VII. INSOMNIA…

VII. INSOMNIA

To the minds of many people insomnia is one of the most serious ills to which human nature is heir. Most of this quite false impression is due to the sensational cultivation of dreads with regard to insomnia by newspapers and in general conversation. If we were to credit such impressions, there is a certain number of unfortunates who, for some unknown reason, find it impossible to sleep and who, night after night, drag out the weary hours wooing sleep that does not come, until when daylight dawns they are in despair, distracted by lack of rest. This is presumed to occur night after night, until finally the worn-out mind succumbs to the intolerable anguish of being kept constantly on the rack of wakefulness and the patient becomes insane or saves himself from that by suicide. No wonder, then, that many a one of these patients takes to the use of habit-forming drugs to produce sleep. These, though effective only to a small degree, soothe him for the time, but finally render him such a wreck that there is not even will power enough for him to take his own life and end his intolerable suffering.

Such gruesome pictures of the awful effects of insomnia run rife and produce dreads in the community until just as soon as the ordinary nervous supersensitive person loses an hour or two of sleep two or three nights in a month, he begins to conjure up the specter of insomnia with its awful terrors and still more awful possibilities, and begins to bewail the fate that has chosen him as an unfortunate victim. This exaggerated dread that slight losses of sleep, for which there are often excellent reasons, will develop into an incurable condition of persistent wakefulness has more to do than any other single factor with the production of the state called insomnia which is, however, never half as bad as it is pictured.

Absolute Sleeplessness.--A certain number of patients insist that they sleep very little at night and some tell their friends and even their physicians quite ingenuously that they sleep none at all, and that this has been the case with them for a prolonged period. Practically every physician has heard such stories, and at the beginning of his professional career has usually wondered how the patients continued to live and enjoy reasonably good health in spite of the lack of absolutely necessary brain cell rest. After the physician has the opportunity to investigate some of these stories he understands them better. Patients in hospital, who insist that they are wakeful all the night, prove usually when faithfully watched by a nurse to be wakeful for an hour or two at the beginning of the night and then to sleep for hours at a time, and all of them sleep for intervals more or less prolonged, though they may wake a number of times during the night and may think that they have not been asleep because they hear the clock regularly or some other recurring noise. It is improbable that patients ever spend several nights in succession without sleep and their story is only an index of the persuasion that they are under that they do not sleep, though they are having so many thoroughly restful intervals that their brain cells suffer but little from {652} the need of sleep. Indeed, the principle source of nervous wear and tear for them consists in their persuasion that they do not sleep and the resultant impelling suggestion that a breakdown must before long be inevitable.

Individual Differences.--There are too many safeguards in nature's ordinary dealings with human beings for us to think that people can pass many nights absolutely without rest. Brain cells may apparently be very wakeful, they may be quite ready to take up at once and seemingly without a break trains of thought interrupted sometime before, yet somehow they succeed in obtaining their needed rest. In this matter, as is well known, though it needs to be emphasized again for the benefit of nervous individuals, different people have very different needs. Some require many continuous hours of sleep or they soon begin to have symptoms of nervous exhaustion. Others live on only with snatches of sleep at intervals, or with interrupted sleep during a limited portion of the twenty-four hours, yet enjoy good health for many years. A few seem to be able to live in health and strength with but a few hours of sleep. It may possibly be thought that those who are living their lives with a small amount of sleep are drawing drafts on their future vital powers, and that what they make up in intensity of activity now by shortening sleep, they will discount by shortness of life. How utterly untrue this impression is, however, will be best understood from the fact that many of the men who have worked hardest and slept the least number of hours in the day, have lived to be eighty or even ninety years of age and some of them have even been centenarians.

Cell Rest.--The great differences in the brain cells of different individuals in what concerns sleep becomes more readily intelligible when we recall the extreme differences as regards the need of rest of the various cells in the same individual. While the brain cells seem to require for healthy life, as a rule, nearly one-third of the time, and a man who is constantly taking much less than eight hours of sleep is probably hindering rather than helping his productiveness, especially if his work is intellectual, there are cells in the body that need no such amount of rest as this. Peristaltic movements occur in the digestive tract almost constantly, with only short intervals, and these cells get their rest between their movements. Pulmonary cells and tissues must do the same thing, and are able to do it without any special strain being put on them. The extreme example of the lack of need for prolonged rest is found in the heart. Two-fifths of every second the cells of this organ have a rest during the diastole, but during the remaining three-fifths of every second for all of life they must not only be ready to work but actually engaged in it or serious symptoms ensue. The cells in the brain that subtend cardiac and respiratory activity must be even more able to do without rest, since their action is ceaseless during life. By analogy with these it is not difficult to understand that the brain cells which are involved in consciousness should on occasion be able to stand prolonged periods of activity, or at least of wakefulness. Persistent wakefulness does not appeal to us as so surely destructive after this consideration.

Solicitude Over Sleep.--For those who are much disturbed by the loss of even slight amounts of sleep and who are prone to complain rather bitterly if they are not able to get more than five or six hours a night, I find it a useful preliminary to any more formal treatment of their so-called insomnia {653} to recall the examples of some of the great workers who succeeded in accomplishing marvelously good work though they took much less sleep than the amount the patient secures, yet seems to think inadequate. In spite of such lack of sleep, these workers lived to advanced old age. There are many well-authenticated illustrations of this in recent times. Perhaps the most striking testimony to the power of the human mind to continue work without requiring the refreshment of sleep, except for very short periods, is that of Humboldt, the great traveller, scientist writer and diplomat. Max Mueller, in his autobiography tells the story. It was when he himself was about forty. Humboldt said to him: "Ah! Max, when I was your age I had time to accomplish something, now I find that I must take at least five hours of sleep every night." At the moment Humboldt was over eighty. Mueller said to him: "But, Your Excellency, how much sleep, then, did you take when you were my age?" "Oh!" he said, "I used to turn the light down, throw myself on the lounge for a couple of hours, and then get up and go on with my work again." Humboldt, after a life full of the hardest kind of work of many kinds, lived well past ninety in the full vigor of his intellectual powers.

There are many other examples that might readily be quoted. The traditions of the University of Berlin contain many illustrations of men who did very little sleeping, yet succeeded in accomplishing an immense amount of work and lived far beyond the Psalmist's limit. Virchow, whom I knew very well, did not take more than four or five hours of sleep on most nights in the year. He would be in the Lower House of the Prussian Legislature, which, like the House of Commons, holds its meetings late at night, until one A. M. or later and would be at his laboratory shortly after seven. There was a tradition at the University of Berlin in my time there of one of the older professors in the theological department who went to bed only every alternate night. He had a forty-eight-hour day for work with a seven-hour break. He lived to the age of eighty-five. I know one of our most distinguished workers in medicine here in America who was so busy and so tired at the end of his day that he could not write his book. He would fall asleep on his chair at his desk to wake up only when the milkman came in the morning. He had constructed for himself a special stool without back or sides, shaped like a bench, so that whenever he fell asleep on it he fell off. The fall would wake him up and he would then go on with his work for some hours. He did this sort of thing for many years, and yet he is alive and in the full possession of intellectual health at the age of eighty-three. He learned this expedient from a German professor of medicine who told him of it and at the same time told him that it was no uncommon practice among German professors. Indeed, most of the famous long-livers of the nineteenth century were also well known for the small amount of sleep they required, and apparently there is no need of being anxious lest loss of sleep should prove serious, unless one is adding to whatever detriment to health it may be by worrying about it find so setting two damaging factors at work.

TREATMENT

Probably the most important immediate assurance that can be given to those who come complaining of insomnia is that practically no one has ever {654} been seriously hurt by the wakefulness called insomnia. Patients suffering from brain tumors, from serious disturbance's of cerebral circulation that give objective signs, from various organic diseases, as of the heart or liver, or certain constitutional diseases, have been made worse by the wakefulness induced by their affections. In the cases where there were no definite objective signs and wakefulness was the only symptom we have no cases on record of serious injury resulting. Men have come complaining of wakefulness for days or weeks and sometimes, though it is strange to understand it, for months or even years, and yet have lived their lives without serious developments and have neither gone into insanity nor into any premature loss of vitality, much less a fatal termination. It is not subjective symptoms but objective signs that are of value for the diagnosis of the serious organic conditions. This reassurance lifts a load from patients' minds at once and does more than anything else to relieve them of the burden of solicitude which is the main factor in the continuance of their insomnia.

Suggestive Treatment.--The psychotherapy of sleep consists in changing the patient's attitude of mind toward his sleep. It is quite impossible for him to sleep normally and regularly if he worries much about it and if the afternoon and evening hours are mainly spent in wondering whether he will sleep, anxious as to when he is going to sleep like other people, marvelling how long he will last in health and sanity if his tendency to wakefulness continues. There is no factor so strong in insomnia as getting one's self on one's mind. It weighs as an intolerable burden, an incubus that is sure to keep its subject awake. Insomnia is a mental and not a physical ailment in much more than nine out of every ten cases. It is not the brain but the mind that is at fault. Patients must be made to realize that if they go quietly to bed, confident that if they do not sleep the early part of the night they will sleep later, and that in case they should lose considerable sleep, so long as they lie quietly for eight hours in bed, their physical organism is not likely to come to any serious trouble. They must be quiet, peaceful and unworried. They must not begin to toss at the first sign of not going promptly to sleep for by so doing they may put off completely the possibility of falling to sleep. Finally they must prepare for sleep by passing a quiet evening, as a rule, occupied with diversions of various kinds.

There are many factors which inhibit sleep that must be removed or at least obviated. These are very different in different individuals and the suggestion of getting them out of the way helps a great deal in making people realize that they are better prepared for sleep than before. They have been keeping themselves awake by contrary unfavorable suggestions. They must be taught to aid themselves in going to sleep by a series of favorable suggestions attached to the doing of certain things that are helpful and, above all, avoiding acts of various kinds that have an unfavorable suggestive influence. In this way an accumulation of suggestions can be secured that will prove helpful.

Drugs.--Of course, patients must be warned with regard to the taking of drugs. Certain drugs may be taken for an occasional loss of a night's sleep, where the loss of sleep is regular and frequent, however, drugs are sure to do more harm than good. Opium leads to a serious habit, chloral is dangerous because it must be increased, most of the coal-tar somnifacients produce {655} serious after results and their physical effect is in the end probably more deleterious than would be the loss of the sleep which they are supposed to counteract. This is true for even the vauntedly least harmful of them, and it is important to make patients understand it.

External Conditions to be Inhibited.--In the treatment of insomnia two sets of inhibitory conditions are particularly to be looked to, those external to the patient, and those internal. Unless every possible obstacle is removed there can be no assurance of the relief of sleeplessness, while very often the careful regulation of a few conditions that are disturbing the patient will bring sleep fully and promptly. It is curious what small annoyances will sometimes prove disturbing.

No Pillow.--I have found patients who had heard somewhere the idea that it was natural for man to sleep without a pillow. The pillow in this theory was supposed to be an added refinement of men in a state of luxury, but a real degeneration opposed to nature, and the many presumed benefits of sleeping on a perfectly level mattress with the head no higher than the rest of the body was emphasized. While in ordinary health these patients had found that after the preliminary discomfort of getting used to sleeping without a pillow, they were apparently the better for it. People will feel better for almost anything if they are only persuaded that they ought to. After a certain length of time, however, worry or work had a tendency to keep them more or less wakeful and then insomnia came on, that is, for several hours at the beginning of the night they did not go to sleep and became very much worried about it.

In several of these cases I have found one of the most helpful adjuncts to more direct treatment of their wakefulness was the restoration of the pillow. Just how the hygienic theory of pillowless sleep originated, or on what it is supposed to be founded, I do not know. The only theory of sleep that seems to have many adherents at present is that it is due to brain anemia. With the head a little higher than the rest of the body the force of gravity tends to help in the production of this brain anemia. The experience of mankind seems to confirm this. Certainly, from the earliest records of history men have slept with something under their head, even though they could find nothing better than a log or a stone. To sleep without a pillow is, owing to the conformation of the head and neck and shoulders, almost inevitably to sleep mainly on the back. From the anatomical relations of the internal organs it is easy to understand that sleeping on the side is more comfortable and healthy than sleeping on the back and hence most people naturally take this position. Relaxation is much more complete and comfort is greater. What the majority of men do is almost surely dictated by instinct, and instinct is the most precious guide we have in the natural functions of life. We are not so differently formed from the animals that the analogy from their habits should not have some weight for us. Patients should then be advised always to sleep with a reasonably firm pillow, not too low, so that the head is a little higher than the body and the lateral position perfectly comfortable.

Too high Pillow.--There is an abuse in the other direction of too high a pillow that deserves to be noted. Occasionally the physician hears complaints of waking up with tired feelings in the large muscles of the back of the neck near their insertion into the occiput. This is sometimes complained of {656} as an occipital headache. Not infrequently it will be found that these people are sleeping on pillows that are too large, or that they pile up several of them. Most physicians have found in their experience that having the head quite a little higher than the rest of the body materially aided sleep, especially in elderly people. This is true even when there is no distinct heart lesion, but this favorable position is best secured not by means of one or more high pillows, but by raising the head of the bed, or by the insertion of bolsters beneath the mattress, so that there is a gentle slope upward from the hips to the head. High pillows should, as a rule, be discouraged, especially in young folks where the assumption of the strained positions which they cause, may encourage various deformities in the anatomy of the head and shoulders so that stoop shoulders or a craned neck result. On the other hand, before attempting to give drugs to elderly people, the arrangement of the mattress so as to put the head a foot, or even more, higher than the body should be tried and will often be found to give relief where other things fail.

Discomfort Due to Cold.--In order to sleep well patients must be thoroughly comfortable in bed. In recent years as the very hygienic practice of having a window in the sleeping apartment open has become a rule among intelligent people, sleeping rooms have been much colder than they used to be. Care must be taken lest the active factor in causing wakefulness should be cold. Over and over again I have found that patients who complain of wakefulness, in the latter part of the night particularly, that is, in the early morning, were awakened by the increasing cold because they were insufficiently clothed. Whenever the sleeping room becomes very cold, then, the patient should not sleep between cotton or linen sheets which are likely to induce sensations of chilliness, but in a light woolen nightgown. It is curious what a difference in the patient's feelings is produced by the touch of wool to the skin in cold weather as compared with cotton. Thin, anemic patients are especially likely to suffer from chilliness. It must not be forgotten, however, that some stout people, in spite of an accumulation of fat, are really anemic. Their red blood corpuscles and hemoglobin are distinctly below normal. These constitute some of that large class of stout women in whom reduction cures fail because of the anemic tendency. They must be as carefully protected from cold as thinner persons, yet they need fresh air for their comfort and health almost as much as tuberculosis patients. The experience of sanatoria in the Adirondacks and at altitudes generally shows that for quiet, undisturbed sleep, if the room becomes distinctly cold during the night because of an open window, a hood or night-cap and gloves, as well as the wearing of woolen underclothing, even to stockings, is almost indispensable. In older times, when houses were not well heated, many persons very sensibly wore night caps. Now that a return to cold fresh air in the sleeping room has come many will have to resume the old night-cap habit in spite of cosmetic objections to it. These may seem little things, but they count very much in relieving disturbed sleep. The curious thing about them is that patients themselves seldom realize that certain common-sense regulations are more important for sleep than formal remedies. They want to be "cured" of their insomnia, not relieved by suggestion.

Cold Feet.--A large number of people have their sleep at the beginning of the night seriously disturbed by cold feet. Some cannot get to sleep for {657} an hour or more, because their feet are cold. If the patients become worried over this loss of sleep, a real insomnia may develop. It is for these people that the old-fashioned warming-pan was invented and it should not be forgotten that the symptom can be relieved very promptly by means of a hot-water bag or a hot brick wrapped in flannel at the foot of the bed. An excellent practice for very sensitive persons, is to have the sheets warmed thoroughly for a couple of hours before bedtime. This is especially important in damp weather.

The distinguished English surgeon. Sir Henry Thompson, who lived well beyond eighty years of age (when surely he would seem to have some right to do so), wrote a little book on how to be well and grow old and describes a habit which he had acquired and that I have often recommended to patients and friends as well as used myself with advantage when there is a tendency to cold feet, either habitually or occasionally. It is, moreover, useful whenever there is a tendency to insomnia because some exciting occupation has preceded going to bed. Before retiring Sir Henry used to sit beside his bath tub and let the hot water flow into it over his feet, gradually becoming warmer and warmer, until he could no longer stand the heat. A temperature well above 120 degrees may be borne with comfort after a while, though at the beginning it would seem entirely too hot. The feet are kept in the hot water at least five minutes. When taken out they should be thoroughly red and show evidence of a good deal of blood having been attracted to them. If they are now carefully wiped and rubbed vigorously there will usually be no further tendency to cold feet that night and sleep will come naturally. Sir Henry said that when he had been out at meetings where he had to make an address or had to take part in business of any kind that inclined to make him wakeful, he found this an excellent method of preparing himself for immediate sleep.

It must not be forgotten that the worst forms of cold feet are found among those suffering from flatfoot. The dropping of the arch interferes with the return circulation and also with lymphatic circulation. These individuals feel very tired because of their foot condition, yet their cold feet often disturbs their sleep at the beginning of the night. The only effective relief for this is afforded by proper treatment of the feet. (See the chapter on Foot Troubles.)

Lack of Air.--On the other hand, occasionally it happens in spite of all that has been said in recent years about fresh air in sleeping rooms, windows are hermetically sealed and even then people cover themselves with many thicknesses of bed clothing and are too warm. I have found over and over again that where people could not be persuaded to leave a window open all night (and when they are old and deeply prejudiced in the matter I do not insist, for the suggestion of possibly catching cold would almost surely keep them awake), the thorough airing of rooms before retiring made a great difference in the sleep of elderly people. When patients are young, I simply insist on the window being wide open for some time before they go to bed and slightly during the night, except in extreme cold weather. Many a patient who complains of waking several times during the night and being awake for some time on each occasion will begin to have longer periods of sleep without a break if such a change in the ventilation of the room is effected. {658} Anyone who has seen fever patients who had been restless, disturbed and wakeful, sink into a quiet slumber after the room has been thoroughly aired and the temperature of it reduced ten or fifteen degrees, will realize how helpful this same method of treatment will be in nervous, wakeful irritability.

