I. PSYCHO-NEUROSES (HYSTERIA)…

I. PSYCHO-NEUROSES (HYSTERIA)

As the derivation of the name indicates, psycho-neuroses are functional nervous affections dependent on states of mind. They are not necessarily originated by the mind, though they may be. Their spontaneous occurrence as pure psychic phenomena, however, is rather rare. There is practically always some slight physical cause. This may be severe, for all diseases have neurotic accompaniments that disturb the nerves involved and exaggerate the original symptoms. In most cases the patient has no serious interest to divert his or her mind from this occupation with self, and as a consequence the particular feeling fills up the whole of consciousness, and as it is painful to begin with, the pain, following Cajal's law of avalanche, may become almost intolerable.

It is of primary importance to remember, however, that there is practically always a physical basis for these curiously interesting affections which are so difficult to treat and which have so often proved the despair of physicians. While the attitude of mind must be changed, the physical state itself must be corrected. These two things must be secured at the same time, however, for attention to the physical state without correction of mental attitude will usually only emphasize the condition by calling further attention to the symptoms. This is especially true of local treatment. The mind must, above all, be treated and diversion of attention secured. Psycho-neuroses may occur in connection with sensory or motor nerves. The patient may either complain of intense pain in some part of the body for which there is but a very slight basis, or may be unable to move certain muscles, or there may be a combination of sensory and motor symptoms with complaint of pain on movement. The painful conditions are most important because they prove a source of worry and anxiety to the patient's friends, as well as often of such annoyance at unsuitable hours as deprives those near them of rest to a degree that may undermine health.

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FORMS OF NEUROTIC SIMULATION

Every possible painful condition is simulated by these psycho-neurotic conditions. They occur probably with more frequency in the abdomen than elsewhere; they may be thought to be colicky in nature and, as a rule, some accumulation of gas will be found. This gas is sometimes swallowed air and sometimes gaseous products that have been diffused apparently from the blood in the intestinal walls. This always produces discomfort but nothing like the discomfort that the patient complains of. The condition if treated by carminatives will nearly always be emphasized rather than relieved. Local treatment by heat will help oftener, but may exacerbate it. When chronic constipation is present, calomel in divided doses is suggestive as well as medicinal.

There may be gastric crises that recall those of tabes, and there may be vesical and rectal crises of a similar nature. I have seen a patient complain of every symptom of stone in the kidney. At the beginning the pains were vague, but after she had been to several physicians and had been asked certain questions intended to elicit pathognomonic signs of stone these questions were answered in the affirmative. Her attacks became strikingly like renal colic. After a consultation, at which two physicians and a surgeon were present, she was operated upon for stone in the left kidney. No trace of it was found. But after this she was well nearly a year. Then she had another crisis of pain in the early morning hours, a time when her painful condition always came on, apparently because it attracted more attention and caused more disturbance at this time, and now all the symptoms pointed to the right kidney. She was treated on the principle that it was a neurosis, was made to gain some fifteen pounds in weight, has since then had no attacks, has not passed any stones, and there seems no doubt but that the whole case was merely neurotic. During her attacks instead of having suppression of urine, she had a free flow of urine and no blood. It is not unlikely that the physical basis of the attacks was that condition of the kidney which allows urine to flow through very freely during neurotic conditions and which somehow got into the sphere of her consciousness and being over-attended to became extremely painful.

Secretory Neuroses.--Lying between the pain and motor neuroses and dependent on psychic elements to some extent at least, there is a series of neuroses that have as their principal symptoms an increase or decrease of secretion. Occasionally, of course, they are complicated by motor neuroses, especially in connection with the viscera. There are various stomach affections, represented by an increase or decrease in stomach secretion, and accompanied by pain, discomfort, and decrease or increase of peristalsis. There are biliary neuroses accompanied by increase or inhibition of biliary secretions. There are gastric neuroses associated with vomiting, often very intractable, in which there seems to be sometimes a hypersecretion of gastric juice and sometimes a lessened secretion. All of these occur, as is said, spontaneously, but there will usually be found a history of some exhaustive work or worry during the weeks or months just before. Apparently nervous control is lost and then the secretory neurosis manifests itself sometimes in conjunction with painful or motor affections.

Neurotic Vomiting.--Persistent vomiting occurs in these cases but is not {587} so serious as it seems and patients do not lose weight, as might be expected. There is sometimes even a probability that some of the food ingested finds its way through the pylorus and is used for nutrition, though the vomiting may come on not long after ingestion. Practically always nature asserts herself and stops the vomiting when serious conditions seem about to develop. The solicitude of relatives may be calmed by this assurance, and just as soon, as a rule, as they show less anxiety about the patient, the first symptoms of improvement will be noted. The fasting girls exploited in the newspapers, in connection with these neurotic conditions are often frauds and investigation has shown on a number of occasions that they were obtaining food surreptitiously. It must not be forgotten, however, that, even though these cases have been discredited, we have a number of cases on record of men and women who have taken absolutely nothing nutritious and only water for from ten to forty or even fifty days. Until at least ten days have passed in one of these gastric neuroses, then, there is no need for urgent solicitude, and this of itself, when properly explained, makes an excellent favorable suggestion for these patients, and, above all, for their friends.

Simulant Appendicitis.--Some of these abdominal psycho-neuroses may simulate serious pathological conditions that, in recent years, have come to be looked upon as surgical. I have seen a number of cases, especially in women who have been constipated for some time, in which there was considerable discomfort in the right lower abdominal segment and occasionally surgeons thought that an operation should be performed. Usually in these cases there is no localized tenderness and no mass of any kind to be felt in this region. Sometimes tenderness is complained of, though when the patient's attention is diverted even deep pressure may be made without their wincing. Whenever there is no history of an acute attack, no temperature and no increase in pulse rate, unless there are very definitely localized symptoms, the question of operation is always to be answered in the negative. Disturbances of the pulse may mean little. The history must guide. I have seen these cases operated on, improved for a while, but relapse afterwards just as soon as there was a resumption of their constipation. As a rule, when the appendix has been removed, either because its function has something to do with the inhibition of putrefactive processes in the lower bowel, or because as the result of the operation and consequent adhesions, the colon was not so active in its peristalsis, the constipation seemed to be worse than before, unless special care was exercised. If there is relapse after an operation the patients' attacks are almost sure to be more frequent than before and their discomfort likely to be more pronounced.

Lest it be thought that such cases are mainly confined to women or that the most striking cases occur only in women, I may say that the most interesting case of this kind I ever saw was in a young, vigorous German soldier. He was admitted to Koenig's clinic in Berlin with a story of abdominal tenderness and pain, the tenderness being located in the right iliac region. There seemed even to be some distention of the abdomen after a time and the development of greatly increased diffuse tenderness. The pulse was considerably disturbed, but there was only a slight rise in temperature, and for a time it was thought that this might be a case of appendicitis without fever. A surprising feature of the case was the presence in the right iliac region of {588} a scar which, on careful investigation, proved to be double. Apparently the patient had been opened twice before in this region. His history was carefully investigated. He had had a fall from a horse about two years before and afterwards had considerable abdominal discomfort. He was quite sure that something serious had happened within his abdominal cavity as the result of the fall and his attention was concentrated on his right iliac region. At the time of the accident his symptoms were considered to be a psycho-neurosis or perhaps an exaggeration of symptoms with malingering tendencies.

Shortly after his term of service expired, however, some acute symptoms developed and there was swelling, or at least tympanitic distention of the abdomen with disturbance of the pulse, and he was operated on in the hospital and his appendix removed. There proved to be nothing the matter with it and no pathological condition was found within his abdomen. He seemed to recover completely. After six months he was admitted to another hospital with the same symptoms. He seemed to have the habit of swallowing air which found its way beyond his pylorus, or else gas leaked from the blood vessels in the walls of his intestines, producing a symptom-complex not unlike the tympanitic distention consequent upon general peritonitis. Once more this was taken to mean very probably a ruptured appendix and another operation was done. This operator went through the old scar, but to his surprise found no appendix and found everything within the abdomen normal. The third time the patient came to Koenig's clinic and, owing to his military record, his hospital experience was available and a third operation was not done. Instead, according to the story current at the time, the patient was tattooed with the legend "no appendix here." The case is interesting as an example of the extent to which an abdominal psycho-neurosis may simulate a ruptured appendix.

Pseudo Biliary Colic.--A similar state of affairs to that with regard to the appendix has developed in all that concerns the gall bladder and the biliary tract generally. Any complaint of discomfort in the right upper quadrant of the abdomen, if persisted in, is almost sure sooner or later to be diagnosed as due to a calculus. Now that operations for gallstones are more common than they used to be, it is probable that almost as many gall bladders are found without pathological conditions as appendices without justifiably operative lesions. In treating individuals who have a history of recurrent symptoms of intestinal reaction to various foods complicated by urticaria, it is important to remember that there may probably be lesions corresponding to those in the skin in portions of the intestinal tract which may functionally involve either the appendix or the biliary passages. Some of these cases are extremely difficult to handle because often there is pain, definite tenderness and some fever with the attacks, and very localized symptoms. The history, however, will be helpful. Operation will not relieve the patient from liability to recurrence. There are, however, other cases where the discomfort is much more vague, where there is no tenderness, no disturbance after jolting rides and where there has never been any severe pain. These should not be set down as biliary calculi without further developments. The possibility of a stone being present should not be hinted to the patient until some definite pathognomonic sign is discovered.

Other Simulated Conditions.--There are many painful conditions of the {589} head that are psycho-neurotic. Many forms of headache are due to sensations of pressure or tension or constriction, usually in the external integuments of the skull, which are dwelt on and then become painful achy conditions. This is particularly true of so-called headaches in the back of the head. As we emphasize in the chapter on Headache, probably most of the headaches of patients who have not much to occupy themselves with, are due rather to queer feelings in the head emphasized by the concentration of attention on them than to real pains. Earache may occur in the same way. Nearly always when one has been out in the wind, there is likely to be an uncomfortable sensation in the ear. By attention to it this may readily be exaggerated into an earache. Occasionally the physical basis of an ache in the region of the ear seems to be an unconscious performance of Valsalva's experiment while blowing the nose when catarrhal conditions are present.

All sorts of painful conditions of the arms and legs may develop in the same way. Unusual tiredness, or some special exertion of the muscles, may produce a sense of fatigue readily exaggerated by attention to it, into severe pain. This condition is not a voluntary simulation, but is due to lack of diversion and a certain inborn tendency in these people to pay attention to anything that is the matter with them. Very seldom does the physical condition need much treatment, though nearly always something can be done for it with advantage, but the mental state needs alteration and, above all, the patient needs to be diverted from over-concentration of mind.

Motor Neuroses.--As has been said, beside painful conditions, various forms of motor trouble may develop. These usually consist of inability to move certain groups of muscles. They have sometimes been spoken of as hysterical palsies or paralyses. The word hysterical, by its derivation connected with the Greek word for womb, apparently indicates that these conditions are limited to women. It is well known now that they are extremely common among men and especially among young men and have absolutely nothing to do with the genital system. As with painful psycho-neurotic conditions, there is practically always a physical basis. This sometimes requires careful questioning to locate exactly. There is some injury of the muscles of a particular region, or some over-use of them, or some employment of them under bad mechanical conditions with over-fatigue, and then attention to this leads to incapacity to use the muscles or inability to co-ordinate them properly.

Neurotic palsies, to use a term that carries much less unfavorable suggestion with it than the word paralysis or the word hysterical, may occur in any limb or group of muscles. They may occur in the legs with the production of complete paraplegia. One well-known form, astasia-abasia, inability to stand or to walk, affects the muscles of the trunk as well as of the lower limbs. These conditions often remain for long periods in spite of treatment, frequently recur, are often called by all sorts of names and continue to be a source of annoyance to the patient, until a definite successful effort is made to change the patient's mental state to one of less attention to the particular part.

There is, it seems to me, an unfortunate tendency to think that our observations upon these cases are comparatively recent. Sir Benjamin Brodie, nearly a century ago, insisted that at least four-fifths of the female patients among the higher classes of society supposed to suffer from diseased joints were really sufferers from neurotic conditions, or, as they called them then, {590} hysteria. Sir James Paget, in his Clinical Lectures and Essays, thinks that Brodie has exaggerated the proportion, for in his own practice, though, of course, he includes his hospital cases and the poor as well as the rich, he found less than one-fifth suffering from neurotic joints. The hip and the knee, which are the most frequent seats of genuine pathological conditions, are also most frequently the subject of neuroses. Next in order, but much more rarely, the metatarsal and metacarpal joints are affected and then the elbow and shoulder. In Sir James Paget's chapter on Nervous Mimicry or Neuro-Mimesis, he cites a number of cases which show how clearly psycho-neurotic affections were recognized in his time. He tells the story of a young man who had been overworking for examinations and who "after a three-hours' mathematical cram, fainted and when he rallied set up a very close mimicry of paraplegia which lasted many weeks." He insists that "such mimicry is found not only or chiefly in the silly selfish girls among whom it is commonly supposed that hysteria is rife, but even among the wise and accomplished, both men and women."

DIFFERENTIAL DIAGNOSIS

For the differential diagnosis of psycho-neuroses from definite organic conditions, the most important element is the patient's previous history and a knowledge of the condition of the nervous system. Where this is known the diagnosis is comparatively easy, but when the patient is seen for the first time it may often be extremely difficult. It is, above all, important not to jump to conclusions, for every nervous specialist knows of cases in which the diagnosis was considered to be surely a neurosis, yet a fatal termination showed that a serious organic condition was at work. It must not be forgotten either that neurotic patients may develop serious organic disease in the midst of their neurotic symptoms and care must be taken not to miss the significance of special symptoms. When the patient is not well known, the presence of certain stigmata, as they have been called, enable the physician to recognize the probability that a neurotic condition is present. Patients who are subject to neuroses are likely to have certain areas of the skin surface and of the palpable mucous membranes more or less sensitive than normal. There are likely to be spots of hyperesthesia or hypesthesia or even complete anesthesia somewhere on the skin. These should be carefully looked for and in serious cases an examination of the whole skin surface should be made. Not infrequently anesthesia or a decided lack of sensitiveness to irritation will be found in the throat or in the nose. Occasionally the conjunctiva is much less sensitive than usual.

These used to be called hysterical stigmata. The word hysteria carries an innuendo of imaginativeness or occasionally of affection of the sexual organs that is unfortunate. It would be better, therefore, not to use the term in any way. The presence of these areas of hyperesthesia, hypesthesia and anesthesia indicates that association fibers are abnormally connected in the brain for the moment at least, and that as a consequence there is over-attention to certain portions of the body with lack of ordinary attention to others. This will account very readily for the occurrence of painful conditions in certain cases and palsies in others. When over-attention is paid, there may be a {591} hyperesthesia corresponding to that seen in the skin in any organ of the body. When, for any reason, there is a disturbance in a particular part, there may be a lack of motility due to nervous influences, just as there is a lack of sensation. In all of these cases the one essential element is to correct the nervous state through the mind as far as possible. Experience has shown that this can be done in nearly all cases. It must be the principal effort of the physician.

TREATMENT

Strong Mental Impression.--In the treatment of these affections two periods are to be considered, one during, the other after the attacks. During the attack a strong impression must be made upon the patient's mind so as to divert the concentrated attention. We have well authenticated stories of the various expedients resorted to by physicians who were confident of their diagnosis in order to secure such a strong mental impression. I once knew an old physician who was summoned to a childless wife whose adoring husband was in manifest agonies of solicitude over her and whose mother and mother-in-law had been caring for her for days with all anxiety, walk into the room of the patient, take one of her hands in his, slap her on the cheek, tell her to get up and walk and she would have no more of that supposed inability to walk which had caused the family so much anxiety. He succeeded. It can be imagined what would have happened had he not succeeded. We know of cases where an alarm of fire or a burglar scare or some sudden emotion has produced a like result. We cannot prescribe these things, however, and at the most, after one or two successes in a particular patient, they would fail.

The only thing that we can do as a routine practice is to relieve by direct treatment the slight physical condition that is usually present and then try and influence the patient's mind. If a thorough examination is made in the course of which the physician is able to show the patient that he understands the condition and that he can demonstrate for himself and them that there is nothing serious the matter with important organs, he can make them feel that their pain or disability is entirely due to concentration of attention on a particular nerve or set of nerves. With many patients this will succeed, not at once, but after two or three seances of positive suggestion, even in the waking state. If the patients are bothering their relatives very much it may be necessary to give some opium as an adjuvant. As a rule, the needle had better not be used, but a suppository given. This is not nearly so attractive to the patient's mind as the use of the needle and is not likely to be called for so often. Every physician has had the experience that after giving opium two or three times, either per rectum or hypodermically, almost anything can be given, provided the patient is persuaded that the drug is being given again. A reasonably large dose may be used the first time, but certainly after the second or third time a much smaller dose will produce the same effect and often a simple gluten suppository, provided it looks like the other, will work just as well as an opium suppository.

After Treatment.--The after treatment of these cases is directed mainly to such alterations of the mental attitude and physical condition as shall prevent {592} recurrences. The general condition of the patient must be improved in every case where there is indication for this. Many of these patients are under weight for their height. They must put on weight. Weir Mitchell's success with the "rest cure" consisted to a great extent in his power to cause these patients to put on weight. This supplies reserve energy, but, above all, replaces discouragement by hope and buoyancy. Gain in weight can be accomplished mainly by two methods. First, by seeing that the patient gets an abundance of air and, secondly, by dictating how much shall be eaten. In this matter details are important and it may be necessary to suggest the actual diet for each meal. This must be liberal and must consist of simple but particularly nutritious materials. Patients' dislikes need not be taken into much account, their likes are often helpful. When there is insistence on lack of appetite and decided objection to chewing, eggs and milk should be given in increasing quantities, until five or six eggs and some twelve glasses of milk are taken every day. Besides this, a good portion of meat should be eaten at one meal with some vegetables. By firm insistence, day after day, it will not be hard to get patients whose appetites are seriously inhibited to take this amount of food. To secure this, a good, firm, sensible nurse is invaluable. Appetite, as we have emphasized in the chapter on Appetite, is largely a matter of will, and anything that is eaten, provided it stays down, will do good unless there is organic disease.

A certain amount of exercise is important in these cases, but not nearly so important as an abundance of fresh air. Patients must not be allowed to overtire themselves. Riding in an open carriage or on the top of a bus, especially where there are distracting scenes and many human interests, is particularly beneficial. Automobiling is often likely to be more tiresome than is good for these patients when they are run down, though it is one of the best of therapeutic measures for those who are physically capable, that is, up to weight, even though they may complain of feeling weak.

Diversion of Mind.--It is in these cases particularly that diversion of mind is of prime importance. Many of these patients have either no serious interest or at most certain interests with which they may occupy themselves if they wish, but that are not engrossing and attention to which may be put off whenever they care to. Duties that are inevitable and that call for the occupation of so much time that the patient has little opportunity to think of herself are often the salvation of these patients. As I mention in the chapters on Occupation and Diversion of Mind, I have seen a number of cases and I am sure that every physician of reasonable large experience has seen similar cases, where women, particularly, who in the midst of prosperity have been constantly suffering from some form of psycho-neurosis, great or small, have, after some sudden turn of fortune, been completely relieved from their nervous symptoms by having to devote themselves seriously to some occupation for a livelihood.

Occupation, particularly with children, with the weak and the ailing, with the poor and those who are unable to help themselves, is specially likely to be helpful to such patients when they are women. Such interests affect them deeply and by the sympathy they arouse through contact with real physical suffering, they prevent over-attention to themselves. I have seen the care of a cancer patient, and especially of a relative affected by cancer, do more for {593} a psycho-neurotic sufferer than all that doctors had been able to accomplish in years. It is often difficult to find occupation and diversion of mind for these patients, but this is the therapeutic problem the physician must solve if he is going to secure relief from present conditions and prophylaxis against further attacks.

Oldtime Cures.--Many of the remedies for obscure abdominal conditions show how well the real character of the affection was duly recognized and appreciated in the past. It is in these cases particularly that the pillulae micarumpanis, the bread pills, of the olden times, were so commonly used with good effect. We have quoted examples in other chapters. Many of the drugs that are employed with reported success for these affections have a strong suggestive element in them. Valerian probably is a good tonic and yet there is no doubt that the suggestive quality of its nauseating smell and the almost inevitable eructations that occur after to emphasize it, are helpful in curing certain internal psycho-neuroses. Another drug that has been much used in the same way is asafetida, whose disgusting taste and odor have been excellent auxiliaries. Fresh pills of quinine and red pepper uncoated and therefore producing definite effects on the taste before swallowing and on the mucous membrane of the stomach after swallowing, often prove the best remedy for persistent vomiting or for enduring nausea. A drop of nux vomica, taken every half hour with the definite warning that the patient must by no means take more, and that the bottle must be carefully protected lest anyone else should be poisoned, is often very efficient. These remedies have a slight physiological action and a large psychic action, but that exactly corresponds with the etiology of the affection for whose treatment they are employed.

