All of this seems trivial from a certain standpoint, but even surgery

is as yet an art and not a science. Art depends on personality and the

influence of it and the power to express itself. The personality of

the surgeon must be felt in the patient, and the more he can make it

felt the better the convalescence and the less discomfort even though

there should be more of pain. The amount of pain actually felt depends

on how much of it gets above the threshold of consciousness.

Almost any surgical patient, especially if he has gone through a

serious convalescence, will tell you how much good the visits of his

physician used to do him, though a glum and over-serious surgeon may

have exactly the opposite effect. Sometimes busy surgeons neglect to

visit their patients daily, and nearly always this has an unfortunate

effect. In serious cases, the seeing of the surgeon several times a

day, when it is well understood that his visits are not due to

over-anxiety with regard to the patient, may hasten convalescence

materially.

Comfort, Mental and Physical.--Everything must be done to make the

patients as physically comfortable as possible. It must be well

understood, however, that comfort lies much more in variety and

response to feeling than in any continuous condition. Patients will

have little complaints and there must be always something novel to do

for them. This does not necessarily imply medicine or even troublesome

external applications, but the rearranging of bed clothing, the use of

a hot-water bag or of an ice bag, the relief of pressure, sometimes

mild applications of pressure, the lifting of the head, slight

turning, even small changes of position and the like. Whenever a

patient can be relieved by some means so simple as these external

trifling remedial measures, confidence is awakened that the discomfort

they feel is not due to any serious condition, but is only such achy

tiredness as comes from confinement to bed. Without relief afforded in

this way, they are likely to let unfavorable suggestion accumulate

until their dread of something serious may inhibit convalescence or at

least interfere with sleep and greatly enhance their discomfort

generally. It is the state of mind that develops as a consequence of

continued trifling discomforts and not the physical results of those

discomforts that must be carefully looked to in post-operative

patients.

Nursing.--In the general management of patients after operations it

would be eminently helpful to the surgeon if surgical nurses were

supposed to read at least once a year, Florence Nightingale's "Notes

on Nursing," [Footnote 61] written half a century ago, and if the

surgeon himself should have read it through once at least and dip into

it occasionally afterwards. In her chapter on Noise there are many

remarks that I should like to quote, but the whole chapter is so

valuable that it is hard to know where it stops, and so only a few

expressions may be given here. For instance, "Never to allow a patient

to be waked intentionally or accidentally, is a _sine qua non_ of all

good nursing. If he is aroused out of his first sleep he is almost

certain to have no more sleep." "The more sleep patients get the

better will they be able to sleep." "I have often {762} been surprised

at the thoughtlessness (resulting in cruelty, quite unintentionally)

of friends or of doctors who will hold a long conversation just in the

room or passage adjoining the room of the patient, who is either every

moment expecting them to come in, or who has just seen them, and knows

they are talking about him." "Everything you do in a patient's room

after he is 'put up' for the night increases tenfold the risk of his

having a bad night. Remember, never to lean against, sit upon, or

unnecessarily shake or even touch the bed in which a patient lies."

[Footnote 61: American edition, Appleton, N. Y.. 1860.]

Miss Nightingale, as might be expected, insists emphatically on the

state of the room, the arrangement of the furniture and the

cheerfulness of surroundings as important factors for the cure of

patients. One of the most important elements is, of course, the nurse.

She must be gentle, patient, quick to understand, often ready to

anticipate wishes, and always as noiseless as possible. Slowness may

be neither gentle nor noiseless. Patients, particularly men, often

grow impatient at the slowness with which things are done for them.

Chattering Hopes.--There is scarcely an element of mind in the

patient's environment that Miss Nightingale has not thought of and

touched with very practical wisdom. She deprecates, as does anyone who

knows anything about the care of patients, the "chattering hopes" of

those who try to cheer patients by simply telling them that they ought

to be more cheerful, that of course they will get well and that they

must not be anxious. She says: "I would appeal most seriously to all

friends, visitors, and attendants of the sick to leave off this

practice of attempting to 'cheer' the sick by making light of their

danger and by exaggerating their probabilities of recovery."

Cheerfulness and kindness towards the sick are one thing and foolish

attempts at encouragement not founded on good reasons quite another.