How important air is for the obtaining of the power to sleep for many hours every day can be best understood and appreciated from the habits insisted on for patients in tuberculosis sanatoria as a result of experience. When there is any tendency to a rise in temperature in these patients they are kept absolutely without exercise. They are either in bed or on a lounging chair all day, but they are out in the air or at least close to an open window. As a rule, they sleep some in the morning and then they sleep again in the afternoon. This would ordinarily be fatal to sleep at night in even healthy people taking considerable exercise and therefore presumably tired and more likely to sleep than these patients who had made no exertion during the twenty-four hours; but it is not often, after patients have been for ten days or two weeks at the sanatorium, that there is any complaint of lack of sleep at night. This is true in spite of the fact that patients are often wakened by coughing during the night, yet after a comparatively short interval they go to sleep again and sleep until morning. This is not true when patients do not pass most of their time in the open air and when their rooms are not well aired.

Sleep at Sea.--I know nothing that is more effective in doing away with insomnia than a sea voyage. The passengers sit on their lounging chairs all the morning in the open air, usually sleeping for some time, often for several hours. During the afternoon this is repeated. In spite of this extra sleep they turn in, not long after ten, and sleep well until morning. There is practically no exercise and the air usually excites such an appetite that five and even six meals a day are consumed. There is no disturbance of digestion unless some special excess is indulged in, and, above all, sleep is rather favored than impaired by the large amount of food taken. This experience which is so common, is very valuable as indicating just what is the best pre-requisite for sleep. It is not exercise and tiredness to such a degree that one fairly drops from fatigue, but such an oxidation of all tissues by the breathing of pure air that there are no toxic waste products left in the system to act as excitants for disturbance of sleep.

Cold Water.--In summer, when wakefulness is due to heat, a cool bath, or at least a rub down with cold water and going to bed without drying is an excellent method of inviting sleep. Under these circumstances the sheet acts as a soothing cool pack and people who have been wakeful for hours before, or at least have found considerable difficulty in getting to sleep, sleep promptly. The mechanism of sleep-production is easy to understand. There is less blood to go to the brain when the little capillaries at the surface are pretty well extended and after the application of cool water the reaction which follows the closing of the capillaries in response to cold leaves them of sufficient size to accommodate a large amount of the blood of the body. Of course, in both cases there is the suggestive value of a proceeding of this kind so well calculated to predispose the patient's mind to go to sleep without solicitude.

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Diet.--As has already been outlined in the hints that precede, the first thing in the treatment of insomnia is to remove any causes that may be at work in producing wakefulness. Among the most common of these in our modern life is the taking of coffee or tea, important in the order mentioned. Every physician has frequent experiences of people who complain of insomnia, yet who take a cup of coffee late at night. A large proportion of humanity cannot do this with impunity and expect to go to sleep promptly. Occasionally one finds that patients complaining of sleeplessness are taking three to five cups of coffee a day. This must be stopped. A physician may be told by such patients that they cannot get along without their coffee. I have only one answer for this and it is meant to show patients that if they want to sleep they must take the means to secure it and, above all, must remove all disturbing factors. I tell them that if they cannot do without coffee they may continue to do without sleep. If they want to sleep they must give up coffee or at least must limit the amount. I have found it comparatively easy to get people to limit coffee-taking by the suggestion that there should be one tablespoonful of strong coffee taken to a cup of hot milk. This gives the taste, or rather the aroma of coffee, for coffee has properly no taste to speak of, and while, at first, patients crave the stimulation they have been accustomed to, it takes but a few days to overcome this craving entirely.

Usually it is easy to get people to confess that they are taking too much coffee. For some reason not easy to understand it is harder to get them to acknowledge that they are taking too much tea. Coffee is taken with a certain amount of deliberation. Tea may be and often is taken at odd intervals for friendliness' sake and sometimes patients do not know how much they are taking. Six or seven cups a day may be their usual quota, yet they do not realize it and at first are inclined to answer that they take it only two or three times a day, forgetting the little potations between meals. Tea is not so prone to cause wakefulness as coffee, yet the toxic irritant principle in both is the same and when the amount of tea and its strength are sufficient, the same results follow. The tea habit must always be given up if there is complaint of lack of sleep, especially early in the night.

There is a very common persuasion that the eating of food in any quantity shortly before going to bed, and especially the eating of certain materials, will keep people awake. It is well known, however, that there are a great many people who can eat anything and sleep well after it and young children sleep best when their stomachs are full. There are undoubtedly idiosyncrasies in this matter that must be respected, but many patients are deceiving themselves. They are eating too little and their wakefulness is more due to the mental state than to anything else. As this contradicts a very prevalent impression, I may say that it is said deliberately and only after much experience with people inclined to be over-solicitous about their diet and their health generally and who were actually producing wakefulness or at least very light dreamful sleep, by their elimination from their diet, and especially from their evening meal, of many nutritious substances. I make it a rule to insist with patients that if it is more than five hours since their last meal they must take a glass of milk and some crackers or a cup of cocoa and something to eat before going to bed. This is particularly important if they have been out in the air much between their last meal and bedtime.

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The Evening Hours.--The use of the hours after the evening meal is an extremely important factor with regard to insomnia. If the patient tries to read the paper or some conventionally interesting magazine or book, thoughts of the possibility of his not sleeping will surely obtrude themselves and he will fail to get to sleep when he lies down. As a matter of fact, he will have so disturbed himself as to predispose to insomnia. Some quiet occupation, interesting yet not too interesting, that diverts the mind from the thoughts about itself and about sleep possibilities, yet does not excite it, is the best possible auxiliary and preparation for sleep. Prof. Oppenheim has, as usual, said this very well in his "Letters to Nervous Patients," to which we have turned so often:

A great deal depends upon the right use of the evening hours. On no account let yourself occupy them with anxious forebodings about the night. But, on the other hand. It is not at present wise to take up your mind with too exciting thoughts, as the strong after-impression of feeling and fancy may counteract the tendency to sleep. You must find out for yourself whether a quiet game (cards, halma, chess, or patience), the reading of a serious or an amusing book, the perusal of an illustrated paper, or a chat with a friend will be most certain to give you that tranquillity of mind through the vestibule of which you will pass into the temple of sleep.

Direct Sleep Suggestions.--Many plans are suggested by which people are supposed to be able to get to sleep. A favorite and very old suggestion is that of counting sheep go over a fence or something of that kind that is merely mechanical, yet takes the mind from other thoughts. As a rule, any plan involving mental occupation that is meant to produce sleep is likely to react and do harm rather than good. Sleep must not be wooed deliberately but must be allowed to come of its own sweet will. It is extremely important that exciting thoughts and bothering interests be put aside, not at the moment when we want to go to sleep, but some considerable time before. This is not always an easy matter and often requires careful planning. It is worth while doing it, however, in order to secure sleep promptly and not allow a prolonged period to pass while one is lying awake, for if nervous irritability ensues wakefulness is still further prolonged and the patient may begin to toss and so disarrange the bedclothing and disturb himself as to prepare for several hours of sleeplessness which would not have occurred if there had been an appropriate interval given to preparing the mind for sleep.

Diminishing Solicitude.--Patients must not be too anxious for sleep. If they worry themselves over the possibility of not sleeping then they will almost surely disturb their sleep, or at least delay its coming. The ideal state of mind is not to bother one's head about it, to lie down habitually at a given hour, compose one's self to sleep with assurance and then wait its coming without solicitude. Many people will say this is not easy to do, but habit makes it easy. Most of our animal life is lived by habit. We are hungry at certain times by habit. Our bowels move at a particular time by habit. We can sleep by habit. If we try to use our intellect solicitously with regard to any of these habitual functions we do much more harm than good. The more anxiety there is about sleep the more likely it is to be disturbed. When the habit of sleep at a particular hour has been broken the best way to regain it is to lie down at that particular hour and then wait patiently for {661} the advent of sleep. If impatience gets the better of us sleep is kept off and will not come for hours. If the patient can lie down feeling "Well, if I do not sleep now I will to-morrow morning" then there is usually little difficulty about sleep.

Dread of Consequences.--Many people who suffer from insomnia fear that their loss of sleep will injure their intellectual capacity or make them prematurely aged, or drain their vitality so that they will not have health and strength of mind and body when they grow old. This adds to their solicitude about themselves and inveterates their condition. There is only one answer to this dread, which has no foundation in what we know of actualities, and that is, to tell them the experience of certain persons which absolutely contradicts such a notion. One distinguished physician who, at the age of seventy-five, is writing books that are attracting widespread attention and is doing an amount of work that many a younger man might envy, has told me of all that he suffered from insomnia between the ages of thirty and fifty-five. His mental productivity was much hampered at that time by his wakefulness and anxiety with regard to it. He feared the worst as regards advancing years, yet he is in the full possession of mental and bodily strength well beyond the Psalmist's limit. His is not an exceptional case, for there are many others in my own personal knowledge. Virchow once told me of years when he suffered from insomnia, yet he lived to be well past eighty and then died, not from natural causes, but from an injury. A man who accomplished an immense amount of work in his day in the organization of a great university suffered from insomnia in his younger years to such a degree that his friends and even he himself feared for his mental stability, eventually overcame this symptom completely and went on to years of great active work, dying in the end, not from his head, but his heart. We have records of a number of such cases. Few of the hard students of the world went through life without having some bother from insomnia. It is well-known, however, that many of the great thinkers, investigators and discoverers in philosophy and in science have lived long lives well beyond the age of the generality of mankind.

Mental Diversion.--The main thing is to banish the thoughts of one's ordinary occupation as far as that can be accomplished without laboring so intently at this as to give the mind another bothersome occupation. Many people find that a game of cards just before going to bed takes their thoughts off business and worry almost better than anything else. Something like this is needed in many people. Most people must not write for some time before retiring, because writing proves so absorbing an occupation, as a rule, that the mind becomes thoroughly awake and then remains so for some time afterwards. Reading is better, but the reading must be chosen with proper care. An exciting story, for instance, may serve to keep one awake for hours, as everyone knows who has tried and found himself still reading at three in the morning after having begun an interesting book. The reading of works of general information, of travels, of description of places, where it is comparatively easy to stop at any place, of short stories which do not hold the interest beyond a brief period, is much better. Osler's recommendation to have a classic author beside one's bed to be read for a few minutes every night after retiring as a preparation for sleep is an excellent remedy for the milder forms of insomnia, as well as a stepping-stone to scholarship.

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William Black in one of his books has a description of an old man who had suffered from insomnia very severely until he discovered a plan of his own to enable him to get to sleep. This consisted in reading the Encyclopedia Britannica. He began at the beginning and read straight ahead, article after article, and volume after volume. He never even by any chance departed from this routine either to look up cross references, or read anything further about men who were mentioned in the article he was going through at the moment and whose names occurred in another volume. He read straight on until his eyes got heavy and then he went to sleep. At the time he was introduced into the story he had already read the whole work through twice and was, I think, at "D" on the third reading. He had had considerable bother about getting to sleep before he adopted this plan, but it proved an always efficient somnifacients. There is a story about an old American farmer who said that he read the dictionary over and over again for the same purpose. The stories were short and disconnected, but they never bothered his sleep, while his wife and daughters were sometimes kept up more than he thought was good for them by their interest in the story paper.

Treatment of Early Morning Wakefulness.--With regard to the disturbance of sleep in the early morning hours there are certain instructions to patients that have always seemed to me extremely important. Most of the patients who complain of wakefulness in the early morning hours are really suffering from hunger at that time. This is especially true with regard to those who stay up rather late at night. They have their last regular meal about seven or a little earlier, they get to bed at eleven or even later, and some of them, following the old maxim that eating before sleep is likely to disturb it, go to bed on an empty stomach. Whenever more than four hours have passed since the last meal the stomach is quite empty, and after the preliminary fatigue has worn off and the sleep has become lighter and the lack of nourishment more pronounced a vague sense of discomfort in the abdominal region wakes them, though most of them do not realize that they are disturbed by a craving for food. In a large number of these cases I have found that the recommendation of a glass of milk and some crackers, or some simple cake, just before retiring does more than anything else to lengthen sleep and prevent what has been learnedly called matutinal vigilance.

After emptiness of the digestive tract, the most prominent cause of wakefulness in the early morning is anxiety about the hour of rising or about some engagement that has to be kept in the early morning. I have known patients who worked themselves up so much thinking over the necessity for rising at a particular hour to catch a train, that they were awake for several hours before they needed to be. Some are much more inclined to this over-anxiety than others. If they move to the country where trains have to be caught regularly, their sleep may be seriously disturbed by this circumstance. If the trouble becomes acute they must simply change their residence. If it is absolutely necessary that they stay, then they must have someone to wake them at a definite time. This must be someone on whom they can absolutely depend, otherwise the old solicitude will reassert itself. This seems a small matter, yet I have known serious cases of neurasthenia with annoying digestive symptoms due to nothing else than this morning wakefulness consequent upon overanxiety with regard to trains and other morning engagements.

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Habits.--In the correction of troubles of sleep one of the difficulties that the physician has to contend with when patients have grown accustomed to staying up late and finally have so disturbed their sleep mechanism that symptoms of insomnia develop, is the declaration that there is no use for them going to bed early since they cannot sleep. If a man has been accustomed for a long period to go to bed between midnight and 2 a. m. and his habits are suddenly changed so that he goes to bed at ten or even eleven, it is very likely that for some time after retiring he will not sleep. If he grows over-anxious he may toss and become somewhat feverish and then, even when the accustomed time for sleep comes, he may not secure it. Besides, the depression consequent upon failure to sleep when he has fulfilled his physician's directions and when he knows that this is considered an important adjuvant in his treatment, acts as a distinctly discouraging factor. Under these circumstances it is important to recall to him that one habit can only be removed by the making of another. It may be necessary to send him to bed for awhile only an hour earlier than before until he has grown accustomed to going to sleep somewhat sooner, and then this habit, in turn, be changed to an earlier hour so as to secure all the sleep that is necessary.

In a word, insomnia is not a definite affection to be treated by giving one or the other of one's favorite drugs, or if these should fail trying still others, but it is a condition of mind very often predisposed to by certain conditions of body. If this condition of mind can be adjusted by careful attention to the correction of whatever may be physically out of order, then there is every reason to look for definite improvement very soon and complete cure without any delay. Insomnia is not the awful ailment that it is sometimes pictured, nor all that it appears to the excited imagination of the young person who loses a few hours' sleep; but a manifold condition to be dealt with very differently in different individuals, according to the indications of the case. If the patient's confidence can be secured that means more than almost anything else that can be done. If a little patience is exercised in obtaining such definite details of the mental state and of certain physical factors as may seem quite trivial to the patient yet are really predisposing elements for his affection, the therapeutics become comparatively simple. It is the use of tact and judgment in this matter that means most, however, and then very few drugs will be required. Between the habits consequent upon the opiates and certain of the serious hemolytic conditions due to the abuse of coal-tar products, this is a consummation that may well be worked for assiduously.

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VIII. SOME TROUBLES OF SLEEP

Certain annoying incidents in connection with sleep annoy those affected by them so much as to arouse them very completely from sleep and make them wakeful for a time. Nothing disturbs most people so much as the thought that some passing incident, a little out of the common, is quite individual and peculiar to them. If they are at all nervous they are likely to think that it portends some serious ailment, either present or about to {664} develop. Nothing reassures them more than to learn that these incidents are not so uncommon as they imagine, indeed that many of them are quite frequent, and, above all, that many people who have had them are still alive and well beyond threescore and ten, and laughing at the fears of their earlier years.

Starting.--Perhaps one of the most annoying of these incidental troubles is starting in sleep. It occasionally happens that just about the time a person is dozing off he suddenly starts and, almost before he realizes it, is fully awake, his heart beating emphatically and there may even be a little feeling of oppression on the chest. The cause is not the same in all cases and individual differences are worth investigating. In most people this starting means that there is, for the moment, some mechanical interference with the action of the heart and that a systole has been delayed and has been pushed through with more force than usual because of this delay. A full stomach will occasionally cause this, especially if patients lie on their left sides. In some people even a drink of water taken just before retiring will be sufficient weight to cause this interference with heart action. An accumulation of gas in the stomach will do it by pushing up against the diaphragm. Where there is a distinct tendency to the accumulation of gas in the stomach I have sometimes been sure that the expansion of the gas consequent upon the cozy warmth of the patient in bed, or its greater effect upon the stomach because the relaxation of sleep affected even the stomach walls slightly, was the cause of it. It happens more frequently in the old than it does in the young, but it is observed at all ages and patients are usually quite disturbed about it, as, indeed, they are likely to be with regard to anything that affects their hearts.

The thought that this forcible beat must mean some serious pathological condition will obtrude itself on many people, and if it does sleep is sure to be disturbed. Even though there may be no discoverable lesion of the heart, these patients often, though they are physicians, will worry lest some underlying condition should be developing. The first patient who ever described this symptom to me told me of it while I was a medical student and he is still alive and in good health, though he is past seventy. At the time I went over him rather carefully with the idea that there might be an organic heart lesion, but found none. The prognosis of these cases is always favorable, for there are many who suffer yet live long. I have found if to occur particularly in elderly people when they were a little overtired on going to bed, or in anemic young people when they had had somewhat more exertion than usual during the day. Unless there is really some demonstrable heart lesion the start does not mean anything and patients can be reassured at once. They should be counselled against lying on the left side, though in some of them it will occur even while lying on the right side and then the mechanism of its production seems to be the gaseous over-distention of the stomach. Patients may be told at once that it occurs in a large number of people and then, instead of lying awake and worrying about it as they often do, they learn simply to place themselves in a more comfortable position and go to sleep again without solicitude. They would learn this for themselves in the course of time, but the physician's reassurance will enable them to anticipate the lessons of experience and they will thus be saved worrying.