Dominant Ideas.--During the attack it is often possible to find either from the patient or from friends that there is some dominant idea which is bringing about the mental short-circuiting that leads to the concentration of attention. From the oldest times it has been recognized that in young women a disappointment in love may prove to be the occasion for a psycho-neurotic or, as they used to call it, hysterical attack. This is, however, not a specific cause. It is the disappointment much more than the sex element in the case, as a rule, that produces the unfavorable effect. It was easy to conclude that the sex factor was extremely important in older times when women's sphere of activity was largely limited to the home, and marriage was the one legitimate object of their ambition. Now that we have had more experience with the business woman, we know that serious disappointments of any kind have a tendency to initiate psycho-neurotic conditions in susceptible and especially suggestive individuals. A failure to secure promotion in a store, or to secure some position that is eagerly sought for, a loss of money in business, etc., especially when they have been preceded by weeks or months of solicitude and worry over the event that now happens, may lead to the development of a psycho-neurosis.

This is particularly notable with regard to educational interests of various kinds. Young women readily overdo application to study, or, rather, anxiety over it, and as a result get into a state of mind in which a failure to pass an examination, or to secure promotion, or even the failure to win a prize, may give rise to a highly nervous condition in which tears and laughter come unbidden and in {594} which further developments may bring on a typical psycho-neurotic attack. All sorts of pains and aches and motor incapacities may occur in these states. The supreme occupation with the single idea present in their minds at all times, waking and sleeping, while they try to study, or when they read or even when they are supposed to be diverting themselves, finally precipitates a nervous explosion along nerves that have been irritated for some reason, though the pathological condition present may be quite insufficient of itself to explain the affection that ensues. These are the popular nervous breakdowns, not difficult to treat once their real character is diagnosed.

Sorrows of various kinds may produce a like effect. Worry or anxiety about the serious illness of a near relative, especially an inevitably fatal illness, such as cancer or tuberculosis or the disturbing mental affections, may have a similar result, but usually not in those who are occupied with the actual care of the patients. The mental states constitute the psychic elements underlying the neurotic condition that develops.

Almost needless to say, successful treatment must include a faithful attempt to lessen the significance of the mental state that is so important in the case. Usually the mere obtaining of the patient's confidence is enough to lessen greatly the irritation produced by the mental condition. A sorrow shared is halved. It is, above all, secretive individuals who become depressed over their sorrows. While the patient who insists on constantly sharing them with everyone becomes a nuisance, it is always a little dangerous not to have a confidant to whom worries and anxieties are entrusted. If they are kept to one's self they are nearly always exaggerated--they are seen out of proper perspective and have a much more depressing influence. Calm, judicious reasoning with the patient over the significance of the condition as presented, is often of great help.

Often these ideas, so potent for mental and bodily disturbance, are almost entirely unconscious or exist in the patient's subconsciousness and are recalled only under such special conditions as remove the bonds of the patient's occupation with himself or herself at the present time and allow memories to come back without interference. There are many curious stories of such cases. A child is frightened or very much disturbed by having a cat kill a favorite bird. The cat becomes a deterrent object. Gradually this deterrence grows. As a consequence, there may develop one of those intense dreads of cats which makes life miserable if near that animal. There may even be physical effects produced by the continued presence of a cat in the same room. Often in these cases the beginning of this mental attitude, or at least its occasion in the incident of the killing of the bird is forgotten, or at least not consciously referred to as an etiological element in the dread.

Patients have been known to develop states of mind which made them object to certain figures or names because of earlier associations with them that were unpleasant. There is the story of a man who would never take a car with an odd number though this was sometimes a source of annoyance and delay and who could not explain to himself or his physician how this objection had developed, until his memory was searched and it was found that, years before, he had witnessed the death of a child under the wheels of a car with an odd number. He had completely lost the sense of the direct influence of this, but it existed in subconscious memory and proved the source of much {595} annoyance to him, for if with a friend he were not able to avoid taking an odd numbered car he would feel quite miserable during the ride. Frights of various kinds may produce this same effect. I have in my notes the case of a man who is unable to sleep at night without a light in his room, because of a fright. Once while asleep in the dark, he awoke conscious that someone was in the room and sat up and demanded who was there. The answer was a revolver shot and a bullet, passing not far away from him, pierced the head of the bed. As he sank back the burglar leaped from the window and escaped. He realized that this was the cause of his fear of the dark, but lesser incidents might easily become subconscious yet continue their influence.

Psycho-Analysis.--In recent years Freud has suggested that in many puzzling cases of psycho-neurosis, where, so far as is known, there seems to be no dominant idea bringing about the concentration of attention, careful analysis of the patients' memories will bring out the fact that there is a subconscious idea as the underlying substratum of these affections. Freud has developed what is called the process of psycho-analysis in order to bring out these ideas which are sometimes exerting their influence unconsciously to the patient. The subconscious is one of the fads of the hour, so that Freud's announcement attracted much attention. Psycho-analysis, however, is not advanced so confidently even by its inventor as a positively curative measure, as it was at the beginning. It has been found that after the dominant idea in the subconsciousness has been found and neutralized with a consequent amelioration of the psycho-neurotic symptoms, there may be a relapse, when another dominant idea will have to be found, and that there seems to be the possibility, in some cases at least, of an almost endless succession of such ideas to account for further and further relapses.

Undoubtedly psycho-analysis has its place in psychotherapy and is of great value in certain cases. There is no doubt, however, in my mind that in most of these cases reported as cured after psycho-analytic methods had been employed, what really happened is that the patient's mind became diverted to another idea--that of marvelous cure through mind searching which relieved the previous concentration of mind underlying the psycho-neurosis. These are the cases that used to be cured by hypnotism. Before hypnotism was developed they were cured by mesmerism. Before mesmerism they were cured by magnets or by the Leyden jar, and during the past century they have been cured by electrical methods or by osteopathy or by Eddyism. Many of the cures were effected by stroking and touches, the use of Perkins' tractors, or Greatrakes' methods, or anything else that attracted attention very strongly. They were given a new idea which occupied them very much and so saved them from that preoccupation with themselves and their feelings and whatever slight ailment might be present that was the physical occasion for psycho-neurotic symptoms. This happened with psycho-analysis. When it was absolutely new and the operator had great confidence in it, this confidence was imparted to the patients, with the consequent cure or decided amelioration of their psycho-neurosis, just as that used to be brought about by our previous method of treating such cases by some strong suggestion.

As I emphasize in the chapter on Dreams, the examination of the dreams in order to get a hint of the dominant idea, is particularly interesting, because it represents a return to the oldest methods of suggestion of which we have record. {596} The fact that sexual ideas seem to represent a great many of the dominant ideas in these cases is of interest for a similar reason. It represents the tendency constantly recurring to refer most nervous ailments, as indeed most other ailments, to something pathological in the sexual or genital sphere. The old idea embodied in the word hysterical exemplifies this very well. The "vapors" or "tantrums" or fits which were supposed to be due, to some extent at least, to suppressed sexuality by medical writers of three or four generations ago, have come back to us under another form and with other terms. Psycho-analysis gives occasion for instruction in so far as it helps the patient to get rid of old persuasions and exploded ideas as to disease and diet and the various functions of the body and the mind that have often almost unconsciously been acquired and secured a dominance. It is surprising how often it will be found that people are taking too much or too little water at meals, too many or too few vegetables, too much or too little of salt or of other condiments as the result of habits and notions acquired when they were young and under influences that they may now forget. In the same way habits of life with regard to bathing, clothing and the like may be the source of unfavorable conditions in mind and body that need only to be discovered to be corrected. Their correction will often bring about the relief of symptomatic conditions that have proved quite obstinate to treatment. We have emphasized this in the chapters on the Individual Patient and the necessity for acquiring just as much knowledge as possible about both his occupations and his mental attitude in order to be able successfully to treat chronic disease.

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SECTION XVIII

DISORDERS OF MIND

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I. MENTAL INCAPACITY (PSYCHASTHENIA)

In recent years we have come to realize that many of the so-called nervous diseases, or if they do not deserve the serious name of disease, nervous symptom-complexes, are really due to a deficiency of vital energy. Some people have a store of energy that enables them to accomplish many different things successfully. Some become exhausted from a few trivial occupations. What is noteworthy in the cases to be discussed in this chapter is that they show always certain symptoms of mental tiredness or, at least, of lack of capacity for affairs. Patients complain, for instance, that they cannot make up their minds so as to reach decisions because they doubt so much whether the decision they come to will be right or wrong. Others dread the outcome of any and every act and feel that something is hanging over them. Slight sources of irritation become so exaggerated by thinking about them and dwelling on their possibilities that they may even disturb sleep and appetite and, as a consequence, the general health. Fears come over patients lest various things should happen and they dread microbes, or infections, or dirt in general, or the approach of insanity, and all to such a degree as to incapacitate them for their ordinary occupations.

Many of these patients become quite incapable of willing effectively. They not only lose initiative, the power to undertake new enterprises, but they find it difficult to make up their minds as to details of the ordinary affairs of life. As we have stated elsewhere in Professor Grasset's expressive formula, these patients say that they cannot do things, their friends say "they will not," and the physician, taking the middle course, which, as usual in human affairs, has much more of truth than either of the extremes, says "they cannot will."

For these states Janet of Paris suggested the word psychasthenia. It is formed on the model of the word neurasthenia and unless it is used with discretion will have all the objections that attach to that other term. Above all, it shares the tendency pointed out by Sir William Gowers with regard to neurasthenia of being "too satisfying. Men are apt to rest on it as they would not on its English equivalent. Physicians, if they do not actually think that they have found the malady from which the patient is suffering, have an influence exerted on them of which they are often unconscious, which lessens the tendency to go farther in the search for the whole mental state." Much more can be said in defence of psychasthenia, however, than of neurasthenia, for the substitution for it of the translation of the Greek words of {598} which it is composed--"mind weakness" would be alarming. While it is important, then, to realize that the term may easily be made too general and prove, as such words as rheumatism has done in our time and malaria did in the past, a cloak for ignorance and an excuse for incomplete investigation for diagnostic purposes, it represents a satisfactory answer to the patient's question as to what is the matter without committing the physician to such definitely detailed opinions as to the patient's condition as would surely prove unfavorably suggestive.

Psychasthenia, Natural and Acquired.--There are two forms of the mental incapacity that underlies many of the curious symptom-complexes that have been studied under the term psychasthenia. One is natural, that is, inherent in the special character of the individual, and the other acquired through disease or exhausting labor, worry, or anxiety. Some people are born without sufficient mental energy to do the work they attempt to accomplish. This is true, also, in the physical order. It is often pitiable to see young men who have not the physical strength necessary for athletic exercises, or the dexterity required for them, faithfully trying to accomplish by effort what others do with ease. When there is some natural defect in the way they will usually fail, no matter how much they strive. Just in the same way some persons are not able to accomplish certain more serious purposes requiring special mental ability or power which they attempt. Their brothers, their friends, their schoolmates, may have the ability, and they cannot understand why they should not have it, but the fact remains that they are not possessed of it and if they try to make up for this defect by overwork they simply break down.

Differential Diagnosis.--Each of the two forms of mental incapacity, congenital and acquired, must be carefully differentiated and treated from a special standpoint. With regard to congenital lack of mental control, all that the doctor can do is to counsel against the assumption of duties and responsibilities that are too heavy for the patient. Some people have not enough nervous energy to run a business with many details, and some even find it difficult to try to do things involving much less responsibility. There is no use for a man five feet in height, weighing one hundred pounds, to try to be a stevedore. There is no use for men of delicate muscular build to try to make their living at heavy manual labor; they simply wear themselves out in a very short time. This inadaptability is recognized at once. Just the same thing is true with regard to many nervous systems, but the recognition is not so easy or immediate. Some cannot stand the strain of intricate business details or the burden of responsibility in important transactions. They must be taught to be satisfied, then, with quiet simple lives without what is for them, excessive responsibility and without strenuous business worries. A country life with regular hours, plenty of open air and as little responsibility as possible, is the ideal for them.

The most difficult problem in this matter is the question of diagnosis. As a rule, the history is the most helpful for this. The patient tells of having found difficulty all his life whenever anything of special significance was placed on his shoulders. He is one of those who were born tired and remain so all their lives. It has been the custom to blame these people; they are rather to be pitied. If they are born in circumstances that allow of their {599} living quietly in the country, they accomplish a certain amount of work quite successfully and live happy, contented lives. If they are born in the city where the hurry and bustle around them and the insistence of friends that they must take up responsibilities becomes poignant, they get discouraged and even despondent. It is from this class of patients that the "ne'er-do-wells" of modern life are recruited. They form the under-stratum of trampdom, the scions of good families with the wanderlust, the willing but incapable. Certain of them become vicious and criminal, either because they do not want to work or because their mentality is perverted in some way. Such patients cannot be treated with any hope of their becoming successful exemplars of the strenuous life, but they may be directed into the less exacting occupations of country life and so live quiet, useful and happy lives. For the congenital class we can do little except to prevent them from trying to do things that are beyond their mental capacity and helping them to see just what their limitations are.

Mental Exhaustion.--Many disturbances of mental energy are acquired. These may be either functional or organic. For the organic variety we cannot do much, since it is dependent on changes in organs that are permanent. We can, however, usually predispose the patient's mind to the recognition of the fact that he should no longer try to devote himself to occupations that constitute a special drain on his nervous energy. The man, for instance, who is already suffering from arterio-sclerosis must be warned that worry and work will surely hasten the process and that his nervous symptoms cannot be cured, but must be palliated. He must be advised to lessen his mental strain and to take up something which, while occupying his mind, does not make insistent calls on his vitality. In this matter it must be remembered that when a man over fifty develops nervous symptoms, as a rule there is no question of functional trouble but of organic change and usually heart or arteries or kidneys are at fault.

In recent years we have come to realize that typhoid fever often makes serious inroads upon a patient's vitality which can only be retrieved by care, not alone for some months but, if possible, even for some years, not to put an overstrain on the vital energy. Certain other diseases produce an even more lasting effect. A sufferer from well-developed tuberculosis will probably never be able to go back to the strenuous city life. If he attempts to do so, not only is there danger of a recurrence of his tuberculosis, but there may even be a development of neurotic symptoms. Syphilis is another disease that leaves patients in a condition in which it is dangerous for them to assume the serious responsibilities of an exacting occupation and especially anything that involves excitement and worry. Syphilitic patients should be warned of the danger of pursuing vocations that make such demands upon them. It is the actor, the broker, the speculator, and the strenuous business man generally, who is likely to suffer from parasyphilitic conditions, tabes, paresis and the like, much more than those who follow occupations that make less demands on them.

Functional Mental Incapacity.--In a large number of cases the incapacity to do things because of lack of mental energy is due to functional disturbances of the nervous system. These are the most important for the psycho-therapeutist because much can be accomplished for them. Nearly always the patient can be benefited by advice and suggestion, and very often some {600} unfavorable factor at work, using up his mental energy to no purpose, will be discovered. In order to do good, however, careful study of the individual patient is the most important element. The most frequent functional disturbance of the nervous system, leading to exhaustion of mental energy, is over-attention to one's self and to one's occupations. Men can do many complicated things quite naturally and easily, but when they carefully watch themselves doing them, accomplishment is not so ready and the task is double. They tire much easier, for, as a rule, what they are doing could be accomplished automatically and they are using up energy attending to it. This is probably one of the commonest causes for the rather frequent development of that state called nervous exhaustion in our time. People watch themselves too closely and by so doing they not only use up energy unnecessarily in the surveillance, but also they hamper their powers to do things and so consume additional energy in overcoming this inhibition.

Morbidly introspective people watch almost ceaselessly everything they do. They not only watch themselves work and worry about it, but they watch themselves play and grow solicitous that it will do them good; they watch themselves divert themselves to see if it is giving them real recreation and so spoil the diversion; they watch themselves eat and disturb their appetite, and watch themselves digest and hamper digestion; they even try at least to watch themselves sleep and so interfere with sleep. Many of the cases of insomnia are really due to this over-attention. They fear they will not sleep, they worry about it, they keep themselves awake hoping that they will sleep, and in the more serious cases even during sleep itself they are so solicitous that their dreams become very vivid and a form of unconscious cerebration goes on with surveillance of themselves. They do not rest even in sleep. They wake feeling not rested, they get up with a consciousness that they are beginning a long day without being properly refreshed and they exhaust enough energy to complete a good part of the day's work in wondering whether they will be able to go on with their occupation for the day, whatever it may be.

Inhibitory Surveillance.--People become afraid that they cannot or that they may not do things well and set a guard over themselves. This is illustrated very well in the doubts about accomplishment because of which they keep going back to see what they have done and how it was done, though usually it was accomplished quite well without any conscious attention. Dreads form another phase of this attitude of mind. For those who are affected with them they make a thing hard to do before it is begun, and harder to accomplish after it has been entered upon because of the suggestion that it may lead to some serious results, or they even inhibit their activities to a marked extent by their solicitude with regard to them. They worry about things before the event and thus consume energy uselessly. Worry has been defined as anxious solicitude about what we have to do next week at the same time that we occupy ourselves with what we are doing now and have to do in the next hour or two. The solicitude about next week is quite useless, as a rule, until the time comes, and it merely disturbs what we are doing now, making it harder to do and making errors in it almost inevitable, and so preparing ourselves for discouragement because of mistakes that have been made and still further adding to the difficulty of accomplishment.

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Inhibition of Automatism.--These introspective people disturb themselves by over-attention to things that need no attention, that are accomplished automatically, and that are not done nearly so well if they are attended to. Not only is it true that it is harder to do work that ought to be accomplished automatically if much attention is given to it, but also nature resents the surveillance. Not only the brain does not work so well if watched to see whether perhaps it is working too much, or whether there are too many feelings in our head while we are doing things, but even the stomach resents being watched and does not do its work as well. The same thing is probably true for every one of our organic functions. In the chapters on the heart we call attention to the fact that surveillance makes a perfectly healthy though nervous heart miss beats. There is a dual waste of nervous energy then. We are employing our attention watching things done that need not be watched, and by that fact we are inhibiting natural processes and requiring that more energy shall be put into them for their accomplishment, and even then accomplishing them with discouraging imperfection.

Mental Short-Circuit.--The reflex mental process that particularly affects many individuals in our time and makes it hard for them to do their work, has been well described under the figure of a short-circuit in an electrical dynamo. The short-circuit diverts the current so that instead of acting outside the dynamo and performing useful work, it is discharged within the machine, brings about deterioration of its elements and soon leads to a reduction in the amount of electrical energy that that particular dynamo can develop.

Association Fibers Diversion.--Prof. Michael Foster in the Wilde Lecture for 1898, "The Physical Basis of Psychical Events," [Footnote 44] has many valuable suggestions with regard to the mechanism of mental operations on the neuron theory. He has particularly dwelt on the function of the association fibers in connection with mental operations, or with the raising of sensation to the plane of mentality. A portion of the brain that is originating impulses, instead of sending them down to the periphery, through the projection fibers, to lead to the accomplishment of external work, may have its messages diverted through the association fibers to other portions of the brain and thus do harm rather than good.

[Footnote 44: Proceedings of Manchester Literary and Philosophical Association, 1898.]

Occurrence of Psychasthenia.--It must not be thought that these curiously interesting conditions occur only among people of low intellectual caliber, or in those of narrow intellectual interests, mere specialists who may have acquired a reputation for doing one thing well. They are frequent among the most intellectual classes. Brain workers of all kinds, unless they are careful to vary the interests of life, unless, as suggested in the chapters on Occupation of Mind and Diversion of Mind, they have a hobby besides their usual occupations, are likely to suffer in this way. As a matter of fact, many intellectual people have had what are called nervous breakdowns of this kind. A biographical dictionary shows any number of them. Dr. Gould's Biographic Clinics furnish many documents for the study of these conditions. A typical instance, told by the sufferer himself, the distinguished Sir Francis Galton, is of special significance for the psychotherapeutist. I {602} quote because it illustrates the fact that such breakdowns do not portend a short or subsequently listless life, for Sir Francis, a most successful scientific investigator, lived well beyond fourscore years in the full possession of health of mind and body.