Variety of Thoughts.--From the chapter on Variety the following

quotations show the very practical character of Miss Nightingale's

persuasion as to the value of influencing the patient's mind:

"To any but an old nurse or an old patient the degree would be quite

inconceivable to which the nerves of the sick suffer from seeing the

same walls, the same ceilings, the same surroundings, during a long

confinement to one or two rooms." "The nervous frame really suffers

as much from this lack of variety as the digestive organs from long

monotony of diet." "The effect in sickness, of beautiful objects, of

variety of objects, and especially of brilliancy of color is hardly

at all appreciated."

As Miss Nightingale insists, flowers are remedies of great value for

the ailing and especially for those who are confined to their room for

a long period. She pleads for having the bed placed near a window in

order that they may see out into the fields and the scenery around

them, to which I would add with emphasis, and so that, if it is

possible, they may see the occupations of human beings. Miss

Nightingale adds: "Well people vary their own objects, their own

employments many times a day; and while nursing (!) some bedridden

sufferer then, they let him lie there staring at a dead wall without

any change of object to enable him to vary his thoughts." Quite

needless to say, variety is more important for the ailing than the

well.

Pain Psychic Conditions.--Pain after operation is an extremely common

symptom and often causes much disturbance. Every surgeon knows how

{763} individual are patients in this respect, and how much depends on

the personal reaction to pain. There are men and women who have very

serious lesions, from which much pain might be expected, who complain

very little. There are, on the other hand, many men as well as women

who complain exaggeratedly after even trifling surgical intervention.

We have probably had some of the most striking examples of the

influence of mind over body in these cases. Many a patient who

complained bitterly of torment that made it impossible to rest has,

after being given a preliminary dose of morphine hypodermically,

subsequently been given less and less of that drug, until finally,

after a few days, he was getting injections of only distilled water.

Without their injection he was in agony. After it he settled down to a

quiet, peaceful night. Very often it is noted that these pains are

worse at night and there is a tendency for such patients to attract

attention only at such times as may be productive of considerable

disturbance of the regular order and as may call special attention to

them. We used to call such conditions hysteria, though, of course,

they have nothing to do with the uterus and must be looked for in men

quite as well as women.

Psychoneuroses.--These neurotic conditions, to use a term that carries

no innuendo with it, may affect other functions besides that of

sensation. Occasionally a neurologist is asked to see a patient in

whom, following an operation, usually not very serious, some paralytic

symptoms have developed. There is an inability to use one or more

limbs, and the suspicion of thrombosis is raised. It is rather easy,

however, to differentiate thrombotic conditions from neurotic palsies.

The ordinary symptoms of the psychoneurosis are present. There is

likely to be considerable disturbance of sensation, with patches of

anesthesia and hyperesthesia, some narrowing of the fields of vision,

and anesthesia of the pharynx, sometimes even of the conjunctiva.

Often there is something in the history that points to the possible

occurrence of a neurotic condition. Sometimes it is extremely

difficult to get such patients over the mental persuasion that is the

basis of their palsy, but usually it can be accomplished by suggestion

in connection with certain physical means. Electricity is often of

excellent effect in demonstrating to these patients that their muscles

react properly under stimulus and that it is only a question of

inability to use them because of mental inhibition. Such conditions as

astasia-abasia may develop quite apart from surgery, but there is

always some "insult," as the Germans say, that is some physical basis

for them, and so they are often considered to be surgical.

Psychic Disturbance of Function.--Besides motion and pain, other

functions may be affected through the mind. After operations within

the abdomen it is sometimes difficult to move the bowels when it is

desired to do so. It must not be forgotten that not infrequently in

these cases the patient's mental attitude of extreme solicitude with

regard to his intestines is inhibiting peristalsis. Such constipation

will sometimes not yield to even rather strong purgatives, and yet

will promptly be bettered by something that alters the mental state.

It must not be forgotten that it is in cases of neurotic constipation

that _pittulae micarum panis_ have proven particularly useful. In the

chapter on Constipation there is a discussion of this subject that

will often prove suggestive to surgeons.

This same thing is true with regard to post-operative urination. In

women, {764} particularly, there may be difficulty of urination after

vaginal operations, which may be attributed to some lesion of the

urinary tract and yet only be due to failure of the patient properly

to control muscles in these cases. As in obstetrical cases, position,

the presence of others, and the mental disturbance, may inhibit

urination. The subject is discussed more fully in the section on

Psychotherapy in Obstetrics. Surgeons are not so inclined now to

insist on absolute post-operative immobility, and even a slight change

of position may enable patients to gain control over their bladders

without the necessity for the use of the catheter, which always

carries an element of danger with it.