At times this starting from sleep seems due to some unusual noise. In {665} certain nervous states even slight noises produce an exaggerated reaction and there seems to be a surprising, almost hypnotic, acuity of hearing just at the moment when all the other senses are going to sleep. Any of the small noises that sound so loud in the stillness of the night may serve to wake the patient so thoroughly after a preliminary doze that sleep is disturbed for some time. As a rule, however, such noises would not disturb people if they were in normal healthy condition, or at least the disturbance would be only momentary. The solicitous effort that some people make to get away from every possible noise is an attempt in the wrong direction. We have heard of people building special houses, or noise-proof rooms in the center of houses where they hoped it would be impossible to be disturbed. What is needed is not so much an effort to secure absolutely noiseless surroundings, which is almost impossible in any circumstances, be it city or country, but to change the patient's physical condition so that slight noises are not reacted to so explosively. There are many general directions for this and certain drugs, as the bromides, are of distinct service. On the other hand, the taking of cinchona products seems often to emphasize it.

I have found that two classes of nervous patients particularly were likely to be disturbed by these starts in their sleep. The first class is perhaps the larger. They are the patients who do not eat enough. They will usually be found to be underweight and to be nursing some thought with regard to their digestion, or some supposed idiosyncrasy towards food that is keeping them below the normal weight for their height. Nothing makes sleep lighter than a certain amount of hunger. This hunger may be disguised so completely, or so covered up by the patient's persuasion that more food cannot be taken without serious gastric disturbance, that it may pass utterly unnoticed. When such patients are disturbed early in the night, it usually means that besides taking a not quite sufficient amount of food they are taking more tea or coffee or some stimulant than is good for them. I say some stimulant because in several cases that I investigated rather carefully the cause seemed to be the alcohol taken with one of the largely advertised patent medicines, a supposed digestive tonic, consisting mainly of dilute alcohol, and really about as strong as whiskey. When the tendency to be startled occurs in the early mornings, then people need to eat something simple just before they go to bed.

The other class of cases who are likely to start at night in their sleep are those who do not get out into the air enough during the day or who sleep in rooms insufficiently ventilated. At the beginning of the night the lack of ventilation makes the sleep light and easily disturbed. After a certain number of hours have been spent in a badly ventilated room the patient sinks into a rather deep sleep, which is likely to be dreamy, however, and then he is rather hard to waken, but wakes not feeling rested, but on the contrary often heavier and more tired than on retiring. In these cases an investigation of the amount of air the patient is allowing to enter his sleeping room or that his circumstances provide him with is extremely important. As for those who do not get out enough during the day, it is easy to understand that their sleep may be light. To them, as a rule, it will be a surprise to find how much depth is added to their sleep by an additional hour or two in the air. Commonly, people who do not get out much during the day are shivery and {666} suffer from cold, especially in the winter time, and so they are likely to keep their rooms rather tightly closed. In this case they have two reasons for a tendency to be wakeful, which is emphasized if there are noises near them or if there is anything that disturbs their sleep.

In young children, of course, it must not be forgotten that starting in sleep may be due to the twitching pains of a beginning tuberculous joint disease. At times the children are so young, or the symptoms so vague and the tenderness, if there is any, so deep, that the real significance of this may not be recognized. The most successful treatment for these starting pains in children that has thus far been found, forms a striking commentary on what we have just been saying with regard to fitful sleep when ventilation is insufficient or when the patient has not been out of doors enough during the day. The children from the New York hospitals who in recent years were taken down to Sea Breeze during the autumn and winter and made to live in wards, the windows of which were constantly open so that the temperature was often below fifty, so that doctors and nurses had to wrap themselves up warmly and sometimes cover their heads and their hands, had all been sufferers from these starting pains before this experience, but gradually they lessened in frequency until after a few months the crying of a child at night because of these pains was extremely rare. The lesson is evident, and abundance of air not only cures tuberculous conditions, but also makes the nervous system so much less irritable that starting pains do not so easily affect it.

Noise.--Slight noises often make it impossible for nervous people to sleep. This is much more a question of personal sensitiveness and anxious expectancy and over-irritability than anything else. One distinguished physician whom I knew was extremely sensitive to noise and would be awake for hours if wakened up early in the night by the slamming of a door or a call in the street or anything of the kind. He suffered from insomnia to a noteworthy degree and found to his surprise that he could sleep better on a train than anywhere else. After he had lost two or three nights of sleep he actually used to make arrangements to take a berth on an express train going out of his city, ride until the morning and then come back. He usually slept well amidst all the noise and jar of the train, though he would be quite sleepless at home as the result of even slight noises. I have known people suffering from insomnia who took a long ocean trip on a slow vessel and who slept well amidst all the noises of shipboard, but were light sleepers after landing, and felt that they missed the noise and bustle. Of course, in these cases the rocking movements sometimes predispose to sleep. It is not the custom now to rock infants to sleep and a very definite agreement seems to have been come to among pediatrists to forbid the practice as harmful. It is probable, however, that the instinct of the race in the matter was not at fault. Rocking seems to relax a certain tension of muscles that of itself prevents the brain anemia which is the physiological basis of sleep. It is extremely difficult for nervous people to relax themselves completely, and the rocking movements, by tending to help them in this matter, are excellent predisposing factors. A rocking chair or a hammock furnish abundant proof of this.

Noise in general, as regards its relation to sleep, is an extremely individual matter. Habit plays the largest role in the matter. We all know the {667} stories of men who have gone to great expense in order to build noise-proof rooms and yet have found afterwards that they did not sleep well. The rustle of the bedclothes as their thoraxes rose and fell in respiration was enough to disturb them when they allowed themselves to become over-sensitive about noise. We all know how impossible sleep becomes with a rustle of a mouse in the wastepaper basket, or the scratching of one on the wainscoting. On the other hand, anyone who has lived in a large city where past hundreds of thousands of homes the elevated trains thunder every few minutes all during the night, or the trolley goes rolling by within a few feet of the bed, knows, too, that a great many people become accustomed to noises so as to be utterly undisturbed by them, though at the beginning any such insensitiveness to noise seemed out of the question.

I remember having a patient who insisted that he could not sleep so near the elevated. At the end of a week he had lost so many nights of sleep that he was almost in despair. If he did get sound asleep he said he used to hear the thunder of the elevated train coming toward him in his dreams and he would begin to pull his feet up so as to get them out of the way of the train, yet always with the feeling that he could not get them quite far enough, until his knees were almost to his chin. Under the influence of a little bromides, two hours more of outdoor air than he had been accustomed to before, and some reassurance that noise need not disturb sleep at all if taken philosophically, he learned in the course of two weeks to sleep quite peacefully and now has lived for ten years where the elevated passes within ten feet of his window, which is wide open for seven months in the year and always at least slightly open, except in the most stormy weather. It is a question, then, of the individual much more than his surroundings. The problem is to predispose the mind to sleep and then the senses will not disturb it except under special circumstances.

As a matter of fact, noises usually disturb people very little at night. The most surprising things can happen between 12 and 3 o'clock and attract no attention. Burglars calmly blow up a safe in a hotel confident that if there is no one awake when the explosion occurs there will be no investigation, because even though people wake up at the noise, they will wait for its repetition in order to see what it means, will not get up to investigate, especially in cold weather, and usually promptly go to sleep again.

Lying Awake.--There are many people to whom lying awake carries with it a sense of discouragement and dread. They seem to forget that lying awake and occupation with pleasant thoughts may be made a very agreeable pastime by those who are not over-anxious to sleep and who let the pleasant thoughts that may be suggested by the environment or the noises that are heard flow through consciousness. Everyone knows how pleasant it is or may be to listen to the rain patter on the roof of a country house, or to hear the murmur of the ocean or of the wind through the trees when there is not too much anxiety about to-morrow and to-morrow's occupations and the necessity for sleep to be ready for them. Stewart Edward White, in his series of essays on "The Forest," has a chapter on Lying Awake at Night that can well be recommended to the attention of those who complain bitterly of an hour of sleeplessness. Of course, in his case the lying awake is in the midst of the forest with all the witchery of wind in the trees and the {668} unusual sounds of forest life, while ordinary lying awake is in the rather monotonous environment at home, but still there is much that can be said for his insistence that in peaceful brooding, faculties revive while soft velvet fingers are laid on the drowsy imagination and you feel that in their caressing vaster spaces of thought are opened up. The impatience that comes to so many almost at once if they fail to go to sleep promptly only serves to keep them awake just that much more surely.

Very often, as suggested by Mr. White, this wakefulness occurs just when a good night's rest is surely expected. There is sometimes even a preliminary period of drowsiness. Then some little noise that ordinarily would not be noticed at all floats into the consciousness with a vigor that indicates that one sense is thoroughly awake. The very surprise of it wakes up the other senses with a start and then comes the thought that there is to be no sleep for some time. If this is resented, the period of wakefulness will be all the longer. If, when it has proved to be inevitable, one sits up quietly, reads a book for a time, plays a quiet game of solitaire, it may be on a board kept beside the bed for such purposes, or in some quiet way succeeds in bothering away the thought of insomnia, then almost surely sleep will come after a time, quietly and restfully, and the lost period will not prove harmful. If nature does not want to sleep she must not be forced into it, but gently led and after a time the wakefulness will disappear.

Night Terrors.--One of the troubles of sleep that is more often called to the attention of the physician than almost any other, is the so-called "night terrors" of children. Little ones wake with a scream, sit up in bed, evidently terrified, usually trembling, and ready to seek refuge from something that has seriously disturbed them. Under Dreams we have called attention to the fact that usually these terrors are due to a dream. Sometimes the dreams are the ordinary experience of supposed falling in sleep, from which the patients wake very much startled, or they are repetitions of exciting scenes through which they have passed, or of stories that they have heard, or, above all, plays that they have seen. Ghost stories, for instance, told shortly before they go to bed will often disturb children. Fairy stories and the ordinary myths of childhood, usually with a happy ending and without any serious terrors in them, are not so likely to disturb them. Melodramatic theatrical performances to which children lend themselves and their attention with great concentration of mind, have nearly as much effect on them as if they passed through the actual scenes. Every physician knows how much a fright is likely to disturb a child and cause it to wake many a night afterwards in a state of terror.

Respiratory Interference.--It is particularly important to remember that any interference with breathing will almost surely wake the child in a seriously startled condition. Adults are often affected by this same sort of dream, due very often to some pathological condition in the throat around which a series of dream ideas collect with somewhat poignant results. I have known a man suffering from elongated uvula wake up thinking that he was suffocating because, as he thought, he had nearly swallowed his tongue, or at least had been trying to do so. The sensation was so startling that it brought him to his feet at once. I have known a patient traveling a long five-days' railroad journey and suffering severely from train catarrh, come to the {669} persuasion that he might suffocate during sleep because his nose was completely stopped up and he had not the habit of sleeping with his mouth open. As a result his sleep was as much disturbed by his mind as his breathing. If these affect adults so strongly, it is easy to understand why children should be so frightened by them. Children who are mouth-breathers from adenoids or nasal obstruction, and still more those whose nasal breathing apparatus is not completely stopped up, but who are frequent intermittent mouth-breathers, are especially likely to be troubled in this way. The neurosis known as nervous croup, due to a spasm of the vocal cords, occurs oftenest in this class of children and is an associated phenomenon to that of night terrors.

Sleeping in the Light.--The habit of accustoming children to sleep with a light in the room nearly always lessens the depth of their sleep. They are more easily wakened and their sleep is not so refreshing. Besides, if they do not grow accustomed to the dark when they are young, they may always retain a dread of the dark and will require some light in the room where they sleep. Nature intended that the eyes and the optic nerve should have as complete a rest as possible and even with the lids lowered some light stimulus, if it is present, finds its way to the nerve fibers. Hence the desirability of having as far as possible an absolutely dark room. For some very timorous children, this may seem impossible. Many mothers will recall how awful the dark seemed to them and what shadowy shapes loomed up in it. It will usually be found on inquiry, however, that in these cases the children, after having been accustomed to sleep with some light and after having had all sorts of exciting pictures shown them and stories told them, were asked to sleep in the dark. From the very beginning they should be accustomed to sleeping in the dark and then it has none of the terrors thus pictured.

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IX. DREAMS

Dreams, that is, thoughts and illusions and mental phenomena of various kinds that occur during sleep, have always been interesting to the psychologist, and have usually been related to physicians by patients either because they were thought to have a significance related to disease, or because something in them disturbed the patient's mind. This is almost as true in the modern time as it was long ago. It is curiously interesting to note that the very latest development of psychotherapy includes the use of hints obtained from dreams in order to determine the origin of psycho-neurotic conditions and certain of the minor psychic disturbances, and also as a foundation for treatment. The oldest stories of therapeutics that we have are those of patients waited on by the priest physicians of the olden times in the temples, who were supposed to be greatly helped by information obtained from the patient's dreams. It is interesting to read such recent studies as that of "Incubation in the Old Temples," by Miss Ingersoll, with the thought in mind that we are once more analyzing dreams in order to accomplish a similar purpose.

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Dreams are so often a source of disturbance of mind for patients, lead to such disturbed sleep, or even so affect the bodily health that it is important for anyone who wants to influence patients through their minds to know the significance attributed to dreams by the most recent studies of them. This is all the more important because dreams are such a universal phenomenon. From our earliest years we dream. The night terrors of children are probably due to dreams and show that even as early as the age of three we dream vividly. Doubtless some of the terrifying dreams of childhood are similar to those that we experience later. Dreams of falling, dreams of being cold, of being out of breath, with vivid repetitions of exciting scenes through which they have gone during the day, or which they have seen in picture or been told in story, form the substance of these dreams. Children are likely to be much disturbed by them. They wake in a terror of anxiety, in cold sweat, and crying bitterly because of their dream visions. Older people are not so much disturbed at the moment, but often brood over dreams and may be seriously affected by them.

It is difficult, however, to persuade many people that their dreams have no special significance, either of present or of future evil, and to many the fact that they dream much becomes a suggestion of wakefulness that disturbs sleep and makes them quite unequal to the next day's work, because they have the feeling that, as they have been dreaming all night, they must be quite tired. Tiredness in nervous people is often a matter of the mental state rather than of physical exhaustion or genuine mental weariness. The actual place of dreams in psychology, then, becomes an important consideration in psychotherapeutics.

Our real advances in the knowledge of the significance of dreams have come from the study of the dreams that are common to most people. These show us exactly how and why dreams occur and just what their meaning is. Probably the most familiar dream common to all the human race is that of falling from a height. Everyone has been wakened with a startled sense of intense relief that the sensation of falling was illusory. The waking came just before the bottom was reached. There is a tradition that if one ever did strike the bottom in one's dream it would be the end and that death would result as surely as if the fall were real. So far we have had no one come back to tell us of that, and the tradition is reasonably safe from direct contradiction. It serves without any reason, however, to disturb timorous people and make them dread to fall asleep again. Often this dream-falling so seriously affects sensitive individuals that they do not get to sleep for an hour or more and occasionally those with an inclination to insomnia may even suffer for the rest of the night from the effect of it. It is important to explain, then, what we know about the causation of the dream. In nearly all cases the subject on waking finds himself on his back, and then the inclination is at once to turn over to the side with a sigh of relief. Commonly the dream occurs rather early in the night, when a rather heavy meal has been taken shortly before retiring. The weight in the stomach, particularly if considerable liquid has been taken, seems to press upon the abdominal aorta and interferes, to some extent at least, with the circulation to the legs. This deprives little nerves at the periphery of the body of some of their nutrition and causes a tingling feeling in them. This is quite different from pressure {671} on nerves, which gives the sensation termed "being asleep" to a limb. This tingling feeling resembles that which we experience when going down rapidly in an elevator. It is the falling sensation. This sensation tries to force its way into the consciousness and in this process does not completely wake consciousness up, but brings about an association of ideas connected with falling--hence the dream of being on a height and of falling therefrom out of which we wake so startled. The whole process instead of being injurious is really conservative. It is important that the aorta should not be pressed upon and this is the mode by which awakening is brought about and the position shifted so that further interference is stopped, though we ourselves are quite unconscious of the real purpose that has been accomplished. An explanation of this kind usually makes people who suffer from such dreams and have been disturbed by them much more tolerant of the phenomenon and more ready to go to sleep again, since evidently nature can be trusted to care for them even during sleep.

After the sensation of falling probably the commonest dream that humanity has, at least in the civilized state, is that of being out in some public place without sufficient clothing. Usually we wake just to find that some portion of our anatomy has been exposed to the air and that it is cold. It is this sensation gradually forcing its way into consciousness that has gathered around it a group of ideas that form our dream.

Among men, a familiar dream is that of running for a car, or away from something, or to catch someone, and finding that it is almost impossible to move. We are so out of breath that we are scarcely able to drag one foot after another and, indeed, sometimes we seem to be actually rooted to the spot. We cannot move at all. When we wake after this dream we find that, because of a cold in the head, our nose is stopped up by the secretion and that our mouths are shut and consequently we were getting no air. When that sensation tries to break into the consciousness there gather around it certain familiar ideas usually associated with being out of breath and hence we have the dream of trying to run without being able to move.

Frequency of Dreams.--Nervous people often complain that they dream all night or else very frequently, and that as a consequence their sleep is not restful. It is probable that there are always ideas in the mind and that literally we dream without ceasing. These ideas, however, do not get into our consciousness except just during the process of waking. All those who have investigated the subject of dreams are practically agreed on this. In subsequent paragraphs we quote a number of good observers on this subject. Certainly this is what we should expect from what we all know about day-dreaming. We can never catch ourselves during the day without finding some thought wandering through our minds. If we want to understand dreaming during sleep this day dreaming is instructive. We jump from one idea to another, apparently without a connection; yet there is always some connecting link. We have just read in the paper of someone in Cairo, and we think of old Egypt, and then of old Babylonia, and the Code of Hammurrabi, and the laws of the Medes and the Persians, and Xenophon and our school days, and of an old schoolmaster now a missionary in Japan, and of Japanese art and of an American artist much influenced by it, and of one of his great windows in a church in New York and of social work in connection with that church, {672} and of settlement houses and then Hull House, Chicago, and then of the Adamses in Massachusetts, and so on.

Thus, also, do our minds go flitting round apparently during the night. We remember only such things as are brought into our consciousness directly and emphatically during the process of wakening. During our day dreaming we recall only those things which for some reason led us to think consciously about them and then follow out our thoughts to definite conclusions. It is an interesting study to follow back our day dreams through their wanderings to the origin. As a rule, however, we lose track of the connections and after a time remember only some of the wonderful transformations and transmigrations of thought; and so it is in our dreams.