It was during my third year at Cambridge that I broke down entirely in health and had to lose a term and go home. I suffered from intermittent pulse and a variety of brain symptoms of an alarming kind. A mill seemed to be working inside my head; I could not banish obsessing ideas; at times I could hardly read a book, and found it painful to look at even a printed page. Fortunately I did not suffer from sleeplessness, and my digestion failed but little. Even a brief interval of mental rest did me good, and it seemed as if a long dose of it might wholly restore me. It would have been madness to continue the kind of studious life that I had been leading. I had been much too zealous, had worked too irregularly and in too many directions, and had done myself serious harm. It was as though I had tried to make a steam-engine perform more work than it was constructed for, by tampering with its safety-valve and thereby straining its mechanism. Happily the human body may sometimes repair itself, which the steam-engine cannot.

The physician with experience in such cases would be much more apt to say, "Happily we can learn to control our mental energy and not let it go to waste by foolish persistence at one set of ideas constantly, nor be dissipated in surveillance of functions that work automatically if left to themselves."

Etiological Factors.--This form of mental incapacity develops particularly in people after they have gone through a prolonged period of hard work and then have come to a time when they are much freer than they were before. They are prone to think that they exhausted their nerve force during the preceding period of labor and that now they are paying for it. Almost invariably what is really happening is that they now have much more time to occupy themselves with themselves and about themselves and to worry over their ills, real and imaginary. This is the typical nervous breakdown, as it used to be called, of elderly retired merchants or bankers. They have looked forward all their lives to a time when they could enjoy themselves doing nothing. They retire from business and then their troubles begin. It is no wonder that the old proverb, "A machine rusts out much sooner than it wears out" should have been so often quoted with regard to this condition. A man who has been working busily at something all his life cannot stop all at once and do nothing. He cannot learn to occupy himself with trivial things. Commonly, he has few, if any, interests apart from his business and he very soon wears the novelty off these and then introspection comes to make him exaggerate the significance of every feeling that he has, every stiffness that occurs, every muscle twinge due to change in the weather, until he becomes supremely miserable.

As a rule, these patients are simple, practical, common-sense, business men, and it is hard for the physician to think that there is nothing more than a functional neurosis present. It is even more difficult for the patient to be made to appreciate that his ills are mainly due to his own over-attention to himself in this idleness that he has looked forward to with so much pleasure. Ordinary medicines fail to relieve and the regular professional man seldom succeeds in doing these patients much good. They constitute the richest material for the quack and the charlatan. Much occupied with their ills they tell their friends all about them. Whenever a strong impression is produced {603} on their mind by a promise to cure them with some new wonderful remedy they are favorably influenced, often get better and then are walking advertisements for the particular quack who has happened to benefit them. It is this class of people that has given more trouble to legislative committees of medical societies than any other. Some of them appeal to legislators whenever a bill for the admission of some new form of practitioners of medicine comes up with the story of how much benefit they derived from the treatment. Since they have been successful business men their word carries weight. It is curious how little the making of money, though often presumed to be so, is a test of real intelligence. It is often the man of one idea with no intellectual breadth who is the best money-getter.

These conditions develop almost entirely in predisposed individuals who, for some reason, are trying to overdo the energy they possess, and who, as a consequence, have lost a certain control over themselves. At times, of course, they occur in persons who have so little occupation of mind that thoughts of various kinds along these lines become insistently suggestive and cannot be thrown off because the patients' interests are not sufficiently deep or sufficiently varied to occupy their attention. The rational treatment of them, then, must be founded on a careful study of individual cases, the recognition of the special cause, and also the occasions at work in each case, a neutralization of unfavorable suggestion and a provision of such favorable suggestions and occupation of mind as will enable the patient to rid himself of the annoyance occasioned by these and the physical symptoms that so often develop as a consequence. In a certain number of cases a history of corresponding or equivalent affections in preceding generations will be found. In many patients, however, there is no such history, though there is usually the story of symptomatic mental conditions of one or other of the types mentioned, earlier in life. When in good health physically the patient has very little bother from them. When run down in weight or when worried or anxious about business or from the stress of important responsibilities these symptoms may become bothersome mentally and physically. Often it will be impossible to obliterate them entirely, but always they can be greatly improved and the patient can be made to realize that they are not seriously significant, that in mild form they are rather common and that, above all, they are not so peculiar to the individual as he is likely to think, with consequent increase of the unfavorable suggestion.

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II. HALLUCINATIONS

Hallucinations Differentiated from Illusions and Delusions.--Hallucinations are vivid impressions on the consciousness which appeal to their subject as strongly as if they were really the result of sensory impressions, though those who experience them know, either at the moment, or on investigation afterwards, that they had no objective reality, that is, were not due to any external physical cause. Illusions are deceptions of the senses, due to the imperfection of the senses or the conditions in which the perception occurs. {604} Delusions are mental states in which ideas are accepted, or conclusions drawn, or information assumed to be gained, though the whole process is mental and has no relation to reality. (For illustrations of illusions see chapter with that title in the Appendix.)

Hallucinations lie in between illusions and delusions as a mode of deception. They are mental occurrences, but they seem to come from the senses and probably the best explanation for them is that a previous sensory impression is vaguely aroused and then finds its way into the consciousness as if it were coming through the senses. It has been suggested that they might be due to a reversal of the nervous process by which a sensation reaches the brain. The external object produces the sensation, this travels along a nerve causing a perception, this perception is stored in the memory, and then, when very vividly reawakened, causes impulses to travel backward along the nerve to the periphery with the production of a feeling very like sensation.

Frequency.--While hallucinations are often supposed to be only incidents in the life of the insane, or at least of those who are in the danger zone near mental disequilibration, carefully collected recent observations show that many perfectly sane people have experienced them, and some of them have been much disturbed by them for fear they portended loss of mental control or some developing pathological condition. A certain number of men and women have seen things that either had no existence or existed only for them and for the moment, and that evidently were due to some state of mind rather than to their senses. They have heard things that were not said or that were not audible to others, or that were only reproductions of their memory of previous sounds and quite naturally such mysterious manifestations disquiet them. It was the rule in the past to dismiss such phenomena without serious consideration, or at most to consider that they were only subjective manifestations not worth discussing, or to go to the opposite extreme and say that they were due to mental disturbances.

Of course, as a rule, hallucinations are an index of mental disturbance. No matter how apparently sane the patient, this must be the first thought and must be carefully excluded before proceeding with the case. The subject of hallucinations is larger than that, however, and it is a mistake to brush it aside in every case as if it were either very serious or of no importance and that in either case nothing can be done to relieve solicitude about it. Physicians can often do much, first to prevent hallucinations by getting at the physical causes of them; second, to prevent them from disturbing patients seriously by showing them how common are such experiences and by indicating their possible physical significance; third, by securing such mental discipline and control as will render their recurrence much less frequent; and, fourth, they can make the almost inevitable unfavorable effect upon the mind of the patient and then reflexly upon his body, much less than it would otherwise be, by sympathetically discussing and entering into the details of them enough, at least, to explain their significance or throw some light on their origin in physical conditions.

Hallucinations of vision, the seeing of things and persons that have no real existence at the time and place they are seen, are usually considered to be rather uncommon and to occur only in those whose mentality is seriously disturbed. Careful studies of the subject, however, show that at least one in ten {605} of educated people consulted have had some hallucinations of vision. Either they have wakened up, or they have dreamt that they waked in the early morning, and have seen some one whom they knew, but knew to be at the moment at a distance, standing near them. Such visions have gradually faded away or suddenly disappeared. Occasionally these persons have in full light had some appearance, wraithlike or otherwise, some manifestation that appeals to vision, yet that they knew at the time or learned afterwards was non-existent.

Many people are backward about confessing that they have had such experiences, for they fear that it will make them ridiculous or even cause them to be suspected of disturbed mentality. Just as soon as it is made clear to them that their admissions will be taken as evidence for a phenomenon to be discussed seriously, many more than would otherwise be thought confess to such hallucinations. Most of these, it may be said at once, are quite sensible people, a great many of them belong to the educated classes; all of them are trustworthy witnesses as far as good will goes, and the circumstances of their hallucinations are such in many cases that there cannot be a mere mistake, or error of judgment.

The frequency with which hallucinations occur may be appreciated from the investigation made some years ago at the instance of the Congress of Experimental Psychology. The following question was put to 17,000 persons, mostly residents of Great Britain, and answers received: "Have you ever, when believing yourself to be completely awake, had a vivid impression of seeing or being touched by living beings or inanimate objects, or of hearing a voice, which impression, so far as you could discover, was not due to any external physical cause?" The answers showed that 655 out of 8,372 men and 1,029 out of 8,628 women had experienced a sensory hallucination at some time in their lives. Some of them had had a number of them. That is, one out of ten in the educated classes has had some hallucination, and nearly one out of every eight women. An analysis of the statistics, however, brings out some interesting suggestions. There were nearly twice as many hallucinations related as having occurred during the year before the question was asked as in the preceding years. There was a definite reduction in the number that had occurred in all the preceding years, except the fifth and tenth, and these were evidently due to uncertainties of memory, so that five- and ten-year periods seemed about the length of time that had passed since the event.

It is evident then that in spite of the fact that an hallucination would seem to be very important and surely startling enough to be well remembered, it is yet easily forgotten, since even a year's interval made so much difference in the number that were remembered. The committee, after considering this easy forgetfulness in the matter, considered that to arrive at the actual total of visual hallucinations experienced by this group of 17,000 persons during the ten-year period in question, the numbers in the table should be multiplied by four. That means that probably very nearly one in three people have had an hallucination of some kind within ten years. The great majority of the visual hallucinations consist of apparitions of human figures. Other forms that are seen are so few, as Mr. Podmore has insisted in his "Telepathic Hallucinations, The New View of Ghosts," [Footnote 45] that they are almost negligible. A frank {606} discussion of these details with a person who is much disturbed by having experienced an hallucination is the best possible remedy for the physical and mental disturbance that may result.

[Footnote 45: The Twentieth Century Science Series, New York, 1910.]

Sir Francis Galton, well known for his investigation of many subjects and who may well be called the father of biometrics or statistical biology, in his "Memories of My Life" [Footnote 46] tells of his own investigations of the visions of sane persons. The fact that he delivered a lecture on this subject at the Royal Institution of London shows how seriously his studies were made and how much value scientists placed on them. Galton's well-recognized training in the careful weighing of evidence and his ability to strip phenomena of everything that might divert their significance from what they really were, add to the worth of his conclusions. Those who care to study the subject further will find his discussion in the Proceedings of the Royal Institution (London, 1882).

[Footnote 46: New York, 1909.]

There are few people beyond middle age who have not had one or more curious experiences in the matter of visions or appearances. Mostly these have been vague and have not proved a disturbing element in the minds of the subjects. Many more than are thought, however, have seen visions vividly and with a detail that makes it almost impossible for them to believe that what they saw was merely an externation of ideas already in their mind. In this matter it must not be forgotten that the dreams of many people, especially nervous people, often present themselves with marvelous vividness of detail. They see people or places in their dreams and reason about them quite rationally. Occasionally a dream will bring back details that have been forgotten. The dreaming state seems in some people to have wonderful power over the subconscious. Things that are not remembered at all in the waking state sometimes come back in dreams, and only then are recalled by the individual as representing past events in his life. He is apt to wonder where the details could possibly come from, since he had before no conscious memory of them. This same thing holds for the day-dreams or sudden visual appearances that come when the attention has been wrapped in something else.

A typical example of such visual hallucinations is the following incident told by a prominent London physician of himself:

One afternoon at tea time, before a meeting of the Royal Society, Sir Risdon Bennett (1809-1891, a well-known physician. President of the College of Physicians in 1876, and a fellow of the Royal Society), drew me apart and told me of a strange experience he had had very recently. He was writing in his study separated by a thin wall from the passage, when he heard the well-known postman's knock, followed by the entrance into his study of a man dressed in a fantastic medieval costume, perfectly distinct in every particular, buttons and all, who, after a brief time, faded and disappeared. Sir Risdon says that he felt in perfect health; his pulse and breathing were normal and so forth, and he was naturally alarmed at the prospect of some impending brain disorder. Nothing, however, of the sort had followed. The same appearance recurred; he thought the postman's knock somehow originated the hallucination. ... I heard the story at length, very shortly after the event, told me with painstaking and scientific exactness and in tones that clearly indicated the narrator's earnest desire to be minutely correct.

Those who are especially interested in this subject will find any number of similar stories, some apparently rich with meaning, most of them quite {607} meaningless, in the volumes of transactions of the English Psychic Research Society, in F. W. H. Myers' "Human Personality," in Podmore's "Naturalizing the Supernatural," in Flammarion's "The Unknown," or many other books published in recent years. It is quite easy to get sufficient material to bring reassurance to any patient that visual hallucinations, at least, mean nothing serious for the mind or body of the individual having the experience.

Hallucinations in the Past.--It must not be thought, however, that this subject of hallucinations is new. Literature is full of it and from the earliest times we find traces of it. Egyptian, Babylonian and Chaldean writers mention them. Nor indeed is the scientific consideration of the subject new. Aristotle speaks of them and it is evident that many of the old writers thought of them as psychic incidents on some physical basis, or at least due to some predisposition in the individual or in some special state of his senses. Two generations ago Johann Mueller, the great German physiologist, discussed the whole subject at length in a monograph, and considered it of so much importance for physicians that he introduced a resume of it into his great text-book of physiology. His explanation of the occurrence of visual hallucinations is not only a striking illustration of the thoroughly scientific character of his treatment of the subject, but it serves to show how well men considered these subjects long before the present fad for the study of abnormal psychology or mental influence came in. His discussion of the subject is sufficient of itself to make any patient understand his hallucinations and keep them from bothering him better than anything else I know:

The subjective images of which we are speaking have sometimes, however, both color and light; different particles of the retina, of the optic nerve, and of its prolongations to the brain, being conceived as existing in special states of action. This happens rarely in the state of health, but frequently in disease. These are the true phantasms which may occur to the sense of hearing and other senses as well as to that of vision. The process by which "phantasms" are produced, is the reverse of that to which the vision of actual external objects is due. In the latter case particles of the retina thrown into an active state by external impressions, are conceived in that condition by the sensorium; in the former case, the idea of the sensorium excites the active state of corresponding particles of the retina or optic nerve. The action of the material organ of vision, which has extension in space, upon the mind, so as to produce the idea of an object having extension, form and relation of parts, and the action of such an idea upon the organ of vision so as to produce a corresponding sensation, are both equally wonderful; and hence the spectral phenomena or visions are not more extraordinary than the ordinary function of sight. (Vol. II, p. 1393, Eng. transl., 1842.)

Apparitions and their Explanation.--In spite of suggested explanations on physical grounds, some of these apparitions that appear to people seriously disturb them. They cannot get them out of their minds. They are sure that they portend evil. Hence worries, and the more nervous the people are and the more worried already, the more likely is such a thing to recur and then to be made much of. Only through their minds can these people be treated, and it must be made clear to them not only how common are hallucinations, but that there is an easy psychic explanation of most of them. Sir Arthur Mitchell, K. C. B., in his book "About Dreaming, Laughing and Blushing," [Footnote 47] tells a story and then gives his explanation of it in such a way as to illuminate many of these occurrences:

[Footnote 47: Longmans, London, 1900, page 21.]

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Perhaps I should illustrate how I think that apparitions may be nothing more than dream hallucinations. A. B., a gentleman of culture and strong character, called one hot day, after a hearty lunch, on an ecclesiastic in a high position, who happened to be engaged in his library at the time of the call. A. B. was shown into a room opening off the library, and requested to wait. He sat down beside a table, and with his elbow resting on it, he leant his head on his hand. While in this position he saw a man in clerical costume come through the door communicating with the library, without any opening of the door. A. B. was absolutely certain that he had seen an apparition, and was surprised and hurt when I expressed a doubt. He called on me to explain, and I said that it was at least possible that he had been asleep for some moments, that if he had slept at all, however short the dream of the sleep, he must have had a dream, if I am right in thinking that there is no dreamless sleep, and that thus what he regarded as an apparition might be nothing more than a dream hallucination. He assured me persistently that he was continuously wide-awake, but I assured him that these moments of sleep often occurred without any consciousness that they had occurred. He refused to be deprived of his ghost, and I refused to believe in the supernormal when the normal was sufficient.

Such wraith-like appearances are supposed to occur especially in connection with the deaths of persons at a distance. Startling stories are told, particularly of those who are very near relatives, husbands and wives, mothers and sons, and, above all, twins, who have been very closely associated with one another during life. There are a large number of stories of this kind, however, that have been collected by the Psychic Research Society and other agents with strong evidence in their favor, in which the appearances have had no ulterior significance at all and have evidently been mere figments of the imagination, the externation of images from memory so vividly that they seem to be the reseen. Reassurances in this matter are the best possible source of relief from the sense of impending ill for many patients. The physician who wishes to relieve such symptoms must familiarize himself with some of the many stories that have been investigated and that serve to prove that these and like appearances must not be taken as significant of anything more than a definite tendency, that exists in human nature at moments of day dreaming or when one's attention is suddenly turned from a book in which one has been absorbed, to see externally what is really passing through the imaginative memory.

A Disappearance.--A very interesting commentary on some of these appearances is to be found in Mark Twain's story of a disappearance, which could probably be duplicated many times if experiences in this line were collected and collated. Mr. Clemens, sitting on the porch of his residence one day, saw a stranger of rather peculiar appearance come up the walk toward the front door and he expected to hear him ring the bell and have the servant come to the door and usher him in, and then perhaps be called to see him. About the middle of the walk, however, the stranger disappeared and Mr. Clemens was quite surprised to come to himself, rub his eyes and conclude that he had had one of these curious visions or hallucinations, in which the Psychic Research Society would surely be interested. He had plainly seen the stranger enter the gate, come up the walk, and then disappear. He was so impressed by the disappearance that he roused himself to go into the house to get his notebook, so as to make notes of what had happened before the details escaped him. To his surprise he found the stranger in conversation {609} with the servant in the house. There had simply been a lapse in Mr. Clemen's vision of him. He had had a disappearance phenomenon instead of an appearance. The story will be found to amuse patients who complain of appearances disturbing them, though Mr. Clemens always told his disappearance story very seriously, and it is as interesting a psychic phenomenon as any told of the wraith-like appearances.

Treatment.--Considering how frequent are such phenomena, the physician must be prepared to treat those who are disquieted by them. A wraith-like appearance, for instance, will disturb many people very seriously and often for days, sometimes for weeks, make them nervous, excitable, and impair their appetite, disturb their digestion and sleep and often such unfortunate occurrences are prone to come just when they are run down in weight and when they need the help of every factor that makes for improvement of health. Simply to dismiss such an appearance as if it were quite imaginary, that is, non-existent in some form of reality, or quite baseless and trivial, serves no good purpose, for, as a rule, the persons concerned are deeply impressed with what they have seen. The only way to remove the unfavorable impression produced by it is to discuss it straightforwardly on the basis of what we have come to know as the result of recent investigations and the collation of the literature which has been published by the various psychical research societies and authorities on the subject. We know now that while occasionally such wraith-like appearances seemed to have a definite significance, because of something that happened simultaneously or shortly afterwards, this is mere coincidence and there are literally thousands of such cases in which a well authenticated wraith-like appearance was followed by no serious consequence, was never shown to mean anything beyond a curious psychic phenomenon, and was evidently merely due to some personal subjective influence, some externation of an image in the memory, unusual, but not at all unique, or even very rare, and evidently due to a curious peculiar externalizing power with which certain intellects are gifted.

Auditory Hallucinations.--Hallucinations of hearing are more common than those of vision. Many people have had the experience of waking up thinking that someone was calling them. A great many people are sure that they have, at some time or other, heard a voice when no one was near enough to them to have said anything. They have even recognized the voice. Some people, when thinking deeply about a person, have the voice of that person occur to them so clearly that they cannot quite make out whether they have actually heard it or whether it has only been very vividly reproduced in their memory. Such experiences are so common as to be well known, though many people hesitate to tell the stories of them, for hearing voices is rightly looked upon as a frequent preliminary symptom of insanity.

Hallucinations of hearing are the most common early symptom of insanity. The hearing of voices must always arouse suspicion at once. It must not be forgotten, however, that a great many recognizedly sane people who have remained so for life, have thought that they heard voices. Of course, we have no definition for insanity, and it is difficult to draw the line. We have no definition for health either, yet we have a practical working standard for the recognition of it, as also for insanity. These hallucinations then, both of vision and hearing, deserve to be discussed seriously, and in {610} nearly every case, even though there is some mental disturbance, the physician can in this way benefit his patients and keep them from being overmuch distressed by their hallucinations.

There is an expression in such common use that it is evidently the result of an almost universal experience, according to which men sometimes explain, after having acted in a particular way, that "something told them to." What they mean, of course, is that a conclusion formed in their minds the reasons for which they could not understand, but which yet had force enough to cause them to follow it to a practical application. When we hear of Socrates being advised in life by a demon, a so-called familiar spirit, we are apt to wonder whether by this term is meant anything more than just this curious feeling of aloofness from ourselves that we sometimes have when we are trying to make up our minds, or, indeed, not infrequently when we are deeply engaged in any intellectual occupation. As discussed in the chapter on Unconscious Cerebration, our minds seem in a certain way to act independently of us. Occasionally they draw us to conclusions quite different from those which we previously expected to reach. There seems to be a something within us that works quite of itself and beyond our will. Whether under these circumstances there may not occasionally come so vivid a feeling of this power within us impressing itself upon us, that it seems to come from without, must always be taken into account in the effort to get at the real significance of these curious hallucinations. Only thus are we able to come to the relief of patients who are bothered by them.

Explanation by Sound Reproduction.--Auditory hallucinations are probably not more than reproductions of sounds heard before recalled vividly and apparently heard again at moments when attention is not attracted to actual auditory sensations and we are in receptive mood. Some of them are very startling because they are apparently warnings of future events, as is proved by their fulfillment. These, however, do not seem to be more than coincidences noted with regard to similar events connected with Premonitions, Dreads and Dreams (see chapters on these subjects). There is, for instance, a well authenticated story published by the English Psychic Research Society of a woman who was about to take a dose of what she thought was some ordinary home remedy, when she distinctly heard a voice telling her to taste it. The dose to be taken was a tablespoonful, and when she tasted it she found that by mistake she had placed her hands on a bottle containing a rather strong poison and a tablespoonful of it would almost inevitably have killed her. Unfortunately, such occurrences are so rare and the reason for them is so hard to find that their consideration as anything more than coincidences seems out of the question. Every medical journal almost brings the story of someone who has taken a dose of medicine that proves fatal, and there is no warning. If such warnings came with definite frequency, it would be easier to appreciate their significance.

There are similar stories with regard to other warnings. There is the story of the young man who in a storm drove under a shed for protection. Just as he did so he heard his mother's voice--she had been long dead--distinctly say "Drive out!" Ho drove out at once in the teeth of the storm, so deeply impressed was he, and was scarcely beyond the entrance when the shed fell, crushing everything within it. Similar warnings of impending {611} accidents are rather frequent in certain people's minds, yet it is hard to think of them as anything else than premonitions. These somehow take on the character of auditory hallucinations in certain sensitive minds. Compared to the whole number of accidents, however, such incidents are extremely rare and follow no law, and while there are those who like to think that perhaps such phenomena are due to the solicitude of some being in the other world, this is extremely doubtful. In that case, as St. Augustine suggested, they would be much more frequent and have a clearer significance than is at present the rule. St. Augustine, discussing the possibility, was sure that he would have had communications from his mother. Most men would re-echo his feeling.

Coincidences.--Most of these stories as they have been analyzed by careful investigators are indeed such trivial unmeaning things that it would be too bad to let people be bothered by them. They have occurred, however, from time immemorial. Veridical warnings are a commonplace in the literature of all countries. Undoubtedly some may suggest the action of a Higher Power, but the more one knows of the conditions in which they happened, the people to whom they came and their ultimate effects, the less will they seem providential. It is evident that under certain conditions they may be produced even at moments when men are not particularly excited and when they think that they are perfectly calm and self-possessed. Each story must be discussed in its own merits. The only thing to do, then, is not to make too light of them and, above all, not to treat them as merely imaginary or as utterly illusory; for they are often natural phenomena, the reasons for which and the conditions of their production we do not as yet fully understand. If patients can be brought to this viewpoint, they may even become interested in searching out just what it was that caused each particular hallucination. Over and over again it has been found that a moonbeam or a peculiar unexpected reflection of the sun, or the light shining through an unnoted aperture, or any or several of these in connection with a mirror has been the main cause of the wraith-like appearance. When they happen during the day it is sometimes at the moment of passing from very bright light to a darker hall that the occurrence takes place and evidently there is some physical occasion for the appearances in the eye itself. Unusual noises of various kinds are responsible for the auditory hallucinations.

Dangers of Serious Considerations.--There is one serious aspect of these hallucinations and supposed warnings--they tend to paralyze action. If a person allows himself to become firmly persuaded that doubts and premonitory possibilities must be weighed and solved before he may dare to act with assurance, then action becomes almost impossible. Premonitions may serve to bring people into danger, or at least keep people from having such presence of mind as will enable them to get out of it, as they otherwise would. Doubts lead to inaction and make a state of mind that is eminently miserable. The patient's one hope is to put aside resolutely such hallucinations if they rise to the level of a disturbing doubt or a paralyzing premonition and to discipline himself against being influenced by them. In many persons this is a difficult matter, but it represents the only efficient path to the regaining of mental health and strength.

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III. DREADS

In any discussion of the influence of mind over body, favorable and unfavorable, too much emphasis cannot be placed on the hold that dreads have over a great many people and how much they mean, not alone for the mental state, but also for the physical sense of well-being or of ill-feeling in the individual. The expression attributed to the old hermit who had lived to the age of one hundred and had spent some sixty years of existence in the solitude of the desert, with all the opportunities for introspection that this afforded, is the best illustration even in our day of what dreads signify in life: "I am an old man," he said to the young solitary who came to him for advice, "and I have had many troubles, but most of them never happened." We are nearly all of us, or at least those of us who spend most of our time in sedentary mental occupations, prone to fear that something untoward is preparing for us and in many cases to dread lest some serious ailment or other is just ahead of us. We are afraid that certain feelings, though we like to call them symptoms, due to some trivial cause or other as a rule that deserves no notice, may mean the insidious inroads of a constitutional disease destined to shorten existence. A little fatigue, over-tiredness of particular muscles, the straining of joints, the discomforts due to overeating and undersleeping, that are meant as passing warnings of nature for the necessity of a little more care in life, are exaggerated into symptoms that have a more or less serious significance.

DEFINITE DREADS

Besides these rather vague dreads, however, there are certain special disquietudes peculiar to individuals, even more groundless, if possible, than the generic apprehension just spoken of and that have been dignified in recent years by the name of phobias. Phobia means only "fear" in Greek, but the term is much more satisfying to nervous people than the shorter but too definite English term, dread, or fear. There is acrophobia, or the fear of looking down from a height; claustrophobia, or the fear of narrow places, as the dread of walking through a narrow street because of the sense of oppression that comes with the shut-inness of it. Then there is agoraphobia, market-place dread, or the fear to cross an open space because one has, as it were, grown accustomed to be near buildings and misses their presence. There are many others, indeed as many as there are dislikes in human nature, for any dislike apparently may be exaggerated into a dread. I mention a few at the beginning of the alphabet and some of special significance. There is aerophobia, dread of the air, a symptom sometimes mentioned in connection with hydrophobia; aichmophobia, the dread of pointed tools; ailurophobia, the dread of cats; anthrophobia or the dread of men; pathophobia or the fear of disease, microbophobia or bacillophobia; kenophobia or the dread of emptiness; phthisiophobia or the dread of consumption; zoophobia or the dread of animals; sitophobia or the dread of food, and even phobophobia, the dread of {613} dreading. Neuropsychologists seem to take a special pleasure in inventing some new phobia or at least giving us a fine long Greek name for a set of symptoms by no means new and that might well be explained in simpler terms. The most familiar examples are: the fear of lightning, which is more frequently brontophobia, the fear of thunder.

These learned words are all formed on the same etymological principle as hydrophobia, but they are entirely psychic in origin, while hydrophobia, as it is well to explain to patients who think of the word phobia in connection with their symptoms, is, of course, a misnomer for an infectious disease--rabies--which develops as the consequence of a bite of a rabid animal, and the principal symptom of which is not fear of water, but the impossibility of swallowing any liquid because of spasm of the esophageal muscles.

Almost any function of the body may become the subject of a dread or phobia that may interfere even seriously with it. Any disturbance of any function is likely to be emphasized by such dreads. The French have described the basophobia, which makes the patients suffering from beginning tabes dread so much walking that it becomes a much greater effort than it would otherwise be and often interferes with walking rather seriously. Then there is the fear of tremor which exaggerates a tremor due to some organic cause, but yet not necessarily of grave import, nor likely to increase rapidly. Many of the hysterical palsies are really due to dreads, consequent upon some incident, motor or sensory, which produced a profound effect upon the patient's mind. A patient who has been surprised by a digestive vertigo while descending a stairs, even though nothing more happened than the dizziness which required him to grasp the balustrade, will sometimes develop a fear of vertigo that will actually make it difficult for him to go down stairs without such an effort of will as is very exhausting. Even the slightest functions may be thus disturbed. Pitres and Regis described some ten years ago what they called the obsession of blushing, or erythrophobia, the fear of turning red. Patients make themselves extremely miserable in this way. Only training and self-control will help them.

These names are long and mouth-filling and consequently satisfying, and most people who are suffering from a particular phobia are almost sure to think that they have a very special affliction. When the word dread is used instead of the word phobia they are less likely to misunderstand the character of their affection and to realize that it is not a disease but only an unfortunate mental peculiarity that needs control and discipline, and not fostering care. Neurasthenia only means nervous weakness, as we have pointed out, but most people are rather rejoiced when informed that they have so high-sounding a disease as neurasthenia, while to be told that they are nervously weak or suffer from nervous weakness seems quite a come-down from their interesting Greek-designated affection. Most psychiatrists feel that it is better not to give the long Greek term, but to state in simple short Saxon words just what is the matter with the patient. They are suffering from the dread of a height, or the dread of a narrow street, or the dread of open spaces, or the dread of dirt, or of cats, or of whatever else it may be. This makes it easier for them to begin to discipline themselves against the state of mind into which they allow themselves to fall with regard to these various objects, and mental discipline is the only therapeutic adjuvant that is of any avail in {614} lessening these conditions. With reasonable perseverance most people can, if not cure themselves of these affections, at least greatly lessen the discomfort due to them. A consideration of particular dreads brings out the specific suggestions that may be made with regard to each and the directions that may be helpful to the patients. Probably the commonest is acrophobia, so that the detailed consideration of it shows the indications for other dreads.

Dread of Heights.--Almost without exception men have a sort of instinctive dread of looking down from a height. In most people this can be conquered to such a degree that almost anyone, if compelled by necessity, can learn to work on a skyscraper and continue to do good work without much bother about the height, though he may have to go up ten to twenty stories, or even more. When he takes up the work at first every workman finds it difficult. It gives most of us a trembly feeling even to sit in our chair and think of looking down from such a height. To see pictures of men standing on the iron frames of skyscrapers twenty or thirty stories up in the air looking down 300 to 500 feet below them gives one a series of little chilly feelings in the back and in many people a goneness or sense of constriction around the abdomen that is almost a girdle feeling. To sit at a window opposite where a skyscraper is going up and to see the men lean over the edge of a beam calling directions of various kinds to workmen below will give most people, even those who are not nervous or especially sensitive, creepy feelings with sometimes a little catch in the breath and an iciness in the hypochondria. It would seem absolutely impossible that we should ever be able to perform these feats of looking from a height, yet experience shows that most of us, after a little training, learn to do it without difficulty.

Even the men who work most confidently have some creepy feelings return to them whenever they stop and think about this and let their eyes wander to the distance below them. It is not difficult for us to walk across a plank raised a foot or two from the ground, though to walk across the same plank at a height of ten feet may be quite a trial and at thirty feet may become quite impossible. This is all due to lack of confidence on our part and there is no reason in the world why, if the plank is amply wide for us at two feet from the ground, it should not be just as wide and safe at 30 or 60 or even 100 feet. This is what the men who have learned to work on skyscrapers have disciplined themselves to. They have learned to disregard the wide vacant space around them and the yawning chasm beneath their feet; they keep their eyes fixed on something in the immediate vicinity, excluding thoughts of all that might happen if they should lose their balance.

Physical Basis.--There is a physical basis in many of these cases that constitutes the underlying occasion, at least, for the development of the psychic dread. Our eyes have grown accustomed to being fixed on near objects. Whenever they are not so fixed we get a feeling of trepidation. Even those who have done a little day-dreaming know that sometimes when they have been looking into space, objects around them have suddenly seemed to be transferred to a long distance and at the same time a curious sense of insecurity came over them. Anyone can get this feeling experimentally by making two large dots on a piece of paper about two inches apart and then gazing between the dots into vacancy beyond the paper as it were, until the dots have a tendency to become four because of the fact that each eye sees {615} each of the dots on a part of the retina not corresponding to that on which the other eye sees it (see Fig. 25).

When the experiment is successfully performed the dots begin to float before the eyes, then they may coalesce into one or become three, but any number up to four may readily be seen. This will give the sense of insecurity that comes from the eyes not having any fixed object to look at and illustrates the discipline of the eyes that must be learned in order that looking down from a height may not be productive of the usual dread.

Dread of Small Heights.--It is often thought that acrophobia, or the fear of a height, concerns only great heights and that ordinary elevations produce no discomfort. I have had patients, however, who, when compelled by circumstances over which they had no control or at least by social obligations that were hard to break, to sit on the front row of even a low balcony, have been extremely uncomfortable. There was a sense of tightness and oppression about the chest that made it difficult for them to breathe, that disturbed their heart action and gave them a general sense of ill-feeling. I have had a curiously interesting series of cases in clergymen who found it trying to say Mass or conduct services or to preach from the step of a high altar. One would be inclined at first to make little of their description of their utter discomfort. There is no doubt at all, however, of their real torture of mind and of the extreme effort required to enable them to support themselves in the trying ordeal. They are often so exhausted because of the effort required that only with difficulty can they do anything else during the day.

To most people such a state of mind is inexplicable. There are deeply intellectual men who, in my experience, are quite disturbed by apparently so simple a thing as having to say Mass on an altar that has three or four steps to it and is elevated five or six feet above the surrounding floor. As for higher altars, like the main altar of a cathedral, they usually find it quite impossible to conduct services unless they are in company with others, when their feelings are much relieved. This same thing is true of agoraphobia in some people. To go alone across an open place or square is agony, but even the company of a little child is sufficient to relieve them to a great degree. I told a distinguished American prelate of this curious dread in priests so often called to the physician's attention, and he said that he had never heard of it. To his surprise some of his clergymen present at the table told him that there were two examples of it in brothers in his own diocese.

Mental Discipline.--The lesson of the many men who, by discipline, have succeeded in conquering the aversion and the dread of heights that everyone has to some extent at least, shows the possibility there is for even those who are extremely sensitive in this matter to so lessen their timidity and the uncomfortable oppression that comes over them, as to make it possible to accomplish whatever is in their line of duty. It is no more difficult for the sensitive clergyman to learn by practice and discipline to walk with confidence on a reasonably high altar or platform, than it is for the workman to learn to {616} walk a beam on the top of a twenty-story building without a thought of the dangers of his position, or at least putting the thought away from him so that it does not interfere with his work. At the beginning he cannot do it, but he disciplines himself to form a habit that makes it easy. Yielding to his feelings makes it difficult to withstand the discomforts that come to him. After an accident on a high building, as a rule, men have to be sent home for the day to get their nerves settled by the night's sleep before they can work with sufficient confidence, and yet accomplish their usual amount of work.

So-called Misophobia--Dread of Dirt.--Misophobia, or the fear of dirt, has grown much more common in recent years, and the spread of the knowledge of the wide diffusion of bacteria has added to the unreasoning dread that possesses these people. Some of them wash their hands forty to fifty times a day, and one young man who was brought to me with the worst looking hands, because of irritation from soap and water, that I have ever seen, seemed to be always either just plunging his hands into water or wiping them dry. These people make themselves supremely miserable. They do not care to shake hands with friends and, above all, with physicians, and they invent all sorts of excuses so as to wait outside of doors till someone else opens them so as to avoid touching the knob or door pull, "which" with a poignant expression of repugnance they tell you "is handled by so many people." When the patients are women, getting on and off cars becomes a nightmare to them, because they do not want to touch the handle bars and unless they do they find it difficult to ascend and descend. The curious excuses they offer for their peculiar actions in avoiding the touch of objects around them are interesting.

Claustrophobia.--This sort of dread seems quite irrational to most people and many would probably conclude that individuals thus affected could not possibly be quite in their right minds, or must surely be rather weak-minded. On the contrary, many of the people who are affected by these curious dreads are above the average in intelligence and sometimes also in their power to do intellectual work. A typical example, for instance, of claustrophobia, or the fear of closed spaces, is found in the life of Philip Gilbert Hamerton. He was a distinguished painter and essayist, editor and novelist. Few men of his generation were able to do better intellectual work than he. His book on "The Intellectual Life" was more read perhaps than any work of its kind in the last generation. He was not a profound thinker, but he was a very talented practical man. The fact that besides being a writer whose books sold he was a painter whose works were in demand, shows a breadth of artistic quality that is quite unusual. His was not the sort of genius, however, that is so often supposed to be allied to insanity, for he was rather a worker who obtained his effects by plodding, than a brilliant genius that got his thoughts by intuition.

In a word, in spite of the fact that he was just the sort of man that one would not think likely to be affected by a phobia, he had a series of attacks of claustrophobia, some of which were intensely annoying to him and seriously disturbing to his friends. His wife has described some of them in his "Life and Letters." Once after crossing the English Channel, he had a severe attack in the railroad carriage on the way up to London. He had not been nervous {617} on the voyage and had not been seasick. He was returning from a vacation and was in the best of health and spirits, yet suddenly the feeling of inordinate dread that he was shut in came over him and he could scarcely control himself or keep from plunging out of the window in order to get into the open. His wife says that "His hands became cold, his eyes took on a far-reaching look, his expression became hard and set and his face flushed." He seemed "as if ready to overthrow any obstacle in his way; and indeed it was the case, for, unable to control himself any longer, he got up and told me hoarsely that he was going to jump out of the train. I took hold of his hand and said I would follow him, only I entreated him to wait a short time, as we were near the station. I placed myself quite close to the door of the railway carriage and stood between him and it. Happily the railway station was soon reached, when he rushed from the train and into the fields." His wife followed him like one dazed, and almost heart-broken. After half an hour he lessened his pace, turning to her and said, "I think it is going." For two hours they continued to walk, at the end of which Gilbert said tenderly in his usual voice, "You must be terribly tired, poor darling. I think I could bear to rest now. We may try to sit down."

Dread of Cats.--One of the most interesting of dreads, very frequently seen and producing much more discomfort than could possibly be imagined by anyone who had not seen striking cases of it, is the dread of cats which has been dignified and rendered more suggestively significant by the Greek designation ailurophobia. While the great majority of individuals suffering from this unreasoning dread of cats are women and usually of a delicate nervous organization, it must not be thought that it is by any means confined to them or has any necessary connection with hysterical symptoms. One of the most striking cases of this dread of which I know personally occurs in a large, rather masculine-looking woman, who cannot abide being in a room with a cat, and who is quite unable to do anything while one of these animals is within sight. Yet she is not at all what would be called timorous and she has more manly than womanly characteristics in every way. She once proceeded to thrash within an inch of his life a small burglar who entered her house and she rather prides herself on being able to protect herself. Nor is this dread necessarily associated with any other disturbances of mind or nervous system. Some of the patients I have seen, who confess to suffering from it, were thoroughly sensible, brave little women, able to stand suffering well, not at all hysterical in nature, and who in the midst of worries found time to be thoughtful of others and not to have that selfishness which, even more than physical symptoms, is so apt to characterize hysterical patients.

I have had men confess to me their dread of cats, and while, as a rule, they were of delicate constitution and inclined to be nervous and did not have the phobia to an inordinate degree, there was no doubt that they were extremely uncomfortable whenever a cat was near them. On the other hand, some of them were vigorous, husky men with strong aversions. One of the most marked cases of ailurophobia that was ever brought to my attention was in an army officer who had exhibited bravery in battle on many occasions, and what requires much more strength of mind, calm fortitude in difficult campaigning, yet for whom a cat had many more terrors than the battery of an enemy or even an ambuscade of Filipinos. More cases of this particular {618} aversion seem to occur in clergymen than in other men, yet one of the worst cases I ever saw was in a priest of great moral courage, who had served a pest-house over and over again in smallpox epidemics.

All that can be said about such a dread is that it exists, that it is unreasoning, that some patients have been known by discipline of mind to overcome the abhorrence to a great degree but never quite entirely. In this regard, however, it must not be forgotten that there are many things abhorrent to human nature that seem impossible to overcome the aversion for, yet discipline does much to relieve them. For instance, the handling of dead bodies so familiar to physicians brings with it an aversion that we never quite get over and which resumes most of its original strength with disuse, but that can be overcome to such an extent as to make pathological work produce very little aversion. Even Virchow, after all his years of occupation with pathological material, confessed toward the end of his life, that whenever he was away from his work for a few months his aversion had to be overcome anew.