With regard to the frequency of dreaming. Sir Arthur Mitchell in his book "Dreaming, Laughing, and Blushing" (London, 1905), insists on the great probability of the constancy of our dreaming during sleep. He says:

It seems to me that there is no such thing as dreamless sleep. During the whole continuance of sleep, the mind, I believe, is occupied with a certain kind of thinking which works round what I have called hallucinations. I do not expect to be able to prove the correctness of this opinion as to the persistence of dreams all through sleep, but I think that it can easily be shown to be possibly correct. I go further, and say that many things show that it is probably correct. I may not be able to prove absolutely its correctness, but it is proper to bear in mind that it is quite as difficult to prove absolutely that it is not correct. My difficulty is frankly avowed. Many things, however, are taught in biology as being certainly true. In regard to which a like avowal could be made but is not made. There is what has been called a "conjectural biology."

We do not and we cannot remember much of what we have been thinking about while we are awake. This is unquestionably true in a large sense. But, nevertheless, we do not doubt that we have been thinking continuously. We do not suppose that at any time all thinking had ceased, though we may be completely unable to recall what it was about.

He shows further that many writers on dreams and careful students of the subject in the past have come to the same conclusion. Robert Dale Owen, for instance, deliberately endeavored to find out whether he had always been dreaming just before he awoke. After months of observation he records that in every instance he was conscious of having dreamed. Hazlitt, a century ago, tried the same thing for a prolonged period and notes that whenever he was waked, and immediately recollected himself as to possible dreaming, he was always aware that he had been dreaming. Sir Arthur Mitchell himself has tried this same experiment on himself and for a considerable time has scarcely ever failed to put to himself this question about dreaming when he awoke and always got a satisfying affirmative answer. Personally, for several years, I have been interested enough in this subject to recur frequently to it immediately on awaking and I cannot say that I have ever, under those circumstances, failed to find that there had been some vague dream fancies at least running through my mind before I was fully awake. This opinion as to the constancy of dreaming during sleep has many authorities in its support. Sir Arthur Mitchell has quoted a number, some of them distinguished physicians, who add the weight of their testimony to this view:

It is not a new thing to hold that there is no sleep without dreaming--in other words, that dreaming goes on unceasingly all through sleep. I have stated my own {673} opinion strongly, but the same opinion has been nearly as strongly expressed by others. Sir Benjamin Brodie, for instance, may be said to express it when he writes, "I believe that I seldom if ever sleep without dreaming." Sir Henry Holland expresses it still more plainly when he says: "No moment of sleep is without some condition of dreaming." Goodwin says much the same thing when he asserts that "sleep is not a suspension of thought"--in other words, that dreaming is sleep-thinking. Dr. John Reid still more clearly holds the opinion, though he does not furnish me with a short apt quotation. Hazlitt, too, may be taken as holding that there is no such thing as dreamless sleep.

Descartes and his followers may, perhaps, be regarded as holding that the mind is unceasingly at work in sleep--even in the "profoundest sleep," though "the memory retains it not," and Isaac Watts says that "the soul never intermits its activity," and that we may "know of sleeping thoughts at the moment they arise, and not retain them the next moment."

Hippocrates, Leibnitz, and Abercrombie have also been quoted as holding that there is no dreamless sleep, and so far as they express themselves on the subject they appear to do so.

A strong weight of opinion in all ages favors the view that during sleep dream-thoughts are constantly running through our mind, though we recollect only those which are impressed upon us at the moment of awaking. We do not even recall those unless, for some reason, we have paid special attention to them. That is just exactly what is true of day dreaming. After it is over we have no idea at all of the thoughts that occupied our minds for hours, though we are all aware that at any given moment, if we turned our consciousness inwards we found that there was something that we were thinking about.

Short Duration of Dreams.--This view of the constant occurrence of dreams during sleep is confirmed by other things that we have come to know as to dreams and dream states. Probably the most interesting of these is with regard to the length of dreams. As our memory of dreams is only such as we have from the thoughts of sleep getting into our consciousness just at the moment of awaking, dreams are never as long as they sometimes seem to be. As a matter of fact, they occupy but a few moments, though in that time a long story may seem to unroll itself. Probably nothing gives more assurance to people who are persuaded that they are losing much rest because of their dreams than this explanation of the brevity of the phenomena. Nervous people wake frequently. Whenever they wake they find themselves dreaming. As a consequence, they acquire the persuasion that they have been dreaming "all the night long," and it is not hard for them to suggest to themselves in the early morning that they are not rested. Nervous people seldom feel rested in the early morning, it is their worst time, and with the occurrence of dreams as a suggested reason for this, they exaggerate the feeling of tiredness with which they get up. A frank discussion of this question of the duration of dreams is often the best possible therapeutic auxiliary for such cases. It gives them a new series of suggestions and, above all, relieves them of unfavorable suggestions.

Prof. Maury of the University of Paris tells a striking story of a very brief dream of his own which shows how short may be the time occupied by what seems surely a long dream. He had been reading before going to bed a very striking book on the Reign of Terror. He dreamt that he himself was arrested during the Terror, taken to prison, that his name was called on the list of the condemned, that he was carried to the guillotine, fastened to the {674} board, pushed beneath the knife and that he woke just as the knife struck his neck. Of course he awoke with the usual sense of thankfulness and relief that comes at such times. When he awoke he found that a light curtain rod had fallen from the bed above him and had struck just across his neck. His dream evidently had all come to him during the extremely short time necessary for him to become fully awake after the rod had hit him. His mind was occupying itself with the history that he had read before going to bed. When the rod struck him the long story of his arrest and imprisonment, the journey to the place of the guillotine and the preparations for execution, all came to him as a series of rapid ideas during his coming to consciousness.

It is probable that most of our dreams are not much longer than this. One of my earliest recollections is of an old gentleman coming into the country school during my first year as a pupil and telling us the story of a dream of his of the night before quite as brief as that of Professor Maury. He had fallen asleep after dinner in his chair and, having a cold that stopped up his nose and his mouth being shut, he had the usual dream of being out of breath from running. It took him back to the story of the massacre of Wyoming, near the scene of which the school was situated. He dreamt that for hours he had been running away from the Indians and seemed at last utterly unable to escape them because he was out of breath. He made such efforts in his chair that his wife awakened him and then he found that he had been asleep altogether only a very few minutes.

Significance of Dreams.--Many people are quite sure that their dreams have a definite significance quite apart from any mere wandering of the mind or the suggestion of half-waking and the ideas that gather round sensations not fully in the consciousness. A number of people, for instance, have dreams of events that are happening at a distance at the moment that they dream. The Psychic Research Society of England has gathered a number of these and it is indeed difficult to understand many of them. There seems no doubt, however, that in many cases there is an illusion of memory, by which, after an event, dreams that might be taken to refer in some vague way to the happening, are clothed with a wealth of detail which appears to make them wonderful premonitory representations of future events or repetitions of simultaneous events. One of the most familiar of this form of dreams is what has been called a phantasm of the dying. People dying at a distance seem to have some wonderful power of making themselves appear to very near friends, especially brothers and sisters, and, above all, twins, and to friends with whom they have been very intimately associated. Occasionally such phantasms are seen during waking hours, or what are supposed to be waking hours, though it must not be forgotten that dreams may come very easily and almost unconsciously in short naps, but much more frequently in what are known to be dreams.

Nearly always these partake of the nature of the ordinary dream, as can be seen by a careful analysis of their conditions, and are mere coincidences occupying a very brief space of time. A typical example of this is to be found in one of the stories told by Camille Flammarion, the French astronomer, in his book "The Unknown." A young man who had fallen in love with a young woman was deeply grieved to be parted from her by the injunction of parents. Separated by a long distance, they kept up a clandestine {675} correspondence for more than a year. For a considerable period, however, he had not heard from her, and he was beginning to be anxious lest anything had happened to her. One night she appeared to him in a dream in his room in white garments with a pale face and, placing her cold hand in his, she bade him good-bye. He awoke with a start. He found it difficult to sleep and was very anxious about her. The next day he learned that she had died the night before and concluded that his dream was a last message from her. The end of the story, however, as it is told, spoils this nice sentimental conclusion. When he awoke he found he had in his hand a glass of ice water which had been standing on the table beside him. The grasping of this had awakened him. During the awakening process the thoughts of her in his mind gathered round the cold sensation in his hand and gave him the dream of her and the last farewell.

There are many instances in which dreams of future events seem to come true. Indeed, so many of these stories have been told that it is hard to persuade some people that dreams have no meaning and can have no meaning. By this we mean that they can by no possibility represent prophetic foresight. What patients need to be made to understand is that dreams represent only straggling sensations trying to get into our consciousness, just barely succeeding, and then arousing trains of ideas unconnected in themselves, but which we connect afterwards when we recollect our dreams. This whole subject has been studied so thoroughly in Maury's work on "Le Sommeil et les Reves" about the middle of the last century and Freud "Ueber den Traum" and Sante de Sanctis' "I Sogni" Turin, 1899, at the end of the century, that there can be no further doubts about the matter for those who are open to conviction. Most people, however, want to believe that their dreams mean something. They like to think that they are in some way picked out from the multitude and that their dreaming has a significance more than is accorded to other people. It is, indeed, this self-centeredness that makes for the belief in premonitions and prophetic dreams and, as in all cases, these feelings work out their own revenge.

If they will listen to reason, however, most people may be rather readily convinced that their dreams cannot have any serious significance. In the chapter on Premonitions we have already called attention to the situation that exists with regard to the possibility of future events giving information of themselves in advance of their happening. Simultaneous events may perhaps in some way give warnings. The possibility of action on the mind at a distance, especially where minds are involved, has been discussed and admitted. The cases in which it is supposed to have happened are, to my mind, all dubious and are mere coincidences. For future events, however, there is no possible physical explanation. When we turn to explanations in the borderland between spirit and matter we find nothing satisfactory. The future event exists nowhere. No spirit even knows it; it is dependent on human free will. To the Creator it is known only as a contingent possibility dependent on free will. The information does not come from Him, for then there would be more design in these incidents. Such dreams would effect some serious purpose, while usually they have but minor significance in the stories as told and they often concern only the most trivial things.

What is thus true of premonitions can readily be applied to dreams. {676} There is no reasonable source of information with regard to future events. What, then, are we to say of the dreams that come true? There is no doubt that dreaming is extremely common. Probably, as was said, we never sleep without dreams. There are a billion dreams at least, probably many billions of dreams every night, then, in this little world of ours. When these are startling they cling to us. It would be surprising if some of them did not come true. Indeed, it is inevitable, according to the theory of probabilities, that some of them will connect themselves directly with future events. We have a few thousands of such startling coincidences in the history of the race. Out of these have been made all the data supposed to underlie the teaching that dreams have a prophetic significance. It is much easier to understand with regard to dreams than even with regard to telepathy coincidence explains all the supposedly wonderful warnings of events that actually happen after we have had apparently premonitory dreams.

An interesting example of a premonition that did not come true, the subject of which was sure that it was a waking premonition and not a dream, though it seems more likely that it was as suggested by the narrator a sleep vision, is told by Sir Arthur Mitchell in his "Dreaming, Laughing, Blushing" (London, 1905). A number of scientists who discussed the story declared that if it had only come true it would have been one of the most startling manifestations of premonition and of the clairvoyant power of dreams, or at least of their telepathic significance, that we have ever had. It involved so many distinguished scientists that there could have been no doubt about it. It was so detailed and those details were known to so many authorities in science, that it would have carried great weight and it would have been extremely difficult to have people accept it as a mere coincidence. It is easy to see now after the event that, if it had been fulfilled, it would have been, in spite of its startlingness, a mere coincidence. Since it was not fulfilled, however, it represents one of the best evidences that we have for the insignificance of premonitory or telepathic dreams.

Sir William T. Gairdner, K. C. B., whose interesting typhus delirium experience appears in the paper by Professor Coates on "Sleep, Dreams and Delirium" (Glas. Med. Jour., Vol. xxxviii, 1892, pp. 241-261), has written to me about his dreams generally, and he concludes his letter with the narrative of a dream, which, as he correctly says, "if it had only fulfilled itself, might have become famous." He prefaces the narrative by this statement: "In all my individual experience, now extending over more than the usual term of life, I have never met with anything suggestive in the remotest degree of telepathy or second sight, or of dream prophecies or any other fact bearing on the marvellous." He then goes on to tell the dream to which I have referred. "In crossing the Atlantic In 1891," he says, "in delightful weather and perfect bodily health, and without a shade of anxiety on my mind so far as I was aware (in waking consciousness), I was suddenly aroused in the very early morning, say, three or four a. m., out of a perfectly sound, and, as I should call it, dreamless sleep, by the apparition of a telegram written on the usual paper, and presumably from home, in these words: 'Miss Dorothea died at ----,' all the rest being blurred and indistinct, but these words having a startling distinctness and a vivid sense of reality. I was not, I think, in the least degree alarmed at first, and certainly had no superstition about it on discovering that it was only a dream; but, failing to get any more sleep, I rose early, took my bath as usual, and went on deck, where I had to repeat the story of my dream to each one of some three or four companions who were on board, of whom I will only mention Sir. John Batty Tuke, Professor Young of Owens College, and Professor {677} Cunningham, then of Trinity College, Dublin. Any of these gentlemen will confirm my saying that I attached no special importance to this dream in the way of a scare or a superstition, but in this way it got abroad to a certain extent within a small circle on board in such a way as would have ensured it a widespread fame had it only come true. In discussing the matter at breakfast I remarked (alluding to telepathy) that the telegram was clearly, judging from its terms, not from my wife or any member of my immediate family, and could only have been despatched by a servant or some one with whom I could not be supposed to be in telepathic rapport. From this point of view it clearly refuted itself, and yet the effect upon my mind was such that, upon arriving at New York, I at once despatched a telegram announcing my arrival and making inquiry, the reply to which showed that the family were pursuing a quite undisturbed course at St. Andrews."

Sir William describes himself as aroused out of sound sleep by the apparition of a telegram, but I think this only means that he became suddenly awake on seeing the telegram during sleep. He does not say whether he knew in his dream that he was a passenger on a great ship on the mid-ocean, but he says that the telegram was written on the usual paper by which I take it that he means the paper used here on shore.

If it happened that the death of Miss Dorothea took place about the time of the appearance of the telegram to so distinguished a man as Sir William in his sleep, I scarcely think there would be any more startling record of a so-called telepathic message. But most happily the death did not take place, so that the story of the dream will be forgotten. Tens of thousands of similar dream stories have that fate.

Children's Dreams.--There is an old tradition that to tell our dreams causes them to come back, or at least to recur in some other form. This tradition is so old and so universal that probably there is more in it than might at first be thought. This emphasizing of certain forms of unconscious cerebration probably encourages their repetition, or, at least, the repetition of further processes of the same kind. There seems to be no doubt, too, that the reading of certain kinds of imaginative writing and the looking at exciting pictures sometimes leads to dreams about them. Certainly children should not be told terrifying stories and the more nervous they are and the more affected they are by such stories, which to some people make renewed temptations to tell them, the more should they be avoided.

Any physician who has had much experience with city children, especially in New York City, is likely to know how exciting, tragic and, above all, melodramatic scenes serve as the basis for disturbing dreams and night terrors. They will not, of course, in vigorous, healthy and strong-minded children, but these are the ones who are most prone to play out of doors and so are likely to be less bothered. Just the nervous, old-fashioned, delicate children who prefer the theater to sports of other kinds, are likely to be most affected in this unfortunate way. The scenes become so real to children that they impress them very deeply and are readily rehearsed in the unconscious cerebration of sleep. Many a child sees in its dreams someone, often a near relative, fastened on the carriage of a sawmill and inevitably approaching a buzz-saw, or fastened inextricably to the rails while an express train thunders down on them. That they should wake up with a start and a scream of terror and lose most of their night's sleep and disturb that of others, is not surprising. It is well known how witnessing actual danger, as of an automobile accident, or a railroad wreck, disturbs a child's imagination for long after; and its theater experiences are almost as actual as the reality.

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Many of the colored supplements of Sunday newspapers seem to be particularly undesirable literature for children in this respect, though, of course, there are many other reasons why children should not be encouraged to look at them. It is not unusual for the newspapers to give lurid pictures of wonderful dreams or things that happen in dreams. This is undoubtedly a suggestion that acts in causing nearly all children, but especially those of nervous organization, to dream much more than would ordinarily be the case. It recalls the old warning about telling dreams. These sets of pictures certainly serve to develop the imagination of the child along undesirable lines. Possibly some of them which emphasize the fact that after eating certain very undesirable foods, dreams are much more likely to come than at other times may not be without their prophylactic sanitary value, but this is a doubtful advantage compared to the psychic harm that they bring. I am not of those who would limit the fairy stories and other pleasant essays in imagination which delight children so much and form a desirable part of their education, but artistic effort that is terrifying or deterrent, whether with pen or brush, should be kept away from them until after their mental control is well established. Children will probably dream anyhow, and, therefore, should have a pleasant fund of imaginative material as a basis for their dreams.

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X. DISORDERS OF MEMORY

Many patients suffering from various nervous symptoms insist that they are losing their memory or that it is becoming notably deficient in some ways. If they are a little on in years they are sure that their memory is not as good as it used to be and that they now forget many things that were formerly remembered without difficulty. Especially are they likely to assert that the names of people and certain words will not come to them when they want them, that they often have to seek for facts and dates that should be quite familiar, that they fail to remember acquaintances and the like. These symptoms of which they complain are often sources of considerable worry and serve to emphasize in them the idea that there is something serious the matter with their general health, or some pathological condition developing in their brain. They have heard much of loss of memory as a sign of degenerative nervous diseases and they are prone to think that their own special loss of memory, be it real or imaginary, must be a forerunner, or perhaps even an early symptom, of some important organic lesion.

This idea of progressive memory disturbance as a preliminary of nervous breakdown often becomes so firmly fixed as to be of itself a profound source of anxiety to patients, and an almost unspeakable dread. So it is important to make them understand what the real nature of their condition is and what their loss of memory, supposed or real, is due to. As a matter of fact, what many of these patients need is not treatment for a diseased memory, but reassurance from what we know about the psychology of memory, that their troubles are only quite natural incidents in the life history of their particular memory {679} faculty. Many a man who is worrying about his supposed loss of memory or, at least, impairment of it in some way, is not suffering from a true pathological condition, but is usually the victim only of some functional disturbance of the nervous system with the neurotic anxiety and heightened introspection that accompanies such a condition.

Reasons for Memory Difficulties.--Nervous patients particularly complain that they do not remember what they wish to as easily as they used to a few years before. They say that it is much more difficult for them to impress things upon their memories and, in addition, that it is much easier for them to forget. There are three quite natural reasons for these phenomena as far as they actually exist, which should be pointed out to these patients. The first and most important is that they are incapable of that concentration of mind which they had in earlier years and which enabled them to give themselves up so completely to the consideration of a particular subject that it could not help but be impressed on their minds. They are now so much occupied with many other things, and, above all, most of these patients are so preoccupied with themselves that they cannot hope to have the concentration of mind that was comparatively easy when they were younger and is now impaired, but which is so necessary for the enduring remembrance of things. Secondly, their over-anxiety to remember things sometimes acts as an inhibitory motive in securing that deep, impression that will enable them to remember details very well. Thirdly, their supposed impairment of memory is due to a false judgment with regard to themselves. They are not comparing their power of memory now with what they used to have, but owing to anxiety about themselves they have taken to comparing themselves with others and, after all, the faculty of memory acts very differently for different people and it is well known that what one man remembers with ease another recalls with difficulty, or only because of special attention.

Attention and Memory.--The first of these causes for supposed impairment deserves to be discussed further. It is often said that as we grow older our memory is not so retentive as it used to be, and that while we remember the events of boyhood and the things we learned in the early years of school life, our recollection of recent events and things learned in later years is much less vivid. This is all very true, but the reason usually given, that in the meantime our memories have failed in power is inconclusive. What we learned in early childhood came to us with the surprise of novelty and for this reason we paid close attention, it was new and impressed us with its importance, it was dwelt upon for long periods and often, because there was little else to think about, has been frequently recalled since and, of course, is indelibly impressed upon our memories. The same thing is true with regard to early acquaintances. We got to know them so well that, of course, we cannot forget them. What we have learned in later life, however, has come in the midst of many other things, has not been dwelt on very long, has not been often recalled and, of course, occupies much less place in the memory than the things of earlier life. That is not, however, because of any defect in memory, but because of lack of attention and repetition that means so much for memory.

Age and Memory.--It is often said that people do not learn so readily when they get older. This is, of course, a truth of common experience, but {680} it is not because of dullness of the faculty of memory, but failure to concentrate the attention sufficiently for memorizing. I have known old men who could learn things just as well as any young man and indeed better than most of them. They were men who had been accustomed all their lives to concentrate attention on the subject they had in hand and who did not allow the cares and worries of life to intrude on their studies. Cato learning Greek at eighty is often quoted as an exceptional example, but I have had some dear old friends who could learn things quite as readily as younger men and whose minds were just as bright and clear. Whenever they devoted as much attention to anything that they wanted to remember as they did when they were younger men, I am sure that they remembered quite as well. It is a question of attention and not of any loss of faculty that makes the difference between the memory of the young and the old until, of course, senile impairment actually comes.

Solicitude and Memory.--Everyone who has had to depend much on his memory knows that over-anxiety with regard to the recollection of anything may seriously inhibit the power to recall it. Public speakers know that to hesitate is to be lost. If they want a particular name or word which they know often escapes them, they must with confidence begin the sentence in which it is to occur, though perhaps wondering all the time whether the word will be on hand or not for them to use it. Occasionally it will not come, but as a rule it turns up just in time. If they allow themselves to be disturbed by the thought that the word or expression may not come, then they know the hopeless vacant blank that stares them in the face when they want it. They have to make a circumlocution in the hope that it may turn up. Some let it go at that, but many start another sentence in the hope to tempt it to come and often it will eventually come, but sometimes it persistently refuses to come. That is not a loss of memory but a failure of neuron connections. There are some of us who know that certain words will always do that with us. Archimedes has bothered me for years and his name will often not come when I want it. Then there are certain words with regard to which transposition is likely to take place. We involuntarily and unconsciously substitute one word for another. We call one man by another's name. We have done it before and we know that we are likely to do it again. Somehow the connections in memory exist along these wrong lines and are constantly mismade. The name of something a man has written comes up instead of his name. This heterophemia is often noted in men of excellent memory.

Peculiarities of Memory.--Memory is an illusive and elusive function at best. All of us have had the sensation of having a word, and particularly a name, on the tip of our tongues. We often know the first letter and sometimes the first syllable of it. What memory brings to us, however, may not always be the first syllable of a word or name, though we are prone to think it must be, and we may go looking for it in the dictionary of names only to discover after a time that we are many letters away from its beginning. Very often we have to give up seeking in sheer inability to get a hint of it and then of itself it will come a little later. Sometimes it will come when we no longer want it. As a rule, words that have escaped us once in this way are prone to do so again. Over and over again the experience will be that {681} a particular word or group of words escapes our memory, or at least fails to be at our command, as most other things are. Those of us who are not much given to introspection take no notice of these difficulties which are common-place experiences enough, but the man or the woman who is looking for symptoms, who is prone to believe for some reason or other that his or her memory is failing, will take these hints of the more or less natural fallacy of memory as confirmations, strong as direct proof of the fact that memory is seriously deteriorating.

Such pauses and lapses of memory are much more likely to occur if we are nervous and over-anxious about possible loss of memory. I was once asked to attend for a few hours before the time fixed for his oration one of the greatest orators of this country, who was about to talk at a university commencement. What surprised me was that this practiced speaker, who had often appeared before very large audiences, took a very light meal in considerable trepidation, immediately after asked to have certain books brought to him and certain facts looked up for him, took notes in a hurried, feverish way and generally displayed all the over-excitement of the schoolboy about to make his first oration. He was a magnificent occasional speaker, often called upon, yet he assured me that it was always thus with him and that the reason for it was that in spite of previous preparation--and the finish of his orations made it clear that he had devoted much thought to them beforehand--certain of his facts and names and dates had the habit of slipping from him in the midst of the development of his theme, unless he had refreshed his memory with regard to them immediately before, and that he feared that sometime he would find himself in the midst of an address with an absolute blank before him and that he would be compelled to sit down in disgrace. He had never done so and never did in the many years that he, lived afterwards, though always with this dread, never trusting his memory as most people do.

Name Memory.--There are certain circumstances in which memory may fail and yet no significance of a pathological nature can be attributed to the fact. All of us probably have had the disturbing experience of undertaking to introduce two friends whom we had known for many years and yet having to ask at least one of them for his name before we could make the introduction. It is not that we did not know the name, but at the moment we were utterly unable to recall it. After this has happened once or twice it is prone to happen again, because when we set about introducing people the thought of the previous unfortunate occurrences of this kind comes to our mind and acts as an inhibition of memory, making it impossible for us to recall names. Not infrequently if we are brought to the pass of having to ask one of the parties for his name we have to ask the other, though it was on the tip of our tongue a moment before, because in the meantime the disturbance of mind incident to having to ask has interfered with the train of recollection. Men have been known to forget their own names under circumstances of great excitement and such a forgetting is not pathological, but only a physiological disturbance of function because of secondary trains of association set to work in the brain which disturb ordinary recollection. Of course, some people have an excellent memory for names and never have such experiences, but they are very rare, though practice in recalling names does much to keep {682} people from such embarrassing situations. On the other hand, there are some people especially gifted with name memories. Napoleon could recall all his soldiers' names.

Fatigue and Memory.--Occasionally it happens quite normally that when we are very tired certain portions of our memory at least become vague and indefinite and may even fail to respond to any excitation on our part. Under these circumstances we seem to be able only with considerable effort to exert the effort necessary to bring about such connections of brain cells as will facilitate recollection and reproduction and we may fail entirely. In a foreign country it is, as a rule, much more easy to talk the language in the morning when we are fresh than in the evening when we are tired. Especially is this true if we are asked to pass from one foreign language to another, which always requires a special effort. Everyone who has traveled must have had the experience that on crossing the frontier suddenly to be addressed in German after he has been talking French for weeks, may quite nonplus the traveler, even though he knows German as well or even better than French. This is especially true if much depends on the answers, if he has been addressed by a railway official or customs inspector. Apparently there must be a momentary wait until some shifting operation takes place in the brain before the German memory can get to work to establish the connections necessary to enable him to talk German. After a man has been talking to a number of people in one foreign tongue he is likely to be quite lost for words for a moment if he has to use another. The effects of fatigue and excitement and unusualness upon memory then must be remembered in order to be able to reassure patients who pervert the significance of the phenomena.

Ribot gives an excellent personal illustration of this peculiarity of memory in his "Diseases of Memory," which is worth recalling here. He says:

I descended on the same day two very deep mines In the Hartz Mountains, remaining some hours underground in each. While in the second mine, and exhausted both from fatigue and inanition, I felt the utter impossibility of talking longer with the German inspector who accompanied me. Every German word and phrase deserted my recollection; and it was not until I had taken food and wine, and been some time at rest, that I regained them again.

Sensations and Memory.--Just as soon as people compare their memories with others, as they do when they worry and begin to grow introspectively self-conscious, they find noteworthy differences and because of differences they will be prone to think that their memory is pathologically defective when it is only different, or, still more, that because they are not able to remember some things, as others do, their memory must be failing. It is well known that some people have a good memory for things seen, others for things heard, and still others only for things in which they have taken actual part. These are spoken of as visual, auditory and action memories. Memories for things seen are divided into special classes. Some people remember forms very well, while others remember colors. It is evident that our memories are somehow dependent on the special mode in which sensation affects us and that our acutest sensations are the sources of our longest and best memories. Color vision defectives are not affected much by colors and easily forget them. The tone-deaf have no memory for tunes. Every sense defect affects the memory. Sense defects are often unconscious. Their effect on memory may {683} only be noted when introspection begins to bring out the special sensation and memory qualities of the individual. Nature, not disease, may be the basis of some memory troubles thus brought to recognition. All these curious phenomena with regard to memory need to be recalled whenever there is question of a supposed deterioration of it, for it is not easy to decide such a question.

Limits of Normal Forgetfulness.--Curious instances of forgetfulness may occur in the experience of men with excellent memories, which, when they happen to persons morbidly inclined to test their every act, are interpreted to signify something much more serious than they really mean. Nearly everyone has had more than once the experience of telling a story to a particular group of people and then forgetting all about having told it and coming back a few days later to tell it over again. Occasionally a teacher hears the same lesson a week apart and yet does not remember that he went over it before, though the class is almost sure to do so. A man may repeat a lecture that he has given before to the same audience without realizing it. The story has been told more than once of a clergyman delivering the same sermon on two Sundays in succession and, though such lapses are very rare, they do not necessarily indicate a failing memory, but may only mean a lack of concentration of attention on the part of the human mind. Prof. Ribot in his "Diseases of Memory" tells the story of one such case in which the subject was quite alarmed lest it should indicate that he was beginning to suffer from some serious memory disturbance due to brain disease, though there was no ground for his fears:

A dissenting minister, apparently in good health, went through the entire pulpit service one Sunday morning with perfect consistency--his choice of hymns and lessons and extempore prayer being all related to the subject of the sermon. On the Sunday following he went through the service in precisely the same manner, selecting the same hymns and lessons, offering the same prayer, giving out the same text, and preaching the same sermon. On descending from the pulpit he had not the slightest remembrance of having gone through precisely the same service on the preceding Sunday. He was much alarmed and feared an attack of brain disease, but nothing of the kind supervened.

Attention not Memory.--When patients come with complaints of the loss of memory, the most important thing is to analyze their symptoms carefully. This will usually enable us to give patients ample reassurance. I have known men who were convinced that they were losing their memories because of their failure to recall important details in their business affairs in the midst of much hurry and bustle in the winter time, find that when they were living a simpler life in the course of travel or life in the country during the summer time under conditions different from the ordinary, their memory could be absolutely depended on for trains and travel details and all important matters to which they were now devoting attention.

Cultivating Looseness of Memory.--Many people complain of loss of memory in the sense that they do not now remember when things took place as well as they used to. For instance, I have had men of fifty tell me that they were sure that their memories were growing weaker than they used to be because a number of times within a year they had found that events which they thought had taken place only a year or two ago really dated four or {684} five or even more years in the past. Some are considerably disturbed by this. As a matter of fact it is only another instance of lack of attention. Most of what we read in newspapers attracts so little of our serious attention that it is no wonder that we do not recall with exactness when events took place. Events crowd each other out of memory. Newspaper reading is, indeed, the best possible cultivation of looseness of memory that we could have. We do not expect to remember what we read. We would probably grow distracted if we did. At the end of the day if you ask a man what he read in the morning paper he will have no idea at all, unless something especially startling or particularly interesting to him has turned up. After a week we could no more separate Monday's from Tuesday's news of the week before than we could recall a random list of events, having heard it but once. We cultivate looseness of memory with great assiduity. Let us not be surprised if, to some extent, we succeed.

Memories Individual.--People are often much worried over children's memories and may communicate this worry and anxiety to the children themselves, making them solicitous. It is probable that our memories are like our stature. They are what they are. By thinking we cannot add a cubit to the one nor facility to the other. The training of the memory is a very small element compared to the natural faculty. It must not be forgotten, however, that many distinguished men have been noted for rather bad memories when they were young and yet these faculties have developed quite enough to enable them to accomplish good work afterwards. The memory is, after all, a comparatively unimportant faculty in itself and other intellectual faculties surpass it in significance. It is the faculty that first develops, however, and so a child is often thought to be intellectually slow when it has not so bright a memory as its companions, though a little later its other faculties may develop so as to put it on a plane above its fellows. Memories, too, are very individual and may not retain any of the ordinary subjects, while they may be very attentive for certain special lines of thought. This form of the faculty is better, for the encyclopedic memory is usually of little use and, except in high degrees, encourages superficiality rather than real knowledge.

As a matter of fact, few of our greatest thinkers have had what would be called brilliant memories and it would almost seem as though the diversion of mental energy to this faculty rather disturbed the development of the others. Many a distinguished man has been rather notorious as a child for bad memory, so that in the early days when memory was the only faculty called upon at school he was set down as a dunce. Perhaps the most striking example of this was Sir Isaac Newton, who was actually called a dunce, and yet the world would welcome a few other such dunces. Thomas of Aquin, the great medieval writer on philosophy and theology, who still influences philosophy so much, was so slow as a young man that he was called by his fellow pupils "the dumb ox." His great teacher, Albertus Magnus, recognized the depth of mind that his fellow students could not see and declared that the bellowings of that "ox" would be heard throughout the world. Sir Walter Scott was spoken of as a very backward child. This is all the more surprising to those who know and appreciate the wealth of information that he put into his Waverley Novels. Goldsmith, than whom we have no more brilliant writer in English, seemed not only a dunce as a child, but all his {685} life, so far as outward appearance went, was a numbsknll. This was due to a lack of readiness rather than any lack of wit.

Tricks of Memory.--Some tricks of memory may be very disturbing to those who are over-occupied with themselves and with the possibility of losing their memory. For their consolation it is well for the physician who hears their complaints to have at hand some stories that illustrate certain of these curious tricks of memory. I had been trying to persuade a literary woman for some time that it was not her memory that was playing her false, but merely her habit of attention and lack of concentration of mind on things because she is occupied with a great many interests, when one day she came to me with what she thought was absolutely convincing proof that her memory was going. She had read a passage in a newspaper the day before which she liked very much, but after reflection it sounded strangely like some of the things that she had thought along these lines herself. It was a quotation, but there was no indication to tell whence it came. A little inquiry, however, showed that the quotation was from an article of her own written only two years before. Here was definite proof of a failure of memory. Strange as it may seem, however, this experience is quite common. I feel sure that there is not a single writer for periodical literature who has not had similar experiences. Anyone who writes much editorially, where the articles are unsigned, finds it rather difficult two or three years later, as a rule, to be absolutely sure which editorials are his. Occasionally it happens that even by the time the proof comes back for monthly periodicals, say six weeks or two months, some at least of what was written may seem quite unfamiliar. This will be particularly true if phases of the same subjects have been treated in successive articles and thus repetitions are caused.

There is plenty of good warrant for such occurrences in the lives of distinguished writers. Scott once heard a song in a drawing-room that he did not care for very much and he said rather contemptuously, "Oh! that's some of Byron's stuff." His attention was called to the fact that he was the author of the stuff himself. Carlyle confessed to Froude when Froude went over some of the passages of Carlyle's own autobiography with him, that he had quite forgotten some of the things written down there. Manzoni, the distinguished Italian writer, whose "I Promessi Sposi" has probably been more read throughout Europe than any novel written during the nineteenth century, except possibly some of Scott's, tells some stories of his own lapses of memory and, above all, of having once quoted a sentence of his own to confirm something that he was saying, though he confessed that he did not know by whom the quotation had been written.

Memory and Low Grade Intelligence.--There are many people who complain of their memory and of their inability to recall many things which others recall without difficulty. They are prone to think that this is some defect in them and not infrequently, as a consequence of comparisons, they persuade themselves that their memory was better and that it has lost some of its qualities. Until they became familiar with some of the feats of memory possible of performance by others, they were quite satisfied, but now they find in every instance of forgetting a new symptom of an increasingly deficient memory. I have found in these cases, that setting before such people some of the curiosities of memory, and especially the fact that memory is by no {686} means necessarily connected with profound intelligence, so that, indeed, its presence is quite compatible with a low grade of intelligence or even with what is practically idiocy, will do much to rob these gloomy forebodings of their terrors with regard to their own supposed deterioration of intellect. Ribot, in his "Diseases of Memory" [Footnote 52] has an excellent passage in which he sums up a number of these peculiarities of memory that are likely to be especially consolatory to people of ordinary memory who are worrying about themselves.

[Footnote 52: International Scientific Series, D. Appleton & Co., New York.]