The Spectator on Dreads.--There might be a tendency to think that these curious dreads came only as the result of the individualistic over-occupation with self and the introspective sophistication of the modern time, but the dread is not confined to our time nor special to it in any way, for we find Shakespeare talking of those who cannot bear a harmless, necessary cat. A number of other writers of different periods refer to it. As in so many other things The Spectator reflects his time in this and so we have a letter with regard to the dread of cats. It would not have been a subject for discussion in one of these popular communications only that the writer felt that a good many people would realize how like it was to things that they themselves knew of. In number 609 the following letter, supposed to be from a correspondent, seems worth giving in full, because it touches on other subjects in which uncontrollable, unreasoning feeling plays a role:

I wish you would write a philosophical paper about natural antipathies, with a word or two concerning the strength of imagination. ... A story that relates to myself on this subject may be thought not unentertaining, especially when I assure you that it is literally true. I had long made love to a lady, in the possession of whom I am now the happiest of mankind, whose hand I should have gained with much difficulty without the assistance of a cat. You must know then that my most dangerous rival had so strong an aversion to this species, that he infallibly swooned away at the sight of that harmless creature. My friend, Mrs. Lucy, her maid, having a greater respect for me and my purse than she had for my rival, always took care to pin the tail of a cat under the gown of her mistress, whenever she knew of his coming; which had such an effect that every time he entered the room, he looked more like one of the figures in Mrs. Salmon's wax-work than a desirable lover. In short, he grew sick of her company, which the young lady taking notice of (who no more knew why than he did), she sent me a challenge to meet her in Lincoln's Inn Chapel, which I joyfully accepted; and have, amongst other pleasures, the satisfaction of being praised by her for my stratagem.

Cat Fear and Furs.--This dread of cats is sometimes exhibited to a surprising degree under rather unexpected circumstances. For instance, it is not unusual, since the fashion for the longer-haired furs came in, to find that some of these patients cannot wear certain supposedly elegant furs, since they are really dyed catskin. At times this is not suspected until other possible causes for the discomfort have been eliminated. Some women cannot even bear to be near catskins in muffs and other such furs, though the imitation {619} may be so good as to deceive any but an expert, and they apparently had no suspicion at the beginning of the presence of cat fur near them. I have been told by a physician the story of a man, poignantly sensitive to cats, who purchased a fur-lined coat and found it quite impossible to wear it because of the sensations it produced in him, though he had no suspicion of any connection between cats and the fur when he purchased it.

Recognition of Presence.--Why this dread of cats occurs and, above all, the reason for the ability to know that a cat is near when the animal is concealed and others are not at all aware of its presence, or that its fur should produce a disagreeable sensation, is not easy to decide. Its discussion is suggestive for other forms of dreads, for there are probably like refinements of sensation, normal and abnormal, connected with them. Much has been said about this as a reversion to powers possessed by man in a savage state when there was necessity for guarding against animal attacks. Unfortunately for any such supposition as this, these people, who are most fearful of cats, that is, of the ordinary domestic animal, have no uneasiness in the presence of the huge cats in the menageries--the lions and the tigers. It is with regard to these that such a specialization of scent would be particularly valuable for men. There seems no doubt but that it is an odor or a sensation allied to an odor, though perhaps below the ordinary threshold of recognition as such, that enables these people to detect the presence of a cat. Dr. Weir Mitchell in his article on "Ailurophobia and The Power to Be Conscious of the Cat as Near While Unseen and Unheard," in the Transactions of the Association of American Physicians, 1905, discusses odor in this connections as follows:

To be influenced by an olfactory impression of which (as odor) the subject rests unconscious, may seem an hypothesis worthy of small respect and beyond power of proof. Nevertheless it seems to me reasonable. There are sounds beyond the hearing of certain persons. If they ever cause effects we do not know. There are rays of which we are not conscious as light or heat, except through the effects to which they give rise. There may be olfactory emanations distinguished by some as odors and by others felt, not as odors, but only in their influential results on nervous systems unusually and abnormally susceptible. No other explanation seems to me available, and this gains value from certain contributory facts.

We must admit that all animals and human beings emit emanations which are recognizable by many animals and are in wild creatures protectively valuable.

This delicate recognition is commonly lost in mankind, but some abnormal beings like Laura Bridgeman and a perfectly normal lad I once saw, have possessed the power of distinguishing by smell the handkerchiefs of a family after they had been washed and ironed. In this lad I made a personal test of his power to pick out by their odor from a heap of clean handkerchiefs mine and those of others, the latter two belonging to his father and mother.

I have seen a woman, well known to me, who can distinguish by mere odor the gloves worn by relatives or friends. This lady, who likes cats as pets, is able to detect by its odor the presence of a cat when I and others cannot.

Two French observers believe that they have proved the sense of olfaction to be nine times more acute in women than in men.

So far as the present paper might serve in evidence, I should be inclined to say that the sense of smell was keener in women than in men, but as to this there is extreme diversity of opinion and the whole question awaits further investigation. [Footnote 48]

[Footnote 48: This question of the varying acuteness of smell in different people is very interesting to the psychotherapeutist for diagnosis and therapy. We have a number of striking cases of very acute olfactory power. This is what might be expected since animals whose respiratory and smell apparatuses are very like our own show extreme differences. The extent to which human power to recognize odors can go is marvelous. In his "Thinking, Feeling, Doing," Prof. Scripture says: "I have a case--reported by a perfectly competent witness who lived for years with the person mentioned--of a woman in charge of a boarding school who always sorted the boys' linen after the wash by the odor alone." Personally, I have sometimes wondered whether this power, like that of feeling in the blind, could not be developed. The blind are supposed actually to bring about an evolution in their nerves of feeling. No such thing happens, however. An examination of them by means of an esthesiometer shows that their nerves are no better developed than those of other people, though they may be able to recognize much minuter differences between the "feel" of things and may be able to read raised type, which the seeing cannot. This is all due to a training of their attention to note slight differences in sensation, however, and not to improvement in the nervous apparatus. ]

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Dread of the Dark.--The discipline suggested with regard to overcoming the dread of heights must be applied to any of these dreads if patients are to be made comfortable. They can form the opposite habit and by refusing to yield to their fears can do much to lessen them. Nearly everyone who is unaccustomed to sleeping in a dark house alone has dreads that come over him when he first tries to do it. Every noise is exaggerated in significance and the creaking of stairs and rattling windows and doors and the wind through the trees are all made significant of something quite other than what they are. Nearly everyone knows, however, that this can be overcome simply by refusing to pay any attention to the idle fears that come over us as a consequence of the tension due to loneliness, and after a time, sleeping in a strange room and a strange house in the dark is not a difficult matter. It is harder for some people to accomplish than others, but it is impossible for none. Here is the lesson that all the sufferers from dreads must learn. Gradually, quietly, persistently, they must resist the dreads that come over them, must deliberately, without excitement, do the opposite to that suggested by their apprehension, until habits are formed that enable them to accomplish without discomfort what was before a source of even serious ill-feeling.

The dread of darkness that so many people have is usually supposed to be cowardice. It is not, however, in most cases, but is due to idiosyncrasy or to certain special physical factors in the environment. If children have been brought up so that when they were small a light has been constantly shining in their eyes, even though only a dim light, it will often be difficult to accustom them to be quite comfortable in the dark. Much depends on habit in this matter. I have known men, who, when they came from Ireland, feared the darkness of the coal mines very much and their dread was increased by the awful horror of possible ghostly appearances, since so many accidents had taken place where they worked. After some years, however, they were quite placid about it and would calmly go into the mine as fire bosses at three and four in the morning, long before others were to go in, examining absolutely dark passages by the mile, with no human being near them and with the creaking of the pillars, the dripping of water, the rumbling of the sides and the occasional fall of a small particle from the roof, besides the noises of rats to add to the disturbing factors. Like going up on a high building, one may get entirely accustomed to it so as scarcely to notice it at all.

When the fear is allowed to take hold of one, however, and no effort is made to overcome it, it may prove quite seriously disturbing. The unaccustomed, however, means more than anything else in this matter. Sometimes, {621} indeed, people have a dread of the dark that seems to be inborn and that apparently cannot be overcome, that, like the fear of cats or of lightning, may be quite beyond rational control. Hobbes, the English philosopher, was so perturbed by darkness that he kept a light in his bedroom all night. I know this to be the case in a clergyman who had been quite undisturbed about darkness until he was awakened one night by a burglar. He demanded "who's there?" and received as answer without further parley a bullet that fortunately struck only the head of the bed, but so close that it singed him. The burglar escaped, but the clergyman was never afterwards able to sleep without a light. Rousseau, the French philosopher, was also much afraid of darkness. Ordinarily it is presumed that superstition has something to do with this fear and that the victim of it has ghosts in mind or at least dreads spirit manifestations. Neither Hobbes nor Rousseau, however, was likely to be timorous about ghostly visitants. It was with them a physical idiosyncrasy.

Associated with dread of darkness is the fear of finding some one in a dark room whose presence may startle us. Sir Samuel Romilly, famous for his labors for the reform of the English criminal law, and who must be considered one of the great humanitarians of the nineteenth century, had this dread to an acute degree. It went so far that whenever he slept in a strange place he carefully examined all the possible hiding-places in the room and in wardrobes or closets connected with it and, as a last precaution, never failed to look under the bed. He did this even when he was in his own house. [Footnote 49] This, however, is not so unusual, even among men, as might be thought. Most women who sleep alone want to investigate under the bed and in a hotel closets and wardrobes and even bureau drawers are likely to be examined. Habit in this regard may make one quite miserable and over-solicitous. I have had patients whose sleep was seriously disturbed by the remembrance that they had not looked under the bed and who feared to get up and light a light to do so lest there should be someone there. Indeed, the idea of putting their feet on the floor before the light had come to reassure them seemed quite out of the question.

[Footnote 49: Curiously enough. Sir Samuel Romilly, in spite of his dread of the dark, committed suicide and went prematurely into the darkness of the beyond, apparently without his usual tendency to precaution.]

Dreads Connected with Water.--Strange as it may seem, water constitutes a source of dread for some people. We have the records of it in the peculiarities of great men and it is not unusual to meet it in common life. Dropping water is a source of disturbance for most people. It is quite impossible for the majority of men and women to go on writing or reading with any comfort if water is dropping near them. Dropping water, when one is trying to go to sleep, is one of the worst of awakeners. The Chinese are said to put people to death in horrible torture by having a drop of water fall at regular intervals on their heads. Robert Boyle, the great father of chemistry and a very sensible man in many ways, is said to have been thrown into convulsions by the sound of water dropping from a faucet. The splashing of water on some people is a poignant source of torture. I have had a woman patient who could not go to services where there was a sprinkling of water, for it seriously disturbed her and gave her a sense of depression that would not be overcome for some time. Peter the Great, though the father of the {622} Russian navy, and though he passed many years of his life in Holland, used to shudder at the sight of water, and if, when out driving, his carriage passed near a stream or over a bridge, he would close the windows and be overtaken with terror that brought the perspiration out all over him.

Dread of Death.--The fear of death is one of the dreads that bothers young as well as old, and, curiously enough, as its inevitable approach becomes more certain, men are prone to dread it more. Long ago Sophocles said:

None cleave to life so fondly as the old,

-- and this has remained true for all the centuries since. A young man is quite ready to throw his life away, but the old man hesitates and even in the midst of suffering, if it is not absolutely continuous, craves that death shall not come. Sophocles' great rival, the elder Greek dramatic poet AEschylus, had said:

How far from just the hate men bear to death Which comes as safeguard against many ills,

-- but his message was only for those with the character to face the worst. One may reason with the dread of death, however, and patients can be given motives from philosophy, literature, religion and experience that will help to relieve, though it will not entirely cure them. Shakespeare said in "Julius Caesar":

Cowards die many times before their deaths. The valiant never taste of death but once,

-- and people may be aroused to appreciate this.

Fear of Early Death.--Many fear that if they have shown symptoms of delicacy of constitution at some time in life or suffered severely from some serious disease, that they are not likely to live long and, above all, that they are almost sure not to be able to accomplish anything worth while in life. The old proverb is "a healthy mind in a healthy body." This is, however, the ideal. There are very few ideals realized in life. Just because a man has a weak body is no argument at all that his mind may be weak and some of the world's finest work has been accomplished by men whose bodies were always delicate. Metchnikoff is the apostle of old age to our generation, but it is he, also, who has pointed out that many distinguished workers in science, in poetry, in art, men who have left a precious heritage in succeeding generations, were delicate all their lives. He cites such typical examples as Fresnel, the great French physicist; Giacomo Leopardi, the distinguished Italian poet; Weber and Schumann, the great German musicians, and Chopin, the Polish composer and pianist, all of whom did work that the world would not willingly miss, in spite of delicacy of health and weakness of body which shortened their lives. Intellectual power is not dependent on bodily energy and accomplishment is not a question of years of work, but intensity of work.

It would not be difficult to add many other names to those mentioned by Metchnikoff. Naturally his thoughts recurred to men of distinction on {623} the Continent, but in English-speaking countries we have a number of typical examples of strong minds doing fine work in weak bodies. Robert Louis Stevenson is the best remembered by our generation. Elizabeth Barrett Browning, delicate all of her life, a neurasthenic during the precious adolescent years that are supposed to mean so much for future accomplishment, always an invalid to some degree at least, did some of the best work that was given to any woman to do during the nineteenth century. J. Addington Symonds, the historian of the Renaissance and of Italian literature, is another striking example of a man who had to do his work under great physical difficulties, yet who left a long bookshelf of large volumes after him as the product of the hours that he could cheat from caring for his health. Henry Harland, whose recent death all too young was a blow to the English-speaking world, is another striking example. The names of such men and women and their stories must be made familiar to people who are themselves delicate in health and who fear for their future and, above all, are despondent about the possibility of ever doing anything worth while.

Dread of Insanity.--People who have relatives who are already sufferers from such severe forms of insanity as require asylum treatment are often likely to be much disturbed over the possibility that they themselves should become insane. Of course, there is no doubt but that these people are much more liable to suffer from insanity than others, but their worrying over the matter is sure to do them harm rather than good. There are quite enough sources of worry in life without the additional one of dread of a future event that may not occur, and this must be made as clear to them as possible. The people who have no obligations on them, who have nothing to do that they feel they have to do, are especially likely to suffer from such obsessions. The best possible relief for them is afforded, not by the effort not to worry about their dread, which usually has exactly the opposite effect and emphasizes their fear by the constant effort which they make to put it aside, but by getting something else to interest them. This must not be merely a passing interest, if possible, but a serious attraction of some kind that fully occupies the mind. A hobby is an excellent thing for this, but alas! a hobby must be cultivated for many years, as a rule, to become powerful enough to bring relief in such serious matters.

Occasionally the thought of the insane asylum or the sight of an institution of this kind passed even at a distance in the train is enough to give some people a fit of depression that may last for some time. The thought of going to visit their ailing relatives is enough to make them even more depressed. I have sometimes found that in chosen cases, especially among women and those of sympathetic disposition, the apparently heroic remedy of making them visit their relatives in the asylum was excellent for them. It is the usual rule for people who are themselves sane to consider that it is the greatest hardship of asylum confinement for the patients to be associated with those whom they recognize to be insane. Exactly the opposite effect is the usual result. To be among people, many of whom are more irrational than themselves and some of whom are quite beside themselves, proves a stimulus and an encouragement. Contentment has been defined by a cynic as the feeling that things might be worse.

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DREADS OF MEN OF GENIUS

The insane are particularly prone to suffer from dreads, so that some people argue from their dreads to the thought of insanity. It is quite a mistake, however, to think of dreads as necessarily connected with insanity in any way. They are irrational though they will commonly be found to be dependent on some special physical condition. This is usually some exaggeration of attention to a sensation natural enough in itself but disturbing when dwelt on to such a degree that it produces a much greater reaction in these individuals than in other people. These dreads have existed in all sorts of people. It is said that they are more frequent in the highly intellectual, especially in the class known as geniuses, and they are often said to represent the definite evidence of a relationship between genius and insanity. I have always felt, however, that they are quite as common among ordinary people who have no genius and no signs of it as among the so-called geniuses. They are not so much spoken of by ordinary people, however, because they are rather ashamed of them. Genius, on the contrary, is quite willing, as a rule, to exploit its peculiarities for the benefit of the public, or what is even more true, its peculiarities are remembered and commented on as details of history.

With this in mind the following paragraph from Dr. Dorland's book on "The Ages of Mental Virility" [Footnote 50] deserves to be recalled. He has gathered a number of examples that are very interesting:

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

Fear has played an important role in the development of the antipathies of the great--fear that was often groundless in its origin and inexplicable in its manifestation. The unaccountable fear of dogs is not so common as ailurophobia, although it is said that De Musset cordially detested them, and Goethe despised them, notwithstanding, forsooth, he kept a tame snake. Much more frequent is the fear of spiders, centipedes, and other insects. Charles Kingsley, thorough naturalist though he was, entertained an unconquerable horror of spiders, even the common house spider; Turenne became weak when he saw a spider; while the author of the "Turkish Spy" once asserted that he would far prefer, with sword in hand, "to face a lion in his desert lair than to have a spider crawl over him in the dark." Lord Lauderdale, on the contrary, while declaring that the mewing of a cat was "sweeter to him than any music," had a most intense dislike for the flute and the bag-pipe; and Dr. Johnson was so fond of his cats that he would personally buy oysters for them, his servants being too proud to do so.

There are curious contradictions to be found in these matters. Montaigne confesses that he did his best writing and was in the best humor for keeping at his Essays while stroking his favorite cat with his left hand, his other being occupied with his writing. This would be seriously disturbing to many people, but apparently occupied certain distracting sensory tendencies and enabled him to concentrate his mental energies. To many people the very thought of doing anything like this would put all ideas for writing out of their mind. Other of Montaigne's peculiarities are quite as interesting. He always refused to sit down with thirteen at table, his liking for odd numbers was so great that he made all sorts of excuses in order not to use {625} even numbers and his aversion for Friday made the quota of work that he could do on that day much less than any other day of the week.

OBSESSIONS

There are many curious obsessions that disturb people and that are often extremely difficult of explanation even by themselves. Dr. Johnson, one of the most sensible men in many ways in his time in England, could not, it is said, pass a post on the street without touching it. At least if he did so he felt that somehow he had omitted to do something that he ought to have done and it would make him uncomfortable. There are many people who have some idea that it is lucky to touch posts as they pass along and the number of people who do things like this is larger than might be imagined. Many people put themselves out of the way in order to avoid letting a post come between the person with whom they are walking and themselves because it is said to be unlucky. Most of them will laugh at it, but still they continue the practice in spite of the bother it may occasion them. Occasionally there is some incident in their past life which accounts for such obsessions, though the patients themselves are occasionally not quite conscious of them. Dr. Boris Sidis tells the story of a man who could not take a car with an odd number. Psycho-analysis showed that he had once seen a child run down by an odd-numbered car.

In such cases there has been a long series of suggestions that have created a dominant state of mind. The only way to overcome this when it becomes a serious annoyance is to undo the influence of the suggestions by a continued series of counter-suggestions, and by such discipline of mind as will prevent the former suggestion from exerting itself. The cure can be accomplished in this way, though, as a rule, the patient will need the help of someone else.

FORGOTTEN FRIGHTS AND DREADS

Dreads founded on terrifying or seriously disturbing incidents of the past, the details of which at times have gone out of the patient's mind, are not infrequent. It is probable that many of the unreasoning dreads have some such foundation and occasionally, if patients' memories are carefully searched, the whole story can be reconstructed. All that is needed, as a rule, is to get the patients interested in conjunction with the physician in tracing the origin of their affliction and not infrequently an interesting story will turn up. Hypnosis used to be considered of great value for such reconstructions, but unfortunately patients then become so suggestible that it is often difficult to decide how much of what is brought out by questioning is due to the suggestive quality that cannot well be kept out of questions, and how much to a true redintegration of memory.

Frights in children may for a time be forgotten and yet the memory of them may come back, or a dread connected with them develop, that will make the patient profoundly miserable. One of my patients slipped and fell on a smooth steel plate at the head of a coal breaker and was only saved by good fortune from falling a long distance. This happened when he was a {626} boy of ten. There were times when the memory of this recurred so vividly as to set him all atremble and he could not look down from a height without something of the feeling of goneness coming over him that he felt at the time of the accident. The calling of his attention to the fact that his memory probably exaggerated the danger he had been in as a boy led him to go back and have another look at the conditions in which he had fallen some thirty years before. He found that they were not so dangerous as he thought and that while he would have been scratched and his clothes would probably have been soiled and torn, he would not have been seriously injured. This has greatly diminished his dread of heights.