It has long been observed that in many idiots and imbeciles the senses are very unequally developed; thus, the hearing may be of extreme delicacy and precision, while the other senses are blunted. The arrest of development is not uniform in all respects. It is not surprising, then, that general weakness of memory should co-exist in the same subject with evolution and even hypertrophy of a particular memory. Thus certain idiots, insensible to all other impressions, have an extraordinary taste for music, and are able to retain an air which they have once heard. In rare instances there is a memory for forms and colors, and an aptitude for drawing. Cases of memory of figures, dates, proper names, and words in general, are more common. An idiot "could remember the day when every person in the parish had been buried for thirty-five years, and could repeat with unvarying accuracy the name and age of the deceased, and the mourners at the funeral. Out of the line of burials he had not one idea, could not give an intelligible reply to a single question, nor be trusted even to feed himself." Certain idiots, unable to make the most elementary arithmetical calculations, repeat the whole of the multiplication table without an error. Others recite, word for word, passages that have been read to them, and cannot learn the letters of the alphabet. Drobisch reports the following case of which he was an observer: A boy of fourteen, almost an idiot, experienced great trouble in learning to read. He had, nevertheless, a marvelous facility for remembering the order in which words and letters succeeded one another. When allowed two or three minutes in which to glance over the page of a book printed in a language which he did not know, or treating of subjects of which he was ignorant, he could, in the brief time mentioned, repeat every word from memory exactly as if the book remained open before him. The existence of this partial memory is so common that it has been utilized in the education of idiots and imbeciles. It is worth noting that idiots attacked by mania or some other acute disease frequently display a temporary memory. Thus, an idiot in a fit of anger told of a complicated incident of which he had been a witness long before, and which at the time seemed to have made no impression upon him.

Training Memory.--In recent years in many departments of therapeutics training has been found to be of value. This is especially true with regard to nervous defects. Probably one of the greatest surprises that nervous specialists have had in the last twenty-five years in the domain of therapeutics came from the introduction of Frenkel's methods of retraining the muscles in locomotor ataxia. This idea of retraining has been found useful in such distinct departments as the use of the eye muscles, the co-ordination of the muscles of speech, so as to get rid of stuttering and stammering, and the muscles of the hand for writing. We are only just beginning to realize that retraining can be of great value in psychic affections also. Patients may be disciplined against their dreads and tremulousness due to over-apprehension and against even certain defective uses of their intellect. Urbantschitsch of Vienna showed that by training defective hearing it might in many cases be very much improved. What he accomplished, however, was not {687} any better use of the external auditory apparatus, but a more intense attention of mind which enabled the patient to catch and understand sounds which had hitherto been so vague that their significance was lost.

In a number of cases of complaint of loss of memory I have deliberately set patients to retrain their memories and have at least relieved their apprehensions if I have not always succeeded in increasing their actual memory power. It has even seemed, however, that in old people some actual improvement of the memory faculties was thus brought about. Under the head of Occupation of Mind I have referred to the exercise of memory in younger people as representing an excellent form of mental diversion. When the idea first suggested itself it seemed as though patients would not take to it at all, and yet I have found that with a little persuasion they become much interested and find a great deal of pleasure in their gradually increasing power to recall the great thoughts of great authors in the literal original words. A reference to that chapter will tell more of my experience. This made me more confident of the possibilities there were of making people understand that if they were losing their memories they could bring them back by proper exercise. In this way many of the modern evils of lack of attention and of failure of concentration of mind can be corrected.

My rule now is to tell patients who come complaining of loss of memory that if there is any real loss of memory it is due to their improper use of the faculty, or perhaps to their failure to exercise it sufficiently, for the proper performance of function depends on adequate exercise. They are then instructed to take certain simple classical bits of literature and commit them to memory. At the beginning such short poems with frequently repeated rhymes of the modern poets as are comparatively easy to learn are set as memory exercises. Later Goldsmith's "Traveler" and "Deserted Village" are suggested. Then passages from Shakeaspeare are given. Just as soon as the patient finds that he can commit to memory as he used to, if he only gives himself to the task, a change comes over his ideas with regard to the loss of memory. For many of these people the occupation of mind is an excellent therapeutic measure. Besides selections can be made in such a way as to keep before their minds the thoughts they most need in the shape of memory lessons. It is a discipline of memory that revives it and also a constant exercise in favorable suggestion.

Gregor in the Monattschrift fuer Psychiatrie und Neurologie, Band XXI, has detailed some of his experiences with the retraining of the memory of patients suffering from Korsakoff's Psychosis--alcoholic neuritis with psychic disturbances, especially of memory. The patient was required to learn words and then after a certain length of time was tested to see if he could learn a similar series with fewer repetitions than at first. The memory increased in capacity with the exercises and there was evidently a definite gain in the faculty. In this disease patients have also lost the power to some degree at least of recognizing objects. After exercises in recognition they are much more capable in this matter, however, and it is evident that in every way the memory can be improved. This experience, with a serious form of disease that gravely impairs the memory, shows how much can be accomplished in circumstances far more unfavorable than are those which usually bring patients to the physician complaining of deficiencies of memory.

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XI. PSYCHIC CONTAGION

The term psychic contagion is often thought of as merely figurative. It is, however, quite literal. Many minds are influenced by what they see happening round them and induced to imitate the activities of others. The term psychic contagion is so thoroughly descriptive of what happens that it deserves the place that it has secured.

Everywhere and at all times we find historical traces of psychic contagion compelling people to perform in crowds or groups the most curious and inexplicable and sometimes the most horrible things. Even in the old myths before the times of the Trojan War, we have the story of hysteria spreading among the daughters of King Proteus, so that the famous old physician, Pelampus, had to administer white hellebore in goat's milk in order to relieve them. It is probable that this rather heroic remedy with its definite effect upon the bowels produced such a revulsion of feeling as to cure the hysteria. Anyone who has read the awful tragedy that Euripides has written in the Bacchae will have had brought home to him a typical example of psychic contagion. The queen mother in the midst of one of the Bacchic orgies kills her own son in the frenzy that has come from the religious excitement exaggerated by the association of a number of women in the religious rites of the god Bacchus. It is well understood that this was not a case of drunkenness, but of psychic intoxication.

Phrygian Bacchantes are described as overcome from time to time by paroxysms of curious uncontrollable automatic movements with or without disturbance of consciousness. This represents the earliest form of what came to be known afterwards as St. Vitus Dance when it spread among a number of people. Such manifestations were not at all uncommon in the East in the earlier days and they have continued during all history. In Hindustan epidemics of automatic movements, evidently choreic in character, have been known for many centuries under the name of lapax. Outbreaks of this kind were common in the Middle Ages and Paracelsus has described them as happening early in the sixteenth century. At any time the occurrence of an hysterical seizure in a crowded hall, and especially in a schoolroom, will lead to other hysterical manifestations. A case of chorea will induce imitative movements in susceptible bystanders that may be quite uncontrollable. Tics of various kinds are readily picked up by children and special care must be exercised to prevent their spread. In general the state of mind is extremely important in all these conditions and they can be influenced favorably only through the mind.

Contagions Trifles.--Perhaps the extent to which psychic contagion influences us can be seen better in little things than anywhere else. Everyone knows how contagious yawning is. Again and again observations have been made while actors were yawning upon the stage. Nearly everyone in the theater begins to yawn in a few minutes and, in spite of the most determined {689} efforts, every now and then even the most serious-minded elderly gentleman in the audience finds himself unconsciously joining in. It seems foolish and to an onlooker appears almost prearranged. It is only necessary, however, to yawn a few times in a street car, especially at night, to have many imitators. Nearly the same thing is true of all respiratory phenomena. Sighing, for instance, is quite contagious. Coughing is often as much the result of imitation as anything else. At certain pauses in church services a preliminary cough is heard and then some scattering coughs here and there, like the musketry of scouts, and then a whole battery of coughs is let off, especially if it is in the winter time, because nearly everybody within hearing is tempted to cough. To talk about yawning or coughing or sighing before some people is almost sure to produce a tendency to these manifestations. These apparently trivial happenings help to explain many phenomena of human imitation in more serious things.

Most of the phenomena associated with expression are liable to be initiated as the result of imitation. Laughing, for instance, is particularly contagious among young folks and is especially likely to be insuppressible when they wish to be particularly solemn. At religious services it takes but little to make people laugh and giggle, no matter how much they may wish to be dignified and reverential. A few giggling girls will sometimes disturb a serious service. Extremes are particularly prone to meet in this matter and the sublime easily becomes the ridiculous. A titter will set off even the best intentioned of young folks in spite of resolutions to the contrary. Crying has something of the same contagious nature, though it is not quite so strong, but among women tears are particularly likely to evoke tears. The epidemic of curious manifestations of expression, usually of an hysterical nature, that we know by tradition to have spread in communities in the Middle Ages and much later, are only typical examples of this tendency for modes of expression to be contagious to an exaggerated degree.

Expectoration is largely dependent on imitation, sometimes conscious, of course, but often quite unconscious. In the recent crusade organized to prevent the spread of tuberculosis the question of expectoration as a diffusing agent of the bacilli has given a new importance to observations on this subject. It is recognized that we have "a spitting sex" and that men spit from force of habit, boys imitate them, while women and girls almost never spit. There is no reason in the world why when men and women are engaged in the same occupations there should be any difference in this regard between them, yet employers know how hard it is to keep corners and by-places in the rooms where men work free from expectoration, while no such difficulty is found where women work. We have a spitting sex because of psychic contagion, and in spite of the fact that there are serious dangers connected with the habit. What is true of spitting may also be true of other habits relating to the respiratory passages. Hawking and blowing the nose more frequently than is needed are spread by psychic contagion and certain habits in these matters that are injurious to the respiratory apparatus often require considerable effort to break.

Fads and Health.--Enlightened as we think ourselves, we have many more examples of psychic contagion in the present than we would perhaps care to admit, unless the facts were called to our special attention. {690} At a particular period in the modern time it becomes the fad to do things in a special way. We write alike, we build our houses after a common type. We take our recreation in a particular fashion. Bicycling comes in and goes out; roller skating attacks nearly every one of the young folks and then is abandoned. There are fashions in everything and fashions, after all, are recurring instances of psychic contagion. The mental influence spreads from one to another. It may be that a particular fashion, as in houses or in clothes, is especially ugly. That makes no difference. After a time taste revolts against it, but in the meantime the psychic contagion is enough to overturn the canons of taste. There are fashions in literature, or at least what is called literature. The nature novel comes and goes, then the novel of adventure has its place, then the detective novel, after a time the little-country prince or princess and their romance comes into fashion. After a time we realize that these are passing fancies, but in the meantime they have influenced many people.

Some of these fashions bring conditions that are deleterious to health. The moving-picture show in places that almost never have a stime of sunlight in them and are, in their way, quite as bad, especially for respiratory troubles, as the dust-laden atmosphere of the roller-skating rink, become the fad of the moment in spite of knowledge or ignorance of hygiene. Just now we are in the midst of a fad for fresh air, that, unfortunately, goes and comes with the centuries and we have no guarantee that people will not learn again to live in closely sealed houses. High heels come and go, as do corsets of various kinds, more or less injurious, in spite of the admonition of the physician. In fact, one of the most interesting studies in psychic contagion is the history of the fashions. A particular fashion, especially in its exaggerated forms, will probably look well on about one-fifth of the women at a given time. About four-fifths of them, however, adopt it in spite of the fact that on three-fifths it emphasizes certain qualities that it would be well to keep in the background. It is woman's principal desire to please, yet this is completely perverted by the psychic epidemic of fashion which causes people to follow after others quite as much as did the medieval people in various fads that attracted attention and have come down to us.

Our enlightenment, at least in as far as that word means general diffusion of the ability to read, has rather added to the power of psychic contagion. People accept ideas from others almost as unconsciously as they catch disease from those suffering from it. The psychology of advertising shows how easy it is to make people accept things just by insisting on them and by frequent repetitions of statements. The psychology of the proprietary medicine business in modern times is about as typical an example of psychic contagion induced deliberately as one could well imagine. Those who stop to reason do not fall victims. Most people, however, do not stop to reason. They have not the mental resistive vitality to render them immune to the influence of certain irrationalities and so literally hundreds of millions of dollars have been spent on perfectly useless, oftentimes harmful drugs, which people had become persuaded through the psychic contagium of printer's ink were sure to do them good. The psychology of the mob has been studied somewhat in recent years and it shows how clear it is that men follow after one another in doing foolish things even more than in doing wise ones. Psychic contagion is a prominent factor in life, it always has been, is now, and evidently always {691} will be, and must be reckoned with by anyone who wishes to recognize the principles that underlie psychotherapy.

Suicide Contagions.--It is with regard to much more serious things than fashions, however, that psychic contagion is most manifest. For instance, there is no doubt that suicide is frequently the result of such psychic influence. Seldom does it happen that a very queer suicide is reported without there being certain imitations of it more or less complete in various parts of the country afterwards. There is no doubt that the reporting of suicides has a serious effect in this matter. Perhaps the most striking example of this that we have ever had in America was the well-known suicidal epidemic at Emporia, Kansas, which reached its height just about the middle of June, 1901. Two or three well-known people in town committed suicide at the end of May and the beginning of June. A veritable epidemic of suicide broke out as a consequence. Nothing seemed to stop it and the authorities were much disturbed. Finally it was agreed that the most potent influence in bringing about the imitation of the epidemic was the publication of the details of the suicides in the papers. The Mayor of the city, after consulting with the Board of Health, decided to issue the following proclamation:

I have consulted the Board of Health, and if the Emporia papers do not comply with my request I shall have a right to stop, and I will stop summarily, the publication of these suicide details, under the law providing for the suppression of epidemics. There is clearly an epidemic in this city, and although it is mental, it is none the less deadly. Its contagion may be clearly shown to come from what is known in medicine as the psychic suggestion found in the publication of the details of suicides. If the paper on which the local Journals are printed had been kept in a place infected with smallpox, I could demand that the Journals stop using that paper, or stop publication. If they spread another contagion--the contagious suggestion of suicide--I believe the liberty of the press is not to be considered before the public welfare, and that the courts would sustain me in using force to prevent the publication of newspapers containing matter clearly deleterious to the public health.

Murder.--In almost the same way murders prove contagious. Especially is this true of murder and suicide together. These occur notably in groups. A man who is downhearted and for whom the future looks blank, will, out of a sense of pity for those who are dependent on him, murder them and himself; then the brutal story is reported and another tottering intellect gives way and a similar story has to be told within a few days. A mother who is melancholic about her health and includes her children in her gloomy outlook makes away with them and herself. Within a few days a similar story is reported because of the influence of psychic contagion. Very often there are distinct imitations of the methods employed in the first case. Often, however, it is only the idea itself that has proved contagious. There is no doubt that this suggestion brings about subsequent cases when otherwise such an awful thought might not occur. The connection is too clear for us to doubt the reality of it or to think that it is mere coincidence. As in Emporia, doubtless the suppression of the description of such events would have a beneficial effect. There are many disequilibrated minds, apparently just tottering on the verge of an insane act of this kind, that are pushed over by the suggestion furnished by the details of another story.

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Place of Psychic Contagion.--The physician who would treat nervous patients successfully and use psychotherapeutics to advantage must recognize the place that psychic contagion has in influencing the generality of mankind. We know that direct suggestions are profoundly influential. It must be constantly kept in mind, however, that indirect suggestion, suggestion that does not come by any formal method, but that is represented by the examples of those around, also has great weight.

Favorable Influence.--Fortunately it is not alone for evil that psychic contagion is manifest. People in a crowd stand fatigue better than when alone. Soldiers marching in step do not notice their tiredness to such a degree and even forget their sore feet. People suffering from hunger, so long as there is a good spirit among them, will help each other to bear it. The accidents in coal mines in recent years in which men have been imprisoned for considerable periods have shown that in groups they stand the hardships of confinement and of lack of food and water better than they do when alone, men live longer, they do not suffer so much or at least their suffering is not so insistent, and they bear up better.

This has been particularly noticed in the cures at various watering places. The very air of the place takes on a favorable suggestion that is helpful to patients. The routine, the hopefulness of those who are completing the cure, the stories of improvement, the evident betterment, all these things combine to give a psychic contagion of health. Health is, in this sense, quite as contagious as disease. This must be taken advantage of just as far as possible for the advantage of patients. On the other hand, ideas are contagious for ill and patients may derive from their environment notions that prove auto-suggestive and against which it is extremely difficult to work. Ideas derived from the general feelings of those around, without any direct suggestion, may become obsessions. The physician, therefore, must be ready to secure prophylaxis against psychic contagion and then by counter-suggestion relieve the patient, who has become afflicted by it, of the resulting disturbance of mind. It must not be forgotten that, instead of being less susceptible as education and civilization progress, people really become more susceptible.

Psychology of the Mob.--The most interesting instance of psychic contagion is the tendency just hinted at for crowds to run away with the sober judgment of serious sensible people that happen to be among them and do things that may be extremely regrettable. A mob always follows the suggestions of the worst elements in it unless perchance there is some extremely strong character who asserts himself and imposes his views on the rest. The tendencies to panic, to cowardly flight, sometimes to destructiveness, that come over crowds represent the power of psychic contagion to override reason. An alarm of fire will, if a few persons lose their heads, lead to the most serious consequences. Persons trample over one another, pull and maul one another, sometimes even pulling out hair or pulling off ears in their insane efforts to escape what is often an imaginary danger, though a few moments before they were rational beings and they will be quite reasonable a short time after. It is possible, however, to overcome even the worst tendencies in human nature by the suggestive power of discipline. Fire drills in schools enable children to get out in a few minutes without confusion when without them the most serious results could be looked for. Discipline and training, {693} following commands and observing tactics, helps an army almost more than the individual courage of soldiers. The suggestive influence of the thought that now is the time to do something that has often been done before at the word of command is enough to enable the soldier to control his panicky feelings. The difference between the trained soldier and the raw recruit is great, but it consists only in this mental discipline and self-control.

Prevention.--Evidently, then, in the many circumstances in life in which psychic contagion manifests itself it is perfectly possible to overcome its influence by such discipline and mental training as gives the individual control over himself. In children corporal punishment is often not effective in breaking up habits and tendencies and the motive of fear often lessens self-control and makes conditions worse. In older people the fear of punishment is likely to be forgotten, whereas the suggestion of discipline will assert itself powerfully. Psychic contagion can be neutralized by psychotherapy, but its force in life must be recognized and its unfavorable influence guarded against. While it concerns mainly the less serious things of life, it may affect the most serious and imitation leads even to such serious criminal acts as suicide and murder. The modes of psychic contagion, then, must be constantly under surveillance.

With this before us it is extremely interesting to realize how unfavorably suggestive for human health and happiness are our newspapers. They are constantly suggesting disease and suicide and murder and sex crimes and crimes against property, by giving all the details available with regard to these subjects. Such news can do no good, only excites morbid curiosity which requires still further satisfaction in the same line, and keeps thoughts with regard to these things constantly before the mind. We have had many burglaries and holdups and stealings of various kinds as a consequence of boys and even girls seeing the pictures of crimes in the moving-picture show. The saturation of mind with disease and crime produced by daily reading of unsavory and sensational newspaper accounts is sure to produce evil effects. There seems to be consolation for some people in reading of the crimes and punishments of others because they feel that, bad as is their own state, there are others who are worse. This schadenfreude, "harm-joy" as the Germans call it, is not satisfying to think of for human nature and it has an inevitable reaction through the unfavorable suggestion of these crimes.

I have found over and over again that the prohibition of reading the newspapers for a time did many nervous people much good. This is particularly true for sufferers from such forms of psychasthenia as bring down on them dreads and premonitions of evil in fears for the development of disease and in general a sense of instability with regard to the future, lest dreadful things should happen to them. At first patients object strenuously and seem to be deprived of a great satisfaction. After a time, however, they are invariably persuaded of the fact that the absence of mental contact with human misfortune, in this morbid way, is doing them good and that their dreads and premonitory feelings of evil drop from them.

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SECTION XIX

DISORDERS OF WILL

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I. ALCOHOLISM

In recent years so much has been said about addiction to alcohol as a disease rather than as a habit that the treatment of it frankly as a disease in psychotherapeutics, even though there be not entire readiness to agree with those who emphasize exclusively the pathological interest of these cases, will not seem surprising. It is with regard to the various habits, drug and alcoholic, occurring in neurotic subjects that psychotherapy proves most effective and has secured some of its real triumphs. As a matter of fact, it has long been conceded that all of the so-called cures for alcoholism are dependent for their success upon the mental effect produced upon the patient. Most of them emphasize the necessity for building up the physical condition of the patient as a necessary preliminary to any lasting cure. There is no doubt that the powers of resistance of a man whose physical health has been seriously impaired by over-indulgence in alcohol and the lack of food and irregular sleep and exposure to the elements that so frequently accompany it, will not be sufficient to enable him to break off the alcohol habit, nor afford him the ability to inhibit the craving for stimulants, that he would have in a state of health. On the other hand, even in good health, unless his moral character is braced up, there will surely be a return to his old habit.

Historical Resume of Cures.--We have had many different cures for alcoholism exploited during the last half century. The older method of the first inebriate asylums founded in this country was to give a man a disgust for liquor, as it was then called, by putting a small amount of alcohol into practically everything that he consumed. This did not give him enough to satisfy his craving, but it did create in him an intense distaste for it by constantly keeping the flavor before him. There was a drop or two of whiskey in his tea, there was some whiskey in his milk, there was a taste of it in the water that he drank, there was some of it mixed even in the gravy of his meat, and he always had weak brandy sauce on his dessert. The consequence was, in most cases, such a complete disgust for liquor that men were sure that they would never touch it again. Of course, in the meantime they were fed well and heartily, they were kept in an environment free from temptations to excessive indulgence in alcoholic drinks, they had brought home to them what a mess they were making of their lives and their health, they had time to reflect what ruin they were bringing on themselves and their families and usually they {695} recognized that they were the kind of men who must stay away from alcohol absolutely, for whom there could be no such thing as a moderate indulgence in stimulants. This, with the intense distaste for alcohol, amounting almost to nausea at the sight of it, acquired from the system in vogue, started them well on the road to reform.

Moral Cures.--It was the moral elements in the cure, however, that were the most important, though its inventors were sure that the physical elements played the largest role. The physical disgust for alcohol consequent upon having its taste constantly recur in everything at table passed off in a few weeks or at the most a few months. It was then that the moral uplift came in and had to be effective if the patient was to be preserved for the future from his old habit. If he was of a weak and flabby character, if, unfortunately, he was placed in circumstances where temptations were frequent, if, owing to the enforced absence in the inebriate asylum his business affairs had become involved and he was subject to many worries, then almost surely he dropped back. As a result his case was even more hopeless than before and, indeed, second cures were seldom of much benefit, for the man's confidence in himself was gone.

All in all, however, this old-time, simple method probably produced as large a proportion of "real cures" as any other method, even the much advertised and discussed scientific discoveries of modern times. All of us have heard stories of men who had seemed to be hopeless drunkards, who were thus reformed and hundreds of men who appeared to be drifting into hopeless inebriety were reformed to such an extent that they became not only useful members of society and supports to their families where they had before been a drain, but even became leaders in the work of uplifting the character of others to resist the temptation of over-indulgence in stimulants.

Modern Cures.--Of late we have had a number of "cures" for alcoholism widely exploited by well-directed advertising in the hands of men who realized what a fortune there was in this sort of thing and who actually have made immense sums of money out of them. Needless to say these "cures," though supposed to be secret, did not long remain so. Perhaps the most famous of them, the one whose institutes were found all over the country, was said to have used only two drugs, strychnin and apomorphin. The strychnin was given as a needed and well-chosen tonic for the physical condition of the patients who came to the institution usually in a rather seriously broken down condition. When patients began the treatment they were distinctly told that if they wanted whiskey at any time they could have it, but that the next injection of the "cure" after they took the whiskey would show how directly opposed to alcohol the ingredients of it were, by producing vomiting and prostration.

As a rule, the patients came in perfectly confident of the effect of the remedy they had heard so much of. The strychnin injections made an excellent tonic for these nervous wrecks, bracing them up at once so that they felt better from the very beginning and this betterment was confirmed by the growing assurance from the physician and the patients around them that now, at last, they were to be relieved of their degrading habit. To those whose craving for alcohol returned in spite of the favorable condition in which they were placed and the stimulation of the strychnin, which made up so well, as a {696} rule, for the absence of their accustomed alcohol, whiskey was actually allowed. When the next time for their injection came, however, these patients who had been given whiskey on their request did not now receive an injection of strychnin but instead a small injection of apomorphin. The apomorphin acted promptly in making the stomach relieve itself and produced a complete and immediate sense of prostration. The limpness and discomfort of seasickness is as nothing compared to the state that, as a rule, develops after such treatment. Anyone who has ever had to handle, in a hospital, a wildly drunk, long-shoreman, whose brute strength in his irrational condition made him a dangerous object for patients and physicians, who has seen even large doses of morphin fail to produce quiet, and then has felt bound for the patient's sake as well as those around him, to administer a tenth of a grain of apomorphin with the result of having an eminently tractable patient in a few minutes, will have a good idea of what happened to the poor alcoholic who got apomorphin instead of strychnin.

After that the inebriate knew that any further indulgence in liquor would be followed by this extremely unpleasant result and so he had a new argument for avoiding it. After a month or six weeks of careful treatment, the preliminary rest that would restore physical health and strength being followed by a course of exercise in the open air with plenty of good food, pleasant surroundings, and hope constantly held out to them, it is no wonder that these patients went out of the sanitariums as a rule confident that their habit was conquered for good. In many cases this proved to be true. It was soon found, however, that there were many relapses. This hurt the prestige of the "cure" and the gradual diffusion of this idea spoiled its effectiveness. It still continued to do good, however, and though it has been modified in various ways, and, indeed, in various parts of the country is said to be applied quite differently, there are still many reformations worked by these cures every year and they undoubtedly do good. The secret of its success, however, is not any marvelous drug or other mode of treatment that is employed, but is because the victims of alcoholism are given an opportunity to retrieve their physical condition and then to brace up their moral characters so as to resist their craving for alcohol.

Mental Influence.--Other so-called cures and treatments have followed almost exactly similar lines. The main element in the cure has been the producing in the mind of the patient a definite idea that he can stay away from liquor if he really wishes to and then helping his run-down physical condition so that he craves stimulants less than before. Whenever such "sure cures" are used on the worst forms of alcoholic patients as we see them in the large general hospitals of our greater cities, the bums of the streets, the drunkards of a score of years or more, they have practically no effect. The man must have moral stamina, he must have some character left, besides, as a rule, he must have some good reasons in worldly interest to help him to brace up and then he may get away from alcoholism if he sincerely wills to reform. The important element, however, is the will to do so. If he is firmly convinced that he cannot stay away from liquor, if he feels in spite of all that has been done for him that he cannot resist his craving, then, of course, he will not reform. Men, however, who have sunk to the lowest depths, who, according to their own and others' testimony, have scarcely drawn a {697} sober breath for ten or even twenty years, sometimes have something happen to them, often it seems very trivial to everyone but themselves, that stiffens their relaxed moral fiber, that wakens their sense of manhood, that serves quite beyond expectation to give them a new purpose in life, and they reform and never drink again.

It is this successful phase of the cure of alcoholism, however it may be explained, that is most interesting. It represents the most encouraging aspect of the whole question. Probably nothing more harmful has ever been done than the public proclamation that alcoholism is often an hereditary disease against which it is hopeless to struggle, and that the poor victims of it are to be pitied and not blamed. Except in those of low mentality, whether of intellect or will, or in the actually insane, there never was a case of alcoholism that did not deserve at least as much blame as is usually accorded to it. This is said after making due allowances for temperament. It is quite clear that for one man alcohol has no attractions at all, while for another the craving for it is almost an insuperable temptation. It is idle to say that these two contrasted men are equally free as to whether they shall take alcohol or not. Of course they are not equally free. If the man who has no craving for alcohol prides himself on his power of resistance against the vile habit, he is simply fooling himself. He probably knows nothing about the real nature of the temptation of alcohol. The Spaniards have a proverb: "He who doesn't drink wine and doesn't smoke, the devil gets by some other way." There is probably something else with regard to which the non-alcoholic has quite as little freedom as the poor victim of alcoholism and the great law of compensation comes in to make up to both of them, for their failings. Man has the defects of his virtues.

Supposed Inheritance.--No man is such a slave to the habit, however, that he cannot correct it if he will. We have heard much about the inheritance of this disease. We have heard even more about its essentially morbid character, though people used to think it a moral defect. It must still be considered a moral defect, however, even though we all concede that there is an element of the pathological in it. We are getting away entirely from the ordinary idea of inheritance of disease. There is no inheritance of acquired characters. The fact that a man's father acquired the drinking habit because he was placed in circumstances where it was easy for him to indulge himself and because he did not have the moral stamina to resist, is no reason why his son should have an unconquerable or even a very strong craving for alcohol. One might as well say that because a father lost a finger when he was young his son would be born without that finger. Alcohol destroyed certain cells in the father's body and injured certain others, but produced no change deep enough to lead to hereditary influences.

Contagion More than Heredity.--Perhaps some tendency to take alcohol runs in a family, that is, perhaps there is lessened resistance to the craving for stimulants that awakens in every human being if it is once aroused. This is what is true in tuberculosis. Some people have less resistive vitality to it than others. Careful autopsies show that practically every man who lives to be over thirty has or has had living tubercle bacilli in his tissues. Seven-eighths of us are thoroughly able to resist them. The other eighth succumbs. Their lack of resistive vitality may in some degree be due to hereditary taint, {698} but that is doubtful and we know that they acquire the disease by contact with others who have it already and, as a rule, it is able to work its ravages because they are not living in conditions that would help them to resist it. If they live in the free open air and have plenty of good, simple food, the disease will not run its fatal course, but nature will cure it. If the craving for alcohol is lighted up by association, aroused by indulgence, rendered strong by environment and by exposure to temptations of all kinds with regard to it, then the resistive power of the individual is so lowered that the alcoholic habit rules him instead of his being able to command it.

Inherited Resistance.--The most curious fact that has come out in our studies of heredity in recent years has been that far from heredity working its will in causing degeneration and deterioration of mankind, immunity, for the race at least, is acquired in the course of subjection to disease and to various morbid habits. Nations, for instance, that have been subjected to diseases for long periods no longer display the susceptibility to them which they formerly possessed. After a disease has been endemic among a people for many generations that people gradually becomes quite insusceptible to its effects and suffers much less from it than before.

Just this same thing is true of alcoholism. Nations that have been the longest in a position to be subject to the temptation to use alcohol in its stronger forms suffer least from the ravages of alcoholism. The southern nations of Europe using wine daily and knowing well the process of distillation to help them to make stronger drink for many hundreds of years, now exhibit much less tendency to over-indulgence in strong drink than the northern nations whose ancestors have only in comparatively recent times been subjected to the temptation of craving for strong alcoholic liquors. The attitude of any nation toward alcohol is a function of the length of time that nation has had a chance to procure strong drink easily. Our American Indians discovered, as has every people at some time, that intoxicating liquor could be made by allowing solutions of starch and sugar to ferment. It was only with the coming of the European, however, that they were provided with "fire water"--strong drink--in quantities. Its effect on them is a matter of history. Two things the white man brought his Indian brother to which the Indians were unaccustomed and that gradually obliterated the original inhabitants of this country--infectious diseases and strong alcoholic liquors. They proved equally fatal because of Indian susceptibility to them.

From these considerations it is clear that just such an immunity to the effect of alcohol is produced in a people exposed to its effects in concentrated form for a long time as with regard to an infectious disease when they have been correspondingly exposed to it. Heredity, then, instead of playing a role that brings about deterioration in the race, on the contrary, carries on the higher qualities and gives us, as might be expected in the course of evolution, a better, that is, a more resistant, race. Most of what is commonly said as to alcoholism, and unfortunately most of the recent so-called popular scientific articles on this subject, seem to point to just the opposite conclusion to this. Men are supposed to be condemned by heredity to an inevitable craving to take alcoholic drinks that, in certain of them at least, cannot be overcome by any natural power of resistance. At this stage of our western civilization this is not true for anyone, as the more susceptible families have been long {699} since eliminated and it is a personal weakness and not a family characteristic that leads people to indulge this appetite to their own destruction.

Unfavorable Suggestion of Heredity Idea.--An alcoholic patient, or even a man with only a moderately strong tendency to take alcohol to excess, who harbors any such notion as this, has a serious impediment to the full exercise of his will in overcoming the difficulties that he encounters in any attempt at reform. In going counter to so much that has been written and still more that has been said and generally accepted on this subject I feel it necessary to quote a good recent authority on the matter and so here insert these passages from "The Principles of Heredity" by Dr. Archdall Reid. [Footnote 53] He says (p. 157):

[Footnote 53: Author of "The Present Evolution of Man," "Alcoholism," "A Study in Heredity," etc. Chapman and Hall, London, 1905. ]

Formerly all the world believed in the transmission of acquirements, and consequently all the world was constantly finding conclusive evidence of its constant occurrence. To-day there is hardly a rag of that evidence left, and, with rare exceptions, only certain French medical observers are able to discover fresh evidence. It is a remarkable fact, however, that the problem of evolution--of adaptation--has excited singularly little interest in France, and it is equally curious that these French observations relate almost entirely to laboratory work which it is not easy to repeat. In Great Britain or Germany, you may cut off the tails of a thousand dogs, or amputate the limbs of a thousand men, or observe the non-infected offspring of a thousand tuberculous patients, and get no evidence of transmission.

With regard to alcohol Dr. Reid in the same volume insists on the proposition that alcohol does not cause degeneration of a race, creating, as is claimed, ever more and more a tendency for people to take it because their immediate ancestors have taken it, but, on the contrary, there is a distinct evolution against it, and that what is hereditary, not by acquisition, but by family trait, is an immunity against the disease which eventually protects the nations that have been longest exposed to the effects of alcohol from the evil consequences of the substance. He says (p. 196):

How, then, has alcohol affected the races that have used it? Are the Jews and the races inhabiting the South of Europe the most degenerate on earth? Are North Europeans only less degenerate? Are the races that have never used alcohol, the Terra del Fuegians, the Esquimaux, and the Australian blacks, for instance, mentally and physically the finest in the world? We have only to state the proposition to see its absurdity. There is no evidence that the hereditary tendencies of any race have been altered by alcohol circulating in the blood and acting directly on the germ plasm. Once again the sufferings of the peoples have produced no effect, but the deaths among the peoples have produced an immense effect. Every race that has had experience of alcohol is temperate in the presence of an abundant supply in proportion to the length and severity of its past experience of the poison. The South Europeans and the Jews are the most temperate peoples in the world. West Africans also are very temperate. North Europeans are not drunken. Those savages, and those only, who have had little or no experience of alcohol--Esquimaux, Red Indians, Patagonians, Terra del Fuegians, Australian blacks--are beyond all the peoples the most drunken on earth.

Lest it should be thought that this discussion of the subject is only of significance with regard to nations and does not touch the individual, and, therefore, has but little significance for the problem that we are treating here. Dr. Reid's succeeding paragraph deserves attention:

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Stated in this brief and direct way, the thesis is apt to excite incredulity. It is sharply opposed to popular beliefs, though that need not trouble us. Popular notions on abstruse points of science are occasionally erroneous. Of more importance is the fact that a mass of statistics purporting to prove that the children of drunkards tend to be degenerate has been compiled, especially by medical men in charge of lunatic asylums. But no "control" observations appear to have been made. We know that many drunken parents have normal children; certainly, therefore, parental drunkenness is not invariably a cause of filial degeneration. We know also that many temperate parents have defective children. There is nothing to show that the proportion is greater in the one case than in the other. Even were it established that the proportion of defective children is higher in the case of drunken parents, it would still have to be proved that the relation is one of cause and effect. People who have an inborn tendency to mental defect, who are abnormally depressed, nervous, restless or irritable, are often so constituted as to find solace in drink. Their children are liable to inherit their inborn mental defects with spontaneous variations--that is, to inherit the defect to a greater or lesser extent. The unborn child of a drunken and pregnant mother is practically another drunken person, as liable, or more liable to suffer from the effects of drink; but in such a case the resulting defect, though a mere acquirement, is tolerably certain to be regarded as a congenital (i. e. inborn) defect by the medical man who sees it. Mere acquirements, also, are the defects due to the ill-treatment, want and neglect to which the children of drunken parents are particularly exposed. Indeed, were it fully established that drunken parents, other than pregnant mothers, tend to have an excessive number of their children "congenitally defective," it would still be a question whether the filial defects were not mere acquirements. Prof. Cossar Ewart's observations on diseased pigeons renders this not unlikely. All these sources of error render the success of a statistical inquiry peculiarly difficult, if not impossible, but there is no indication that they ever occurred to the minds of the compilers.