Various physical manifestations may be due to dreads which are often supposed to be the result of some physical process in the nervous system. Occasional fits of trembling, for instance, are, in sensitive people, due to more or less forgotten memories of dangers or frights. Occasionally even slight convulsive seizures may follow such recurrent dreads. Not a few of the cases of so-called hystero-epilepsy in the borderland between hysteria and epilepsy but always one or the other, are due to such mental states rather than to any physical conditions. Such incomplete memories are sometimes spoken of as subconscious. The word subconscious has been so much abused, however, that I prefer not to use it. The reminiscences have been obscured by an accumulation of other facts but may with an effort of attention and concentration of mind be recalled. Hypnosis, or the milder form of it spoken of as the hypnoidal state, may enable the patient to recall them more vividly by enabling him to concentrate his attention, but there are always risks that suggestion will vitiate the old story in these cases. With care all the details can usually be recalled and the patient is thus given renewed confidence in himself and his own powers and does not learn to lean on someone else in the process.

TREATMENT

The most important psychotherapeutic factor for the relief of the discomfort due to dreads is the knowledge that there are so many and such different varieties of them and that so many people suffer from them. Many of those afflicted are inclined to think that their cases are almost unique. To have them know that there are all forms and phases of these curious aversions is to make them laugh a little at their own because they laugh so readily at others, and it gives them new courage for the attempt to conquer them. The aversion cannot be entirely overcome, but it can be prevented from seriously influencing sleep or appetite or occupation. This is after all the important feature of the case from the standpoint of psychotherapy. Besides, patients are encouraged not only to take up, but, above all, to continue, the practice of that mental discipline and self-control which will enable them to lessen their natural aversion, if not to remove it entirely. I have many cases in which patients' aversions have been entirely overcome. Curiously enough, there are rather often relapses when the patients are run down in weight, or are in an irritable condition from worry or emotional stress, and then something of the former mental discipline has to be reinstituted to make them once more free from disturbance.

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I have sometimes found that the recommendation to patients suffering from dreads to read Mary Wollstonecraft Shelley's "Frankenstein" has proved an excellent therapeutic agent. This is particularly true when the patients are women, for it is likely to bring them close to the sad lives of the Shelleys. The circumstances in which the book was written add to the appeal. "Frankenstein" itself is interesting, so that the mood created by this combination of interests is excellently therapeutic. It will be recalled that in "Frankenstein" the inventor seeking to make a man does make an automaton that is able to move and to talk, but that then haunts its inventor, demanding of him a soul. It proves a plague to him, but he cannot escape from it. Fly where he will his creation follows him and bothers the life out of him, killing a friend, strangling his bride, and making existence intolerable. The symbol is complete and to the point. The things that bother us in life are to a great extent of our own invention. The dreads that make so many people miserable are practically always without any groundwork in reality, figments of our imagination without the soul of real life, but capable, as was Frankenstein's monster, of making their creators intensely miserable and with them, to an even greater degree, their friends.

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IV. HEREDITY

There are so many false and, indeed, from a scientific standpoint, utterly groundless notions with regard to heredity which, as a result of the popularization of science, have become widely diffused, that notions about inheritance are a most copious source of dreads and discouragement and even produce inhibition of resistive vitality against disease on the part of many patients. At first it seemed to me as though the subject should be treated in the chapter on Dreads. It is so much more important than the other dreads, however, and there are so many people with so many different notions as to the evil influence of heredity that it seems advisable to devote a special chapter to it in which to provide contrary suggestion. Many patients are constantly suggesting to themselves that, because they are suffering from certain symptoms due to real or supposed hereditary conditions, there is little or no hope of their recovery or of any effective relief. In the old days, when tuberculosis was considered to be hereditary, it was almost hopeless to try to rouse patients into a state of vital resistance to their disease because of this overhanging dread. Such a prepossession of mind must be overcome.

In spite of all that has been said about the power for evil of heredity, and in this as in every other phase of pseudo-science, the reason why there are false popular notions is because the medical profession first cherished them and then they spread popularly, we now know that it means comparatively little in pathology. The false notions will continue, however, to be popularly diffused probably for another generation, at least, and will have to be combated. Their force must be lessened, for they are a heavy incubus on the patient's mind, imposing a burden on vitality that inhibits normal, vital reaction. This can only be done by a frank and complete statement of {628} our present knowledge of heredity, which is even yet not nearly so definite as we would like to have it, but which contradicts entirely most of the older impressions. In the matter of disease what we know of heredity, instead of being a source of distress and discouragement for patients, provides rather new incentives for vigorous reaction, since nature helps rather than hampers the effort of the individual to throw off disease from generation to generation.

False Impressions and Expression.--Probably the commonest expressions that the physician hears from his patients, though we hear many stereotyped phrases in our time when patients so freely discuss their ills and their physicians' opinions among themselves, are such as: "My father suffered from rheumatism, and I suppose I must expect to be bothered by the same ailment." "My mother died of heart disease and I think I have a weak heart; I suppose that we have weak hearts in the family." "I have had three relatives die of cancer in the last three generations, so I presume that cancer is in the family, or at least we are much more liable to cancer than the generality of people." And, finally, what used to be the commonest of all, but fortunately we have changed that at least, though we sometimes hear it still: "Tuberculosis runs in our family, my mother and an uncle died of it and one of my brothers is suffering from it, so I suppose I must just make up my mind that I, too, am sure to get it." Even the rarer affections, like kidney disease, liver disease, various nervous troubles, stomach and intestinal disturbances of many kinds, flatulence, constipation or diarrhea, are all supposed to be hereditary and patients explain their ill feelings by an appeal to the supposed principle of heredity and its application to themselves and their families.

In many chapters in this book the subject of heredity has been considered with regard to specific affections. We have no evidence at all, or the evidence is so trivial as to be quite negligible, that anything acquired by the individual, be it for good or evil, is ever transmitted to the next generation. That acquired characters are not transmitted is now almost a universally accepted principle among biologists. The more a biologist knows of recent biological research and investigation the more will he be likely to consider this principle of the non-transmission of acquirements as definitely settled. According to this, then, no disease is ever transmitted to the next generation. This is such a complete reversal of former opinions, such an open contradiction of popular beliefs, that the subject merits thorough discussion from this newer standpoint for medical applications. We must not forget that popular medicine, even when egregiously wrong, is founded on opinions held by the medical profession aforetime and, indeed, on this subject of heredity many of the medical profession still cling to the former opinion.

Tuberculosis, which used to furnish the most serious argument in this matter, has now come to be the best possible explanation that we have for the fallacy of the transmission of anything acquired. The disease followed families so constantly that it seemed impossible to explain it unless the principle of its heredity was conceded. Now that we know its contagiousness, however, it is comparatively easy to explain its occurrence in families. When we recall how carelessly people coughed and even expectorated around the house, while children crept on the floors and carried the germs of the disease to their mouths on their hands, the wonder is, not that so many members of the family acquired the disease seeing the manifold opportunities for contagion, but that {629} any of them ever escaped. We know now that practically every adult above the age of thirty either has or has had tuberculosis. Careful autopsies show us remains of the disease even in the bodies of those who, without any history of tuberculosis, die from other diseases. One out of eight of the population dies of tuberculosis, but the remaining seven are quite capable of resisting the disease and so we find healed lesions at autopsies in this proportion of cases.

Family History Favorable.--It is certain, then, that tuberculosis is not hereditary. On the contrary, as we have learned more about the disease in recent years, it has been recognized by specialists that patients who have a family history of tuberculosis are notably less likely to succumb to the disease early than those who have no such history. An acute case of tuberculosis with considerable loss of weight has a very unfavorable prognosis unless there is a history of the disease in the preceding generation, when at once the outlook becomes more hopeful. This newer view is confirmed by what we have learned from the ethnological pathology of the disease. Peoples exposed to the disease for the first time rapidly succumb to it. This is practically true for all the infectious diseases. Our American Indians succumbed in large numbers not only to tuberculosis but also to smallpox and even to measles when each was first introduced among them. The same thing was true in the South Sea Islands. Where nations have been exposed to the disease for some time they have acquired not an immunity, but at least they possess a greater resistive vitality to its ravages and while they still may be susceptible they are not so subject to the fatal forms of the disease, and even if they acquire it they live on for many years.

Many people may insist that this immunity or comparative immunity to tuberculosis and increased resistive vitality against the disease is transmitted and illustrates the principle of heredity. The reaction of the system to the disease increases in each generation and this increase is an acquired character which passes down with the family strain. This immunity should be viewed from another standpoint, however. Certain families possess a resistive vitality to the disease; others lack it. The resistant families do not succumb to it, and propagate themselves. The others gradually die out. What caused the resistant families originally to possess this quality we do not know. We have no trace of its being acquired. Like so many other characters by which men differ from one another, we do not know the beginning of it. Once it comes in as a family trait it is transmitted. In successive generations we have no evidence that it is stronger, only the danger is recognized from experience and better precautions are taken; the consequence is that the original resistive vitality has a better chance to make itself felt and so the family is preserved. This is as true with regard to the conquest of the tendency to excess in the taking of toxic substances, as alcohol and opium, as with regard to disease. It is not the transmission of an acquired character, but the descent of a family trait the origin of which we do not know.

Hereditary Syphilis.--Many physicians will protest that, at least, we have ample evidence for the transmission of syphilis by heredity. We have for many years talked of hereditary syphilis as if it were absolutely sure that its transmission by inheritance took place. There is no doubt, of course, that the disease is conveyed from mother to child. If a mother is actively syphilitic, {630} then her child will surely have syphilis when it is born. This, however, is no argument for the hereditary transmission of syphilis. We know now that if a mother is tuberculous, in an active stage of that disease, her child will almost surely have the disease, but this is a question of contagion not of inheritance. If a mother with active tuberculosis nurses her child she is likely to give it tuberculosis. Usually the idea is that the milk is not infective unless there are tuberculous lesions in the breasts, and in cattle it is well known that such lesions in the milk apparatus inevitably bring tubercle bacilli into the milk. The demonstration of tubercle bacilli in the blood of patients in the active stage of the disease is now much more frequent than used to be the case and there seems no doubt that the bacillus can pass through glandular structures into the secretions.

In the same way syphilitic nurses are likely to infect nurslings, though, of course, in this case there are usually syphilitic sores on the nipples which directly communicate the disease. It is almost impossible for a syphilitic woman to nurse a child, if she is in an active stage of the disease, without the production of such infective sores on her nipples. When children are born with syphilis it means only that in the process of feeding the child through the placental tissues, a mother has infected her child quite as she might infect it by nursing afterwards, in case she acquired syphilis after the birth. Lesions corresponding to those on the nipple occur in placental tissues and can be demonstrated without much difficulty. Congenital syphilis, however, can always be traced to contagion and the being born with the disease or having the manifestations of it occur shortly after birth is no argument for heredity at all. It merely emphasizes the danger of contagion.

Mothers of Syphilitic Children.--But there are some cases in which the child who shows symptoms of syphilis after birth is born from a mother who never had any manifestations of syphilis and therefore it has been supposed that the infection must have come from the sperm, and that in these cases, at least, there is a true heredity. It is perfectly possible, however, that syphilitic infective material may accompany the spermatozoon and so bring about the occurrence of syphilis in the offspring. Even this would be infection, however, and not heredity. Much more frequently it would seem that the disease in the infant was contracted from the mother while suffering from a latent form of syphilis, rather than from the paternal contributory particle to its existence. The mother gives no sign of the disease, but Colles' Law is that the mother of a syphilitic child may, without danger to herself, be allowed to nurse her own infant even though she herself has never had any symptoms. This can only mean that she is thoroughly protected against the disease. We would not think for a moment of allowing an ordinarily healthy women to nurse a syphilitic child. Such immunity in the mother of the syphilitic child can only come, so far as the present state of our knowledge goes, from her having had the disease. It has been said that as the result of the intimate communication with her child in utero she has acquired an immunity by the passage across the placental membrane which separates maternal and fetal blood of protective substances of various kinds due to the reaction against the disease already beginning in the child. As a matter of fact, however, there is no evidence of any such reactive substances in the blood of the child which after birth proceeds to have a series of acute lesions that are, as a rule, indicative {631} of almost complete lack of resistive vitality. Maternal immunity is evidently due to the occurrence of the disease in some form within the maternal tissues which produces the usual protection against the disease in a briefer time than usual. This certainly seems to be a more satisfactory explanation than that of a transmission of an immunity from the child to the mother which the child itself does not possess. It is easier to understand the transmission of an infection that does not manifest itself externally than of an immunity which there has been no time to acquire. Both explanations leave a mystery, but the mystery in the second case can be explained more in consonance with what we know about syphilitic transmission and immunity than in the other case. It does away with the transmission directly from the father almost completely, of course, leaves practically no ground for the heredity of syphilis, but it accords much better than older explanations with biological principles.

Late Lesions and Heredity.--Many physicians will be likely to insist that the late developments of syphilis in children, in which not only three or five years afterwards, but even fifteen or twenty years after birth, there are syphilitic manifestations, are beyond all doubt examples of heredity. In the last twenty-five years, however, our ideas with regard to the after-effects of syphilis have been entirely modified by what we have learned of such diseases as locomotor ataxia, paresis and the like. These are undoubtedly parasyphilitic diseases in most cases, yet they not infrequently develop from ten to twenty years after any manifestation of syphilis and they seem to occur, by preference almost, in cases where the preliminary symptoms have been very mild. In not a few cases, indeed, the symptoms of syphilis have been so transient in these patients that the true significance of them was missed until the later developments showed their real character. Krafft-Ebing, at the International Medical Congress at Moscow in 1897, detailed some experiments that he had made on paretics in Vienna. They were patients in whom no history of syphilis could be found, yet they were suffering from typical paresis. As they were in the ultimate stage of the disease it did not seem unjustifiable to inoculate them with syphilis, and in most cases it was found that they would not take the disease, showing that they were probably protected by a previous attack, though there was no history of it.

The development of the late symptoms of syphilis in the second generation can then be much more satisfactorily explained on the basis of a mild infection with very few primary symptoms, almost lacking in secondary symptoms, yet followed by subsequent symptoms of great severity consequent upon the deterioration of vitality produced by the disease. As for the manifestations in the third generation, they are not directly syphilitic, but are, whenever they occur, due to conditions consequent upon the degeneration that had been effected in the preceding generation and which directly weakened the offspring--on the same principle that weak parents give birth to weak children, and starving parents cannot have strong, healthy children--but not because of any direct influence of the disease. It is worth while to discuss this subject from this standpoint, since it disposes of the only supposed evidence left for the hereditary transmission of disease that we now have, though only a few years ago most diseases were supposed to be hereditary.

Heredity in Cancer.--With regard to other diseases, the evidence for any inheritance has been founded entirely on coincidence. All the human race {632} dies and must die some way, and so in families a certain number will die of the same disease. The argument for heredity in cancer is extremely weak. When all the relatives of a person afflicted with cancer as far out as the third generation are taken into account, only about one in five of them are found to have suffered from cancer. When we remember, however, that more than one in thirty of all those who die, die of cancer and that the death-rate of this disease is greater than that of typhoid fever, smallpox, scarlet fever, measles, and all other infectious diseases put together, it is easy to understand how large a role coincidence plays in any such set of statistics, and how little the significance of the occurrence of cancer in different members of the same family means, unless possibly there is an occasional element of contagiousness which must not be left out of the reckoning.

Heredity in Other Affections.--Other ailments present much less possibility or probability of any element of heredity. For instance, over-indulgence in meat or drink may readily bring about various ailments of the gastro-intestinal tract. These are, of course, definitely acquired conditions, some of them temporary and some persistent, that will continue to give trouble so long as the patient continues to produce irritation of them. They may, of course, lead to permanent pathological conditions. To say that any of these are likely to be inherited would be quite as absurd as to say that a corn could be inherited, or the permanent deformities produced in toes by wearing badly-fitting shoes could be transmitted to the next generation. We do not think for a moment that because a man has lost a finger his children are likely to be born without a finger, and still less if by some accident or abuse he has been deprived of the use of an arm or leg, that that is likely to be transmitted to the next generation. Yet people calmly talk of the heredity of similarly produced conditions within the body, and even physicians are not entirely free from the superstition, for such it is, of the influence of heredity in producing pathological conditions.

Habits of various kinds, physical and mental, are calmly accepted by many people as influenced by or having their origin in heredity. Under Alcoholism and Drug Addictions we have discussed this phase of the subject, but a word or two more may make it clearer. A tendency to form the same habits may be a family trait and descend from one generation to another. That a specific habit should be the subject of heredity or transmission is as much out of the question as that a facility for doing anything should be transmitted. The son of an acrobat must practice quite as faithfully as did his father in order to secure his father's skill. He may inherit from his father that particular constitution of body, that specific combination of muscle and sinew and bone that enables him to become an acrobat by practice, though with a different kind of body it would be impossible, but his father's acquired facility influences in no way the son's ability. We often hear of a man being the descendant of a series of generations each of whom has gone to the university, as if that somehow assured him a readier and better facility for education, but we know very well that this is not true and that the boys straight from the soil are often the best students and far ahead of the scions of long-time academic families.

Inheritance of Defects.--Acquired characters are not transmitted, though family traits are the subject of inheritance. Disease is not hereditary, but {633} defect is. Crossed eyes occur very commonly in families and are evidently a subject of transmission. Family noses are often very peculiar and may be traced for many generations. The Hapsburg lip has been noted in sixty per cent. of the Hapsburgs since the family came into prominence in the thirteenth century. Features of all kinds are inherited, as anyone who has ever spent some time in a family portrait gallery where the ancestors were genuine and the paintings reasonably true to life, knows very well. Certain features of European families can be traced for many generations. The tendency to have six toes or to have an extra finger runs in certain families. So small a thing as a patch of white hair in a particular part of the head may be the subject of hereditary transmission. Moles on a particular part of the body are inherited. All these, however, are characters with regard to the acquisition of which we know nothing, but that have somehow found their way into the family strain and have become subjects of transmission from generation to generation. They provide no evidence, however, as to the transmission of acquired characters.

Variation.--What is even more surprising in biology, however, is that there is another marvelous force at work quite as incomprehensible in its way, perhaps even more so, than that of heredity. This is variation. All creatures have a tendency to vary from their parents. A very small proportion of the offspring resemble parents so closely as to be quite similar. The great majority of them, however, have noteworthy, individual, distinctive qualities. Occasionally these qualities may be traced to the less immediate ancestors and then we talk about reversion. Occasionally there appears in a child some trait or anomaly supposed to be remotely ancestral and it is spoken of as atavism. Whenever there is a tendency of the offspring of exceptional parents to regress toward the racial average, we talk of regression. Tall parents often have tall children, some of them may, by a special tendency of heredity, be taller even than themselves. Most of them will be shorter, however, and tend to regress toward the racial average.

Few people understand what a wonderful power among living things is exerted by this very opposite of heredity--variation. All the possibility of improvement not only in humanity but among all living things is dependent on variation. It does not seem difficult to understand how offspring resemble parents. They are of them, therefore they are like them. When we analyze the problem of heredity, however, and find that the connecting link between offspring and parents is always only a single cell of less than one one-hundredth of an inch in diameter, the mystery of heredity looms up in all its immensity. This minute bit of protoplasm, so small that it requires a rather strong power of the microscope to see it, somehow contains compressed within itself all the qualities that characterize the parent and are to be transmitted to the offspring. Among animals, the color of the eyes and hairy covering, the form and height of the animal, its generic characteristics, and its individual characters--all are contained within this minute spherule. The white blaze on the horse's hind leg, the black blotch on the puppy's face, the white lock on a human head, are all carried over from one generation to another with all the other qualities in this small package. That is the mystery of heredity.

To this must be added another mystery quite as great and even more {634} difficult to understand--variation. This tendency to vary is the basis for whatever evolution there is in the world. Some living things vary in such a way as to be better suited to their environment than they were before and then these outlive others because more favorably situated, and natural selection brings about a maintenance of the favorable variation. Instead, then, of patients being impressed with the unfavorable influence of heredity, they should rather be made to feel the weight of the idea that whatever evil tendencies the parent has the child is more likely to have less of them than more, so that variation tends to make the race better. We have had too much stress laid on the heredity of unfortunate qualities and entirely too little made of the variation tendency, which is constantly lifting the race up. It is, of course, only what happens in everything else, unfavorable are likely to have more weight than favorable suggestions, and unless these latter are emphasized their influence becomes swamped. This has happened with regard to variation. It is quite as important a biological element as heredity and it makes for the removal of unfortunate qualities, yet it has never become a popular idea and is little appreciated even by physicians.

Patients who are worried about their heredity will, after a frank discussion of our present knowledge of heredity and its co-ordinate factor of variation, lose most of their dread of this specter of supposed evil influence which so often proves the source of discouragement and failure to react properly against pathological conditions. There is probably no phase of modern biology in which the so-called popularization of science has done more harm by providing an abundant source ol unfortunate suggestions. Whatever influence heredity has in relation to disease is favorable to the human race. It is true that this is exerted by the elimination of the unfit, yet the very consequence of this is that the children of parents who have suffered from a particular disease are likely to have greater average resistance to it than the generality of mankind, since their parents passed the age up to reproductive activity without succumbing to it. For cancer, tuberculosis and syphilis this teaching is of special value and is probably more effective than any other single means could be to prevent the ravages of the disease if it should occur, since it keeps the patient from interfering with his own resistive vitality by the discouraging conviction that there is no possible hope for him because his parents also suffered from the disease.

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V. PREMONITIONS

A state of mind that disturbs many people seriously, sometimes even producing physical results, because of the burden of dread that hangs over them, is that in which attention is paid to premonitions of evil. There are two of these general conditions to be considered. In the one there is a definite feeling that some special evil, occasionally very particularly outlined in the mind, as a railroad accident, fire, or a street accident of some kind, is to occur. In another mental condition there is a generic premonition of evil, {635} as if the worst were sure to happen and the patients must be constantly preparing for it. Occasionally this takes on some such form as an assurance of early breakdown in health, or of death at an untimely age, or of some crippling infirmity. This represents, of course, only one form of lack of control over the mind, but it is surprising how much physical suffering it may occasion. Only those who have had much to do with patients who suffer from this state of mind realize it. Sympathetic knowledge of the conditions that bring it about and of the real significance of premonitions will do more to help patients than anything else.

Every now and then newspapers tell the story of someone who had an impending sense of danger, perhaps of a particular form of accident or misfortune, which he could not shake off and which finally came true. Sometimes it is a fire that was anticipated, though without any reason except the dread, and precautions that eventually proved life-saving to the patient were taken, or at least friends were told of it so that the person seemed actually to have had some warning beforehand of the danger that was to come. Sometimes it is the story of a railroad accident, which some particularly fortunate individual escaped, because of a premonition that made him take another train or make a happy change of cars. Nothing is said of the times when premonitions failed, nor of the disappointments of such dreads. Most people laugh at the stories, but a few individuals become seriously impressed with the possibility of such warnings and then make themselves miserable by having frequent premonitions.

Etiology.--As to the origin of these premonitions it is hard to say. They occur more frequently on dark days than in bright weather and are complained of much more in spring and fall than during the cold brisk winter or during the summer time. A succession of very hot days, however, brings a series of premonitions, especially with regard to accidents by heat, that is not surprising since the newspapers have many accounts of sunstrokes and there is every suggestion of the possibility of danger of this kind. How large a role suggestion plays in the matter can be realized from the fact that after some particularly serious railroad accident many people have premonitions that they may be hurt and occasionally they put themselves to considerable inconvenience in choosing the car in which they will sit, if the last serious preceding accident of which they have heard happens to have brought death mainly in a particular car of a train. It is always suggestible people who are likely to have premonitions. The thought comes very simply at first, they dwell on it a little unwillingly, then they find it impossible to banish it and finally it may become a positive obsession. The soil and the seed for suggestion are both needed to produce premonitions.

Royce suggests that many of the supposedly fulfilled premonitions are really only pseudo-presentiments and represent an instantaneous and irresistible hallucination of memory, which may give rise to the impression that there has been a previous dream or other warning presaging the facts, though no such phenomenon actually took place. In other words, there would be an auto-suggestion consequent upon the hearing of other fulfilled presentiments that sometime some such thing must also occur to us, and then when a happening that reminds us of something in the previous stories of {636} presentiments comes there is the sudden responsive feeling "why, this is what I saw or must have seen in my dream."

Podmore suggests an illusion of memory magnifying or rearranging the details of a recent dream or premonitory impression, so as to make it fit into the happenings. Dreams are so vague that unless they have been written down we are not quite sure of them an hour after they occurred and a day or two later we have only the merest hint of what they were. If this can be made to have any connection with a casualty of any kind that happens subsequently we may very readily recreate the dream with its details concordant to the event. Certainly no reliance can be placed on a story of a dream fulfilled unless the dream was told before the happening.

Premonitions of Death.--Certain premonitions are common and are frequently brought to the physician's notice. Among old people it is not unusual to find that a premonition of death will hang over them for days, seriously disturbing them and their friends, hampering often a healthy reaction against disease and always lowering resistive vitality. Many of them have heard stories which make them credit the belief that such premonitions are likely to come true and therefore they cannot shake them off. They have heard stories of people who have become convinced that they were going to die at a particular time on a particular day and whose conviction has been proven by the event. Like all the other premonitions, whatever truth there may appear to be in them, is due entirely to the fact that nearly everybody has premonitions and occasionally, therefore, one of them must come true. Those that are fulfilled create such an impression that they are remembered, while those that fail are forgotten, until, though it is not realized, it becomes true that fulfilled premonitions represent exactly that much misunderstood principle that the exception proves the rule. The rule is that premonitions fail. Exceptionally, however, a premonition comes true. Instead of proving that premonitions mean anything, the rarity of their fulfillment proves the rule of their non-significance and demonstrates that they are merely coincidences.

Persuasion of Short Life.--Much mental suffering occurs in nervous people as a consequence of a premonition or persuasion which comes to them in middle life that they are destined not to live very long. This is a commoner impression than is usually thought and comes to nearly everyone at some time in life. Especially is it likely to come to those who have suffered some severe illness and who know how weak they were during their convalescence and, in spite of their thorough recovery of strength, cannot quite persuade themselves but that an ailment which made them so weak must surely have sapped their vitality so as to make long life for them impossible. It is, of course, one of the vague dreads that men always seem to be harboring, but there are times that it becomes so prominent and so influential in the production of depressive feelings that it is worth while to have the means at hand to counteract it as far as possible. In the last ten years I have made it a practice to ask, not only all my patients but most of my acquaintances above 70 years of age whether they had ever experienced such a premonition. I have particularly asked what were their feelings with regard to the hope of long life for them when they were in their forties and fifties. Without exception I have been told by all those who had the education and leisure to {637} be at all introspective, that they had felt sure that they would not have long life.

Most of the men consulted took out life insurance in such a way as to benefit their families after their death rather than themselves during life. Indeed it seems not an unusual thing for men to have some experience with an ailment between 40 and 55 which makes them realize their mortality much more than the deaths of their friends around them had succeeded in doing. Premonitions and impressions, then, of this kind evidently mean nothing, so far as the prospect of long life is concerned. Practically everyone has them, and since, of course, the great majority of men do not live to die of old age, it would seem that their premonition of comparatively short life was fulfilled. Occasionally a man will be found at the age of fifty unwilling to take up further work or develop his business because of the dread that has come over him that he may not live long enough to make it worth the while. Where there is serious kidney or heart trouble such an abstention from business is commendable, but in many cases it leaves a man without occupation or with insufficient occupation and he becomes short-circuited on himself with more serious results from worry than would have come from work.

Publication of Fulfilled Premonitions.--The publication of fulfilled premonitions has always seemed to me to be an especially fertile source of premonitions for other people. Every now and then someone goes to bed in a hotel having communicated to friends the idea that he fears there may be fire before morning. I do not suppose that one out of ten people who sleep in a strange hotel fail to have some such thought, they do not consider it a premonition, however, but only a suggestion for the taking of proper precautions so as to know where exits and fire escapes and other means of escape are situated, so that in the excitement of the fire they may not have to do any thinking, but may have already made up their minds what they shall do. This sort of premonition, if we call it by that name, has a definite useful purpose. Occasionally it seems marvelously provident. The other makes its possessor toss sleepless a portion of the night, does no good and much harm. If, however, the premonition has been communicated to someone else and then a fire should occur, the reporting of the fulfilled premonition comes to a lot of weak-minded people as a confirmation of their worst fears. It is, of course, only a question of coincidence in a succession of events by no means connected in any causal relation, yet by the unthinking set down as showing the possibility of such premonitions being supremely significant. If we had all the stories of unfulfilled premonitions also published then the true significance of the others would be clear.

An Unfulfilled Premonition.--There is an excellent story of a strong but unfulfilled premonition told by Carl Schurz in his "Recollections," which seems to me such a good antidote to the influence of supposed premonitions, that every physician should know its details for their psychotherapeutic value with patients prone to be troubled in this way. The ease with which the depression consequent upon the premonition was relieved as soon as another forcible suggestion that the danger was past took possession of him, shows how such states of mind can be altered with no more real reason for the alteration than there was for the original depression.

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On the morning of the battle of Chancellorsville General Schurz awoke with the absolute persuasion that at last his time had come and he was to be killed that day. He had never had such a premonition before. He had heard of many cases in which such premonitions proved the forerunner of death. He realized how ridiculous was the idea that he should know anything about what the future held for him, even vaguely, and he tried to shake it off. He found it impossible to do so. He thought that after he took up the routine work of the day the force of the premonition would be lost. It was not, but, on the contrary, seemed to increase in power over him. Finally the idea became so imperative that he sat down and wrote letters of farewell to his wife and friends, telling them that he had been tempted to do so because of this premonition of danger. When he went into battle--and it may be recalled that the Eleventh Corps did some fighting at Chancellorsville that day--he was sure that now the end was not far off. It did not take away his courage, however, and though he was well in the zone of danger, he issued his orders and kept his troops well in hand as we know from the history of the battle.

Finally his aide-de-camp, riding toward the front of the line beside him, was killed by a cannon ball. All in an instant the thought came over him that this was the only danger that was likely to be near him for the day. The burden of premonition lifted from him as if the fact that a friend had been killed beside him gave him an assurance that he himself was not to be taken. There was absolutely no reason for his thinking so, but his feelings of solicitude with regard to himself and his fate faded completely and at once. He continued in the thick of the fight and of danger and was untouched. He himself called attention to the fact that if his premonition had come true, as well it might in the midst of the very serious danger which he faced, it would have seemed a strong confirmation of the impression that premonitions have a meaning other than that of coincidence. It was, however, a magnificent example of a failed premonition quite as striking as any of the stories that are told about premonitions that came true.

Role of Coincidence.--This must be remembered in many of our arguments in medical and other scientific matters. Most diseases are self-limited, therefore anything that is given as a remedy for them just about the time that nature has succeeded in conquering the virulence of the disease and bringing about the cure of the patient, seems to be curative. Such cures, often remedies of supposed wonderful potency, come and go in medicine by the hundred every ten years. Such curious doctrines as that of the influence of maternal impressions in producing deformities and defects in the unborn child are founded on nothing better than these coincidences. They are often very startling, but the rule by which they must be judged is the number of times in which in spite of similar conditions no premonition takes place. Literally thousands of people go to bed every night who are to be waked by the danger of fire before morning and yet have no premonition of it. Literally millions of people have gone to bed in recent years without any premonition of earthquake, yet have been wakened before morning with their houses tumbling around them. If a few people have premonitions in these cases it is easy to understand that it is coincidence and not anything else, for these are exceptions, and this again is a case of the exception proving the rule.

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Premonitions and Superstitions--Thirteen.--Occasionally premonitions are connected with certain events that are themselves, even though happening quite accidentally, supposed to be portentous. How many people, for instance, feel quite uncomfortable if they sit down thirteen at a table. The very fact of the gathering of thirteen is supposed to be a spontaneous or automatic premonition that is a forewarning of evil that has to come to some of them. Unfortunately, this superstition continues to have a vogue and an influence over people's minds because stories are told that are supposed to confirm it. Needless to say, when these stories are true, they are merely coincidences. Out of any baker's dozen of people who sit down to dinner it is not surprising if one should die or be killed during the year. Some of the stories, however, are merely sensational inventions worked up to be given to the public because a number of people are interested in this sort of thing. Probably one of the stories that has gone the rounds most and that has served to confirm many people in their uneasiness over the number 13 is that which is told as happening to Matthew Arnold and some friends, supposedly the year the great English litterateur died.

The story runs that just as Mr. Arnold and his friends were about to sit down to the table it was discovered that there were thirteen present. According to the old tradition in the matter it is the one who first gets up from table under these circumstances that is likely to be affected by the malignant influence. When the end of the dinner had arrived, by previous arrangement Mr. Arnold and two very healthy friends, brothers, arose simultaneously. According to the widely diffused newspaper account of years afterward, Mr. Arnold himself died within the year and one of the brothers was lost in the wreck of an English passenger vessel off the coast of Australia in six months, while the other brother committed suicide before the end of the year. Careful investigation of the details has shown, however, that the story was made out of whole cloth. Mr. Arnold himself, who was suffering from heart trouble towards the end of his life, was not likely to take part in any such arrangement because of the constant danger, well-known to himself, of sudden death in his case. This might happen at any time and might seem to confirm the superstition. The dates of the story, moreover, are all wrong. Matthew Arnold's death and the loss of the English passenger vessel in Australian waters, referred to, do not occur within five years of each other. The story has gone round the world. The correction will never reach so far. The story is startling; the explanation commonplace. Many people will continue to believe that here, at least, was one striking confirmation of their superstition.

It is curious how the force of this "13" superstition has continued in spite of education and enlightenment. Most passenger vessels now built have no staterooms numbered thirteen. On certain streets in large cities one finds the number 12-1/2 (until this year it was so on my own) substituted for thirteen. Sometimes one finds "twelve a" or something similar. In the large hotels, where they have immense banquet halls with the tables numbered so that guests may be able to find their places, I have often noted that there was no table number thirteen. It is said that in some of the new skyscraper buildings twenty stories and more in height there has been question of skipping the thirteenth floor as a designation, because while most {640} people would be quite undisturbed about it, some do not care to have an office on the thirteenth floor, giving as an excuse that clients or patrons do not care to come to the thirteenth floor. In automobile races men are willing to risk their lives by going a hundred miles an hour on roads never intended for such performances, but they refuse to race behind the fell number thirteen. This, after all, can be readily understood. The slightest thing that takes away a man's complete confidence in himself may be serious in an automobile going as fast as these. Men must not think of fear or they lose some of their power and control over themselves and their machine. They must simply forget everything except the task before them.

The belief in the thirteen superstition is one form of acceptance of premonitions. That of itself should be enough to enable sensible people to throw them off. Above all, it must be remembered that such supposed malignant influence, when allowed to affect people, impairs their presence of mind and may thus lead up to the accident or mishap which it is supposed to foreshadow. This is the serious feature of such premonitions and dreads. Unless people can be persuaded sensibly to be rid of them they handicap themselves whenever they are placed in danger that causes them to recur to the thought of the premonition or dread. While there is absolutely nothing but coincidence in even the supposed true stories, and many of the stories are merely sensational inventions, yet people need to be persuaded to rid themselves of the incubus that settles over them because of such ideas.

Premonitions and Telepathy.--There are many people who think that premonitions have something to do with telepathy. Somehow the future event is supposed to be able to send some message to specially susceptible minds. Either that, of course, or there is some being in another world whose interest is sufficient to convey some inkling of the future. A little consideration of this subject, however, shows the utter lack of rationality in any such opinion. Future events, having as yet no existence, cannot in any way influence intelligence. Such future events, when dependent on human free will, are quite impossible of being foretold and, as has been said, no being except the Creator Himself knows anything about them. It would be only from Him, then, that information might be supposed to come and it would be hard to think such information would be so vague and indefinite as to leave room for doubt and, besides, often defeat its purpose of protection by seriously disturbing patients and lessening their presence of mind. There is no reasonable explanation by which a human being can be supposed to obtain knowledge of a future event unless there is a complete overturning of the ordinary laws of nature and then it would be reasonably supposed that no doubt of the significance of the event would be left.

Nearly all of us have premonitions that fail. Only a few especially introspective people who are constantly afraid of what will happen to them, and who are sure that the worst is always preparing for them, have their premonitions come true more than once or twice in life. The striking fulfillments of a few premonitions could be paralleled by an endless number of just as striking failures, only that most people dismiss the idea completely from their minds as too foolish to be further talked about. It is quite the same with dreams. All the world dreams and there would be a serious violation of the theory of probabilities if some dreams did not come true. The great {641} majority of mankind, especially after the age of thirty, is fearful lest something ill is going to happen to them and their premonitions are rather frequent. If some of these did not come true then the mathematics of coincidences as based on the theory of probabilities would prove false.

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VI. PERIODICAL DEPRESSION

Fits of periodical depression, familiarly known as "the blues," occur in the experience of practically everyone. In some people they are only slight and passing. In others they last for hours and make the individual quite miserable. In still others, without actually running into melancholia, they produce serious discouragement and continuous discomfort which persists even for days and makes life intolerable. They come and go quite unaccountably. During their occurrence all vitality is lowered, appetite lessened, aches and pains are emphasized, sleep may be disturbed, exercise becomes distasteful, and they usually present an interval when health is at a low ebb. Ordinarily when described as "the blues" they have no definite connection with any known physical cause. They are passing incidents which seem to recur at irregular intervals. When connected with physical ills they are thought of directly as symptoms of these ills. All forms of disease may be associated with such fits of depression and many physical symptoms seem to be due to the fact that during these periods there is a distinct lowering of physical vitality so that the nerve impulses which ordinarily enable functions to be performed without interference are interrupted, or at least are inhibited, to a noteworthy degree. While to a certain extent the condition is a mental disease, it may be modified by the correction of physical derangements, by stimulation and, above all, by suggestion and a change in the point of view.

Serious Pathological Conditions.--Of course, such periodical fits of depression are associated with various serious progressive ailments and then are primarily physical, and are only secondarily psychic. From the standpoint of psychotherapy it is important to remember that certain serious organic lesions may show their first signs in the patient's mental state. It is not unusual, for instance, for the disposition of a patient suffering from kidney disease to change so materially that the attention of friends is called to the change before any physical symptom of the nephritis has been noted. Sometimes for a year there will be a progressive clouding of what had previously been a rather happy disposition. Decisions will be made more slowly than before. The judgment will be impaired. There are some striking examples of this in history, of which the unfortunate Athenian general, Nicias, put to death for incapacity that was undoubtedly pathological, is one. Pleasures will be taken half-heartedly; men who have been bright and jovial will now become saturnine. Men who have been the life of parties will try to hold the place they acquired before, though all around them will perceive how difficult it is for them to maintain the role they have set for themselves. Whenever there is a notable change in disposition, it is well not to attribute it to some passing mental condition and, above all, not to dismiss {642} it as a peculiarity unamenable to treatment, but to look for the underlying pathological basis of the new condition.

In this way physical disease will sometimes be discovered long before it otherwise would be. This must be particularly noted when there have been a series of worries. Occasionally it seems enough to many people to ascribe a change of disposition to the troubles that have come over a patient. If a business man fails or passes through a crisis in his affairs in which failure is very near, or he has many business worries over a prolonged period, these are sometimes thought to be quite enough to explain a change of disposition. They are, but not to the degree that is often noted, for, in excess, melancholic tendencies are always pathological, that is, they have some basis in a serious mental or physical change. If there is an insidious nephritis already at work, its symptoms will be much exaggerated and its progress accelerated by the worries and disquietude of such a time. If a wife loses her husband, or an only son, or a favorite child, the occurrence of a prolonged period of depression should lead to a careful investigation of physical conditions and of the underlying mental state in the hope of guarding against serious developments.

Heart Disease.--Periods of depression are also common in heart disease and are often the first symptom of the beginning of a break in compensation. This effect is not so simple and direct, however, as in the case of the kidneys. Probably the first physical symptom of a break in compensation, where there is real valvular heart disease, is a decrease in the amount of urine. This points to an insufficient elimination of the products of metabolism and to the retention in the circulation of toxic substances. The reason for this is the lessened circulation through the kidneys because of the diseased heart. There is also a lessened circulation through the brain. This impairs the function of the brain and quite naturally leads to mental depression, slowness of decision, and unwillingness to occupy one's self with many things. Besides, because of the lessened function of the kidney the circulating blood not only does not nourish so well but it tends still further to depress the brain cells by the toxic substances that are in it. Depression in such cases is rather to be expected and at the beginning is not continuous but comes in ever longer periods with shortening intervals as the disturbance of the circulation progresses. At first, like other diminutions of function, it is conservative in order to spare the heart work.

Respiratory Affections.--Very curiously an affection of the lungs has exactly the opposite effect and is likely to create in the patient an artificial sense of well-being. Spes phthisica, the characteristic hope of consumptive patients, is well known, and has been described by many a careful observer from Hippocrates and Galen to our own time. A lessened amount of oxygen in the blood produces a certain sleepiness, but this seems to be preceded by a period of slight excitation. The most familiar example of this occurs at the beginning of the inhalation of laughing gas. Practically the only direct physical effect of the inhalation of nitrous-dioxide is to shut off our oxygen and it is a slight period of deoxygenation that produces the anesthesia by this agent. Whether we have not in this the explanation of the feeling of the consumptive, so that often on the day before his death he plans a number of things that he is going to do next year, may require more careful {643} investigation, but the suggestion may serve to show how much disposition, both lively and serious, depends on physical factors as well as on the natural state of mind.

MENTAL STATES OF DISAPPOINTMENT

Quite apart from these serious ailments, however, there are passing phases of depression that come to nearly everyone after adult life is reached that are likely to be somewhat more frequent as years go on, but that are not entirely unknown even in early years. They are more likely to come to those who feel that life has been somewhat of a failure and that they have accomplished very little in spite of all that they have tried to do. Not infrequently they come, however, to those who in the estimation of other people have made a magnificent success of life. The rich man, after he has made his fortune, unless he continues to engross himself with some time-taking and interest-claiming work, may be the subject of repeated attacks of mental depression. Social leaders among women who begin to feel something of the emptiness of social striving, after they have made what is called a success in society and at the time when they are the envy of many on the social ladder below them, are particularly likely to be subject to attacks of "the blues." The only men and women who are free from them to a great extent, and even they not absolutely, are those who are busily engaged with some occupation not entirely selfish in which they can see that what they are doing is accomplishing something for the people around them.

Very often an attack of depression is ushered in by some small disappointment. As a rule, however, this is not the causative factor but is only an occasion which makes manifest the depressed state that has existed for some time and that now declares itself openly. In the same way only a slight occasion is necessary apparently to dispel clouds that hang over a person in the milder attacks of depression, because, for some time before, relief has been preparing itself and a livelier phase of existence has been gradually coming on. Relief can be promised with absolute assurance, but freedom from relapse cannot be assured and the only true source of consolation that is helpful is the frank recognition of the fact that these are successive phases of existence quite as likely to be periodic as certain physical facts in life. Depression is likely to be a little more manifest in the morning than at other times, partly because the interests of the day have not yet come to occupy the mind, but mainly because the physical life as indicated by the pulse and the temperature is lower during the morning hours than in the afternoon and evening. Just as soon as people realize the physical nature of certain dispositional changes they give much less depressive significance to them.

Occupation of Mind.--The most important feature of the treatment of depression of mind is to secure somehow such occupation as will catch the attention and arouse the interest. This is not always an easy matter. How effective it is, however, can be best judged from what one notes of the effect of such things as physical pain or great solicitude for someone else besides themselves. I have known a mother, whose fits of "the blues" were getting deeper and the intervals growing shorter to be roused from her condition when all means had failed by the elopement of a daughter who had been partly pushed into leaving because things had become so unpleasant around home {644} during her mother's depression, and any change seemed welcome. On the other hand, I had a doctor friend who felt quite alarmed about his growing depression and who even had some fears lest, if it continued to deepen, he might commit suicide. He was completely lifted out of his increasing depression by the occurrence of pneumonia in his boy of sixteen. The pneumonia did not end by crisis but by lysis and for weeks he had very little sleep. He confessed that the intense preoccupation of mind had completely driven away his blues and had even done much to relieve him of various digestive symptoms to which he had previously attributed his depression.

Again and again I have known men who, in the midst of prosperity, found life dull and rather hard to bear, and who just as soon as a crisis in their affairs compelled them to pay attention to other things than themselves and the state of their feelings, grew better mentally and physically. It seems almost a contradiction in terms to say that it is the man of little occupation, as a rule, or at least of occupations that are not insistent, who is likely to be troubled with insomnia, while the very busy man, especially the man busy not about one or two narrow interests, but about a number, is seldom so bothered. Nothing contributes more to the depression of mind than loss of sleep or supposed loss of sleep. Even women who, while living in ease and comfort, had much to complain of as regards depression, often lose entirely their tendencies to "the blues" or have fits of them at much longer intervals, when necessity compels them either to earn their own living or, at least, to occupy themselves much more with absolutely necessary duties.

Provision of Occupation.--It is a hard matter to create such occupation of mind as will be satisfactory. Patients have to be tried by various suggestions. The tendency to periodic fits of depression deep enough to be called to the physician's attention is much more noticeable in recent years than it used to be, and seems to me at least to bear a corresponding ratio to the decrease of home life. Home duties usually mean joys and of late there has been a neglect of the joys of life while seeking its pleasures. Certain phases of city life are responsible for much dissatisfaction with existence and depression of spirits. Most of the women who live in apartment hotels have practically no serious occupation of mind. They need not get up if they do not feel quite right or quite rested--and who after the age of forty ever does feel quite all right in the morning hours unless sleep has been in the open air? Nothing is so likely to start a day of depression than failure to get up promptly, lounging around with forty winks here and there, reading in bed, and the like. If breakfast is taken in bed, then some reading indulged in, and then some sleeping, and only an hour or two of dawdling around comes before lunch, that meal is not properly enjoyed and the afternoon is started badly; unless there is some special diversion of mind depression is almost sure to get the upper hand.

Place of Children in Psychotherapy.--Where there are children the interests are much more urgent and there is little time for such preoccupation with self as gives one "that tired feeling." We are very interesting to ourselves, but just as soon as we have no other subject to occupy us than ourselves we soon grow very tired of the subject. Children are the best interest that one can think of, for women particularly. When they have none of their own an interest in orphan asylums, in day nurseries, in various children's {645} institutions, and, above all, in the adoption of a child, will do more than anything else to relieve the tendency to blues. Of late years the adoption of children has been much less frequent than used to be the case in childless families, and doctors see the result in mental depression. Children are a great care, but they are a great blessing to women, and while the present trend of social life eliminates them as far as possible, this elimination, beginning with their relegation to nurses when they are infants, to nursemaids as they grow a little older, and then to the kindergarten up to six years of age, far from adding to comfort rather increases the discomfort of many mothers. Nature takes her revenge. The reason why the mothers of past generations could stand the suffering that they must have borne with patience before gynecology developed to relieve them, was that they had their children around them, and their minds and their hearts and their hands were so full that they had no time to think of themselves, to brood over their ills, and consequently these troubled them much less than would otherwise have been the case.

Delicate mothers really interested in their children undoubtedly suffer very little compared to delicate women who are alone in life, and what is thus true of the mother is true also of those who have the care of children. It is not alone a satisfaction of the maternal instinct, but it is an occupation of mind and heart with cares for little ones. Other people's children serve just as good a therapeutic purpose, if only their necessities are imposed on the attendant. The reason why women in religious orders have such happy peaceful lives and are happier in spite of a routine of life that would seem to be fatal to happiness, is that their minds are filled with the interests of others, every moment of their time is occupied, and, above all, they have to care for children, the ailing, the poor, sometimes the vicious, who make many demands on them, many calls on their sympathies and keep them from thinking about themselves.

Occupation with Living Things.--After occupation with human beings the most important therapeutic factor against periods of depression is occupation with living things of various kinds. Horseback riding is an excellent remedy for the blues and the outside of a horse in the old axiom is literally very good for the inside of man or woman. There is a sympathy between man and animal that in itself means much, but the most important element is the absolute impossibility of preoccupation with oneself and one's little troubles and worries while one is trying to manage a somewhat restive animal. If the horse, however, is old and very quiet--so that one can throw the reins on his neck and allow him to jog on for himself, then horseback riding may mean very little. Where the care of the animal is entirely taken off the rider's shoulders by a groom who brings him to a particular place and takes him afterwards, then, also, much of the benefit of horseback riding is lost. Care for other animals as well as the horse is of great service and especially is this true if the owners feel the duty of exercising the animals. Many a downhearted person finds that to take an animal out for a stroll will do much to lift the clouds of depression.

With the disappearance of children from the families of the better-to-do classes, pet dogs have grown in favor mainly because of this influence. They awaken sympathies and so keep people from thinking too much about themselves, For many an elderly woman who is alone in the world her dogs or her {646} cats or a combination of both are the best possible remedies for depression. At times it will be found necessary to prescribe them. There is no better way to get an elderly person to go out at certain times than to have them feel that their pets need exercise.

Garden Cures.--After animals the next best thing is the care of a garden. Here once more human sympathies with living things are aroused and it is easier to cultivate a forgetfulness of self while cultivating flowers and plants. Growing plants do not arouse the interest that growing animals do, but still they have advantages over things that do not vary, and their growth is a subject of day-to-day interest and the effect on them of vicissitudes of the weather arouses feelings of solicitude which help to dissipate the little insistent cares for self that depress. The care of a garden is the very best thing for the "pottering old." Younger people are too impatient to get much benefit out of a garden, but after middle life many an hour of depression will be saved in the care of plants.

Intellectual Occupations.--It might be expected that intellectual occupations would serve to brush away "the blues" for educated people. They are perfectly capable of doing so, but they must be of the kind that grip attention and must be undertaken seriously, usually with an appeal quite apart from mere cultural interests. Hobbies of various kinds, especially the making of collections, even of such trivial things as stamps, will often serve the purpose of distraction from gloomier thoughts. Unfortunately, a hobby cannot be created all at once and usually does not take a strong enough hold to be available for mental therapeutic purposes unless it was acquired when the person was comparatively young and has been indulged in for many years. Reading and study utterly fail unless there is some end in view apart from the reading and study itself. The reading of novels and newspapers is particularly likely to be a failure. The gloomier thoughts obtrude themselves in the midst of the reading and very often what is read proves suggestive of melancholic thoughts and all the time the mind and the person are not occupied seriously enough to push away the state of depression which exists. The mind must be interested, not merely occupied superficially, or the depression will continue.

It might be thought that the reading of books that concerned human suffering might have a similar appeal to that to be obtained from real touch with human suffering. This is true to a certain extent when the books concern real and not fictitious suffering. For this reason the trials and hardships of travelers at the North and South poles or in the heart of tropical Africa--Nansen and Peary and Stanley and Livingston--have all been excellent therapeutic agents. The stories of mountain climbers have something of the same effect. Adventures in Alaska and in the Far North, especially, come in the same category. Novels, however, even though they use the same material, soon fail to have a corresponding effect. Even when the novel does touch the emotions deeply it is prone to make the reader forget the suffering around him and does not prove a good diversion from his own feelings. In his play, "The Night Asylum," Maxim Gorky, the Russian novelist and playwright, brings this out very well. One of his characters, a young scrubwoman, wears her fingers to the bone during the day for a miserable pittance and sleeps in a squalid night lodging house, yet this comparatively young creature, {647} crouched near the only light in the room, sheds tears over the imaginary sufferings of the fictitious people that she reads about, while the real human suffering around her fails entirely to arouse her sympathy or affect her emotions, except to anger her if lodgers come in between her and the light or when the complaints made by some of those who are suffering around her annoy and distract her from her reading.

In younger folks, study, provided there is some definite object to be attained by it, is often helpful. Correspondence schools are of value by setting a definite purpose before the mind. In a number of cases I have found that the suggestion to make translations from a foreign language when the patient knew that language even tolerably well, afforded excellent relief from that over-occupation with self which was the real cause of the depression. There are many people who know enough French to be able to translate fairly well and there are many articles and books a translation of which may at least be submitted to editors and often proves available for publication. To have some such end as this in view is of itself one of the best means that can be provided for these people to relieve their tendency to depression. Occasionally even the suggestion to write stories may prove helpful. One hesitates to add to the number of story-writers in this country, but it may be remembered as a last resort. I know at least two people saved from themselves by even a very moderate success as writers of short stories.

Consolation from History.--Perhaps the most serious thing about depression is the feeling of those afflicted by it that they are singular in this respect and that other people who seem gay never have depressed states. There is probably no one who has not periods of depression. They may not be very deep and "the blues" may be only of a light tinge, but they are there. The higher the intelligence, as a rule, the more tendency there is to feelings of discouragement and depression at intervals when one is not occupied. Those who have the artistic temperament and the striving after the expression of the beautiful as they see it, whether it be in art or in letters or in the betterment of humanity, usually suffer more than others because they realize poignantly their failure to reach their ideals. This is well illustrated by the experience of writers and artists. As a rule, most men and women look forward to the completion of any intellectual work with confidence that after it is finished they will have a period of rest and peace. Commonly just the opposite is true. The completion of any work leaves one with a sense of dissatisfaction with what has been done, for no man of real intelligence ever thinks that he has so realized his ideals as to be satisfied, and only the foolishly conceited fail to feel the many defects that there are in their work.

There is abundance of evidence, however, that it is not alone artists and writers who thus feel the hollowness of life and the tears there are in things. Many of the men who have accomplished great things in science and in politics have been prone to times of depression. Virchow told me there were moments when life seemed very empty to him and that he had to shake off feelings of depression in order to be able to go on with his work. At one time in the sixth decade of his life he suffered considerably from what we would now call neurasthenic symptoms, gave up his medical work and spent a long time with Schliemann in the Troad. His presence was valuable to the excavator in his work at Troy, and the change gave Virchow back his health.

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Even more striking is what we know of Von Moltke, who seemed in many ways to have an ideally happy life. He had had the fulfillment of all his desires or, at least, the fruition of all his hopes, and the successful accomplishment of what he worked for beyond what is usually given to man. He had come to be one of the most highly respected men of Europe and was the subject of veneration on the part of his own German people and of intimate affection from his sovereign, who loaded him with honors. He was a man who had probably no enemies and many, many firm friends. It was said that "he could keep silence in eleven languages" and so he had avoided most of the pitfalls of life. His domestic life was ideally happy and his letters to his wife for over fifty years read like those of a lover, before all his great battles his last thought and written word was for her, after them his first thought and message was for her. In spite of this, towards the end of his life, when the question of reincarnation was a subject of discussion in Berlin and it was brought particularly to his attention, he declared that looking back on his career, in spite of all its good fortune, there seemed to him to be so many chances in life, so many possible sources of failure, so many springs of discouragement, that he would prefer not to have to live again. Surely, if anyone, he might be expected to be ready to take the chances of re-incarnation after such happy experiences of life, yet he was not. Such an expression could only come from a man who had looked depression often in the face, who had shaken off the blue devils and who knew that even the joy of success was followed by the gloom of uncertainty as to the future and solicitude as to the real significance of accomplishment.

Literature and Life.--We have many examples of this tendency to depression that come to the literary man in the lives and letters of distinguished writers that have been published so frequently in recent years. Perhaps one of the most striking is to be found in the life of Robert Bulwer Lytton, the second Lord Lytton, so well known as a diplomatist in European circles and throughout the English-speaking world as a poet, under the pen name of "Owen Meredith." [Footnote 51] It might be thought that Lytton would be one of the men safely harbored from storms of depression and discouragement, for his life seemed ideally situated to enable him to get the best out of himself without worry or dissipation of energy in occupation with mere personal matters. His father had made a distinguished success as a literary man and a politician, had been raised to the peerage and the son began life with every possible advantage. He made a distinguished success in literature so that he even converted his father to praise him and as a diplomatist he occupied nearly every important post in English diplomacy and had hosts of friends all over the world.

[Footnote 51: Personal and Literary Letters of Lord Lytton, edited by Lady Betty Balfour. New York, 1909.]

It is all the more surprising, then, to have many passages in his letters refer to periodic attacks of depression. He says, for instance, "My physical temperament has a great tendency to beget blue devils and when those imps lay siege to my soul they recall those words of Schopenhauer's and say to me 'thou art the man.'" Perhaps the price that the artistic temperament pays for the satisfaction that it gets out of life in other directions is this occasional tendency {649} to depression because achievement does not equal aspiration. Certainly the price often seems excessive to those who have to pay it. In the same letter to his daughter, Lytton continues:

When my blue devils are cast out, and I recover sanity of spirits, then I say to myself just what you say to me in your letter--that the main thing is not to do but to be; that the work of a man is rather in what he is than in what he does; that one may be a very fine poet yet a very poor creature; that my life has at least been a very full one, rich in varied experiences, touching the world at many points; that had I devoted it exclusively to the cultivation of one gift, though that the best, I might have become a poet as great at least as any of my contemporaries, but that this is by no means certain to me for my natural inclination to, and unfitness for, all the practical side of life are so great that I might just as likely have lapsed into a mere dreamer; that the discipline of active life and forced contact with the world has been specially good for me, perhaps providential, and that what I have gained from it as a man may be more than compensation for whatever I may have lost by it as an artist.

It is surprising to think of a man of this kind becoming so depressed by the death of a son that all the world and the meaning of life took on a somber hue for him. In 1871 Lord Lytton lost a young boy by a very painful illness which had probably been more painful for sympathetic onlookers than for the patient himself. The incident proved sufficient, however, to make the father think that there could not be a beneficent Providence ruling over the world. He felt sure that somehow God's power must be shortened, if such suffering, for which he could see no reason, had to be permitted. He was much depressed after this and never was quite the same in his outlook upon the world and the significance of life. It was easy to understand that this was due rather to his character than his intellect, but it illustrates forcibly how much a deeply intelligent man may be affected by something that seems after all, only the course of nature.

It is sometimes surprising to find from the life stories of men how often those who would be thought least likely to suffer from periodical depression were victims of it. Few Americans in our time have apparently had a more satisfying career than that of James Russell Lowell, a successful author as a young man, then a successful editor, a teacher whom his students appreciated very much, and in later life the subject of many honors and such honors as provided him with splendid opportunities for the exhibition of his special genius. He would seem to be the last who should suffer from depression. His post as Minister to Spain gave him an opportunity which he took magnificently to study the great Spanish authors and to store up material for writing about them. As Minister to England few men were so popular. He was constantly in demand for occasional addresses and his special style enabled him to respond to these demands with brilliant success. Here in America no great occasion was complete without Lowell. In spite of all this that would surely seem ample to satisfy the aspirations of any man, Lowell was often depressed and sometimes even talked about the possibility of suicide. Life seemed at times very empty to him. The story of the lives of such men, if made familiar to patients, proves a source of consolation, for it makes them realize that they are not alone in their experiences, that depression at some times is the lot of man, and that very few people are without the sphere of its influence.

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Depression an Incident, not a State.--This suggestion may, in the case of some of those inclined to longer periods of depression, lead to indulgence in the luxury of being depressed and so putting off the doing of things. It must be pointed out, however, that just inasmuch as depression has this effect it is pathological. It seems to be natural to man to suffer from periods of discouragement and depression which keep him from devoting himself too persistently to lines of work that may be insignificant and make him take cognizance of the real values of what he is doing. Depression, however, that continues after the recognition of this takes place is morbid and must be actively resisted. Just inasmuch as depression precedes and prepares patients for a reaction, it is an incident in practically all lives. Indulged in as a luxury, it is abnormal.

Suggestive Treatment--The most important thing for patients who suffer from periodic depression is to make them understand that this state of mind, far from being personal to them or very rare, or even uncommon, is an extremely frequent experience of men and women. There are certain men and a few women eminently occupied with the external life, busy with many things, though often they are trivial enough, and even when they are important, significant only in a financial or a social way, but meaning nothing for the great realities of life, who seem during their younger active years to escape the periodical attacks of depression that come to most people and come almost without exception to people who think seriously. Some of the best thoughts and inspirations of men come to them as the result of the serious mood that follows an attack of depression. A butterfly existence lacks these sources of inspiration. Far from being objectionable then, attacks of depression, if not allowed to proceed too far, and if kept from paralyzing activity, prove to be intervals when life values are seriously weighed and when a proper estimation of such values is come to. Men are prone without such interruptions to get too interested in trivial concerns that seem to them important because they are occupied with them to the exclusion of other ideas, but that prove to be of no real import when seen on the background of a certain hollowness that there is in human life, if lived merely for its own sake.

The occurrence of periodical depression is a part of the mystery of life and it affords us a better opportunity to get a little closer to the heart of the mystery than almost anything else. It is out of such periods that men have risen "on stepping-stones of their dead selves to higher things" and have even risen to the highest that there is in life. Geniuses have nearly always had deep periods of depression, but in the midst of them have read new meanings into life and have read the lessons of humanity in their own souls better than at any other time. Depression throws a man back on himself and makes him think deeper than in his mind--in what has been called his heart. "The fascination of trifles obscures the good things in life" are words of old-time wisdom and men are weaned from this by fits of depression that are really moods of precious dissatisfaction with their work inasmuch as it falls short of the best accomplishment. Without periodic depression, apparently, a man never gets as close to the heart of life as he otherwise would. Far from being an unwelcome visitant, it should be rather welcome as a stimulus to the possibility of further study of self and the realities of life.

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