Warnings as Suggestions.--I have a case in my notes in which a rather prominent professional man insists that he is quite sure that the alcoholism from which he suffered during the ten years between twenty-five and thirty-five was entirely due to suggestion. As a boy of sixteen he had gone off to boarding school, but not until his mother had taken him aside, told him that his father had drunk himself to death, had done it by secret tippling, and that they had found that for many years he had been accustomed to have whiskey near him in his office and take it rather frequently. He had never tasted spirituous liquor at this time and his mother begged him not to, for she felt sure that if he did his father's craving would awaken in him and would become uncontrollable. The day that he went away his father's eldest brother took him aside and said practically the same thing to him. A maiden aunt was not quite so emphatic, but she, too, pleaded with him to understand all the dangers. For his first year at school he did not touch liquor, but in his second year he tasted it once or twice but had no particular craving aroused in him. By chance when he was home at Christmas time some college mates who were visiting him gave his mother the impression that he belonged to a rather jovial set. Once more he was warned by mother and uncle. Above all they told him never to keep strong drink near him because that was what his father used to do. During his college years the fear of this hung over him. He resented it and probably took more liquor than he would have so far as actual craving went. After getting out into active life once more he suggested himself into the habit of taking an occasional glass of whiskey by himself. After a time he was constantly taking too much. For {701} ten years he hurt all of his prospects, broke his mothers heart, and was looked upon as a hopeless alcoholic. Then one day the thought came to him that it was not that he craved alcohol so much, but that his thoughts turned on it constantly and at first he dreaded it overmuch, then wondered what attraction there could be and then acquired a habit by suggestion. Once this train of thought worked itself out in his mind, he quit spirituous liquors for good. For ten years he has not touched them, he does not care for them, they do not constitute a temptation.

It must not be forgotten that many warnings may so preoccupy the mind with regard to a danger as to constitute temptations by suggestion. This is eminently true of alcoholism, the drug habits, sex habits and the like, in spite of the foolish present-day notion that information and warning must necessarily be helpful. In all these, teaching may be suggestively harmful.

Prophylaxis.--The most important part of the treatment of alcoholism through mental influence is by prophylaxis, and that, to be effective, must begin very early. Just as with regard to overeating, as I have pointed out in the chapter on Obesity, it is extremely important not to permit children to acquire habits with regard to alcohol when they are young. During the growing years the system, indeed one may say all the systems of the body--the nervous, the muscular, the digestive and the mental systems--are all more or less unstable. Deep impressions may be produced on them then, and if children are allowed, much less encouraged, during their growing years (and this includes practically all the years up to twenty-five) to indulge in alcohol, then one can look for the development of a craving very hard to eradicate later in life. Many of them will be able to conquer the desire thus awakened, but a great many of them will not. We have some very definite evidence on this point and some of it collected here in America is very valuable. Dr. Alexander Lambert of New York made a study of over 250 cases of alcoholism seen in the wards at Bellevue Hospital, paying special attention to the age at which the patients remembered they had begun the use of alcoholic liquors. If anyone doubts the influence of youth in this matter, then his statistics should be read:

Of 259 instances where the age of beginning to drink was known, four began before six years of age; thirteen between 6 and 12 years; sixty between 12 and 16; one hundred and two between 16 and 21; seventy-one between 21 and 30; and eight only after 30 years of age. Thus nearly seven per cent. began before 12 years of age, or the seventh school year; thirty per cent. began before the age of 16; and over two-thirds--that is, sixty-eight per cent.--began before 21 years of age.

Dr. Henry Smith Williams, commenting on Dr. Lambert's study of this subject in his article on "The Scientific Solution of the Liquor Problem," [Footnote 54] states emphatically the conclusion so inevitable from these statistics that more than anything else alcoholism is the result of habits and occasions created in early years. He adds some remarks that are worth noting for those who are interested in the prevention and cure of alcoholism, not only in particular cases, but also for the community:

[Footnote 54: McClure's Magazine, February. 1909.]

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In the light of such facts, it is clear that the drink problem is essentially a problem of adolescence. The cumulative effects of alcoholic poisoning frequently fail to declare themselves fully until later in life; but the youth who does not taste liquor till his majority minimizes the danger of acquiring the habit in its most insistent form; and the man who does not drink until he is thirty is in no great danger of ever becoming a drunkard. As to the man who has passed forty--well, according to the old saw, he must be either a fool or his own physician. His habits of mind and body are formed, and if he becomes a drinker now he can at most curtail by a few years a life that is already entering upon the reminiscent stage. As factors in racial evolution, the youth of each successive generation, not its quadragenarians, are of interest and importance.

Treatment.--The conclusions that naturally flow from the historical introduction to this chapter which show mental influence as the basis of all cures, simplify very much the treatment of alcoholism on psychotherapeutic principles. There is no doubt that moral means are the only really effective remedies in this matter. They fail often, not because of any lack of power, but because of lack of co-operation on the part of the patient. There are men whose mentality and responsibility is breaking down, and who are on the way to the insane asylum for various causes, who cannot be thus influenced. They are, however, not alcoholics, but incipient insane patients likely to go to excess in any line. There is no pretense that psychotherapy will cure mental disorder that rises to the height of real insanity. On the other hand, just as after several relapses of tuberculosis due to the foolishness of the patient, further improvement by sanatorium treatment is usually out of the question, so each relapse of the alcoholic patient makes it increasingly difficult to bring about noteworthy improvement. There are examples, however, which demonstrate that even after seventy times seven relapses men may still encounter something that rouses their dormant wills to real activity and then their alcoholism is a thing of the past, for good and all.

Sanitarium Question.--There always comes the question whether these cases need to be sent to a sanitarium or can be treated at home. The answer to this question is the same for alcoholism as it is for tuberculosis or, indeed, for any of the exhaustive diseases. It all depends on the individual's physical condition and his circumstances. If tuberculosis is discovered, as it should be, at a very early stage in the disease--not when the patient is coughing up bacilli in large numbers and already has many physical signs in his lungs, but when he has a slight unproductive cough and over-rapid pulse and some prolongation of expiration at one apex--then he may be cared for at home, if the physician is confident that he can make his patient feel the absolute necessity for following instructions and can make him realize the seriousness of his condition in spite of the few symptoms that are present. If his environment is unfavorable, in a crowded tenement house or where an abundance of fresh air cannot be readily obtained, the patient may have to go to a sanitarium for proper treatment even at this early stage, or at least he will have to change his living conditions.

This question has received a very different answer in recent years from what used to be given to it. Formerly the physician hesitated to say "tuberculosis" to his patient until the disease was well advanced and then he advised the distant West or some other change of climate, though, as a rule, this brought only a palliation of symptoms, the case being too far advanced, and {703} the fatal termination came in the course of two or three years. Now the careful physician diagnoses tuberculosis much earlier, detects the disease in its incipiency, and is able to treat the patient at home quite successfully, if conditions are at all favorable. It is true he has to make him give up fatiguing occupations, and especially those in dusty places; he has to insist on his living out of doors a good part of the day, even though there should be no better means of securing this than the roof or a fire-escape, and on keeping his windows open all night. He has to watch his nutrition carefully and see that he gains in weight. If all this can be accomplished, however, there is no reason why a tuberculosis patient in the incipient state should not get better at home almost as well as he would at a sanitarium. The only difference between the two methods of treatment is that in a sanitarium the patient realizes that his one duty in life is to care for his health and he does not bother about other things, as he is likely to do if he remains at home.

If this precious development of teaching with regard to tuberculosis, which is founded on such thorough-going common sense and the application of good therapeutic principles to the treatment of the disease, be transferred to the sphere of alcoholism, then the answer to the question whether there shall be sanitarium treatment or not is practically arrived at. If the patient is in an early stage of his alcoholism, if the pathological character of his tendency to take intoxicants has been recognized and made clear to him early, then there is little difficulty in treating him at home. The crux of the problem is just that which occurred with regard to tuberculosis years ago. The physician does not take the early symptoms of the affection seriously enough. He does not want to disturb his patient's equanimity by the suggestion that he is in the incipient stage of alcoholism any more than a few years ago the family physician cared to suggest the awful thought of tuberculosis until the condition had reached a serious stage. But this is the essential preliminary to the successful treatment of alcoholism just as it is to the successful treatment of tuberculosis.

It is almost useless to send advanced cases of tuberculosis, in which cavity formation has already occurred, to a sanitarium. The course of their disease may be delayed for a while, but scarcely more than that. Their resistive vitality has been so overcome by the ravages of the disease that their ultimate cure seems beyond hope, yet not infrequently wonderful results are obtained even in these cases. Just this same thing is true with advanced cases of alcoholism. No one can do anything with them, though careful treatment in a sanitarium may, on a number of occasions, afford them opportunity to brace up and be themselves, i.e., their better selves, for several months. Just as with tuberculosis, however, even the quite advanced cases will sometimes be so much bettered by sanitarium treatment that, though their prognosis seemed absolutely hopeless and was so pronounced by good authorities, all the symptoms are relieved and the patients get a new lease of life that may last for many years.

In the same way some apparently hopeless cases of alcoholism will brace up after sanitarium treatment and have many years of useful sober life without a break. In alcoholism, as in tuberculosis, the will of the individual is the all-important consideration. Someone has said that tuberculosis takes away mainly the quitters. Those who have the courage to insist that they {704} will live in spite of everything being apparently against them, pull through crises that seem absolutely hopeless and survive for years. Robert Louis Stevenson bravely doing his work, living on in spite of fate and disease, is the typical example. Alcoholism completely overcomes only the quitters. If a man wants to give up drinking even when he seems practically a hopeless wreck from the effects of alcohol, he can do so if he has a physician in whom he has confidence, who will relieve him from depressing symptoms due to previous excess, who will lift him up and strengthen him by food and stimulation, and, above all, by faithful, unending, never discouraged assurance that he can conquer the craving which has such a hold of him, if he only persists a little and does not give up the struggle. The victory is worth while and it is not hard to lift a man up if he has any remnants of character left.

Confidence.--In the treatment of alcoholism, then, just two things are necessary. One of these is that the patient has confidence in himself, the other that he has confidence that his physician can help him over the hard spots on the road. There is no doubt that many drugs can be used that will lessen the patient's irritability, increase his nerve force, stimulate organs which are depressed by the reaction against over-stimulation, arouse appetite and correct disturbed functions. All these things must be done. It is no use laying down any set of rules as to how they shall be done, for they must be done differently in individual patients. It is not alcoholism that is treated nor the effects of alcoholism, but an individual alcoholic patient, and a set of symptoms that are very different in every individual. The more physiological disturbance can be relieved by proper drug, dietetic, hydropathic and remedial measures, the more chance is there for the patient to get over his habit without trouble. Every ill feeling that he has tempts him to think of alcohol. Above all, he must be made to sleep, his bowels must be thoroughly regulated, and he must be made to eat heartily. For stimulation full doses of nux vomica, not less than thirty drops three or four times a day or even oftener, are probably best.

For cases of alcoholism in the earlier stages there is but little difficulty. Those who try the effect of favorable suggestion, of confident assurance, of constantly repeated encouragement on individuals who have begun to be afraid that they cannot break the habit, will frequently have the most gratifying results. The important point to remember is that men are suffering from alcoholism who are indulging in alcohol every day and to whom it has become more or less of a necessity, though even as yet its effect upon their business is not marked and they are not known, even among their acquaintances, as drunkards. Whenever a man must have three or four whiskeys a day or he cannot do his business and his appetite fails him and he does not sleep well, he is an alcoholist. He has the cellular craving that later may become an absolute tyrant. If we can educate the community generally to realize this as we are gradually educating them to the knowledge that tuberculosis must be caught in its incipient stage and that pulmonary consumption begins in very mild symptoms after a person has been exposed to it, we shall have little difficulty in curing tuberculosis or in treating alcoholism successfully by suggestion.

For alcoholism, as for the drug habits and also the sex habits, moral influences are all-important. Hence the necessity for exercising them {705} frequently. It is probable that the best way to break any of these habits is to have the patient come regularly to the physician's office, at least once, and at the beginning twice a day. In cases of alcoholism the method of giving for the first week, at least, the dose of the stimulant drug which replaces the alcoholic stimulation directly to the patient is often of great service. It seems a good deal to ask the patient to come three times a day just to get a drug (tonic), but it is comparatively easy to resist the craving for liquor for four or five hours, that is, until the doctor is seen again, while sometimes twenty-four hours will seem a long while. The personal element in this matter is extremely valuable. It is this that has made the efficiency of all forms of cures, and it is only this that can be successfully used.

How much can be accomplished for even the worst forms of drunkenness and under extremely unfavorable circumstances once a really strong impression is made on the individual's mind and his will is aroused to help himself seriously may be readily learned from the lives of any of the great temperance advocates. Their experience is illuminating. It shows clearly that strong personal influence will do more than anything else for these sufferers. Sometimes their efforts are supposed to affect only certain classes of individuals who have character but who, for some reason, have fallen into an unfortunate habit. A little investigation will show, however, that they affect all classes and kinds of individuals and, indeed, may reform a whole community. The story of Father Matthew is very interesting in this regard because there is some striking testimony as to his reformation of whole neighborhoods that had been given over to drink before and that among a people especially emotional and susceptible. The movement that he initiated still lives in the temperance societies of the English-speaking peoples everywhere which help by prophylaxis in youth and the moral force of association in later life.

After-Treatment.--In alcoholism the most important feature of the treatment is what has come to be known in our time as the after-treatment. This department of therapeutics has taken on great importance in recent years in every form of disease. For early and middle life most diseases have a definite tendency to get better, though many of them leave distinct pathological tendencies. The after-treatment, then, has become much more important than the cure for the patient during the existence of the acute or sub-acute stage. Even in children's diseases it is now generally recognized that while measles and whooping cough are not dangerous affections as a rule, they may prove the forerunners of tuberculosis, because of the weakened pulmonary resistance consequent upon their invasion. For scarlet fever, the possibilities of injury to the kidneys after the great irritation to which they have been subjected, is now recognized and convalescence is prolonged. In typhoid fever we realize that not weeks but many months of convalescence are needed to put the patient beyond the risk of various degenerative processes that may be serious. There is even question in the minds of many observant physicians whether the weakness incident to typhoid fever may not, if a premature return to work is allowed, prove a potent cause of precocious arterio-sclerosis.

In a word, after-treatment has become one of the most interesting subjects of modern therapeutics. It will not be surprising, then, if we insist that the after-treatment of the alcoholic is the most important part of the remedial methods to be employed. If a man who has suffered from tuberculosis because {706} he was working in one of the many dusty trades and living in a badly ventilated tenement house is restored to health or at least has all his symptoms disappear as a consequence of sanitarium treatment, it is almost needless to say that he must not be allowed to return to the conditions in which his disease originally developed. If he does, he is absolutely certain to have a relapse. This phase of tuberculosis has been much discussed in recent years. It is often said that it is impossible to keep working people from a return to their occupations. Just so far as that is impossible, so far will any real hope of keeping their tuberculosis in abeyance be reduced. They are much more likely to suffer from the disease, as a rule, after their return from the sanitarium than they were before they originally contracted it, because apparently some of their immunity has been destroyed by the invasion of the bacillus.

It is only recently that we have thus planned for the after-treatment of tuberculosis. If we are to be successful in the after-treatment of alcoholism, at least some of this same thoughtfulness must be exercised. The victims must be discouraged from going back into the conditions in which their habit developed. It is comparatively easy, especially at the beginning of his alcoholism, to stimulate a man back to normal physical condition, to reduce his craving for intoxicants, give him back his appetite and set him on his feet again. The affection is quite curable. If a man returns to the conditions in which it originally developed, however, it will develop again quite as inevitably as tuberculosis does under similar conditions. We do not blame the sanitarium if, after having given a man a new lease of life in spite of tuberculosis, he resumes the unsanitary life in which his disease originally developed and has a relapse. It is not the fault of the system of treatment for alcoholism if men relapse, but the blame is upon them that they do not take their danger of relapse seriously enough, permit themselves to get into an unfavorable environment, and, as a consequence, suffer once again from their affection.

Religious Motives.--More and more we are realizing the place of the higher motives of life in the reform of alcoholic patients. Religious motives probably form the best possible source of suggestions that enable a patient to lift himself out of the slough of despond of chronic alcoholism. Many of the best workers for the reform of the drunkard were themselves drunkards for many years. The motive of helping others is particularly important in its effects upon any alcoholic. Some motive apart from himself is more helpful than any appeal to his selfishness or even to what he can do for his children and his wife. It is the newer motive that appeals most strikingly. In recent years certain church movements have done much for alcoholic patients. In this they are only repeating the effect of other great church movements and the effect of the lives of apostles of temperance in recent generations. Without these higher motives cure is probably impossible in many cases. With them it not only becomes possible but even comparatively easy in the most hopeless-looking cases.

In the light of what we have heard recently of the success of the Emanuel movement in the treatment of alcoholism, it is interesting to recur to what was said in this relation by Prof. Forel of Zurich on the treatment of alcoholism, in a communication read to the South German Neurologists and Psychiatrists at its meeting in Freiburg over twenty years ago. Prof. Forel, who is not what {707} would be called a particularly religious-minded man, insisted that "an inebriate asylum can only with great difficulty be successful without religious auxiliaries, since most inebriates, and especially at the beginning of their reformation, are entirely too weak to get along without religious consolation. To secure this, however, the nicest tact is required in order to permit the practice of all the different nuances of faith that men have, in peace and comfort. This can only be secured if in practice faith is subjected to charity for one's neighbor as the basis for religion."

Many such expressions have been used before and since in practically every country in Europe. The assertion that physicians have failed to recognize the part that religion plays in such cases is entirely without foundation and can only be made by those who are quite ignorant of our medical literature.

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II. DRUG ADDICTIONS

Much of what has been said with regard to alcoholism finds ready application to the treatment of drug addictions. At the very beginning it must be realized that there is no specific remedy that will enable the patient to overcome his craving for a drag to which he has become habituated. There is no method of treatment that will infallibly and without serious and prolonged and determined effort on his part enable him to overcome his craving. The first and most important thing in any system of treatment is the patient's good will. If the patient is not ready to give up the drug, then nothing that a physician can do for him will make him do so, or will turn him against it; above all, nothing will make the process of cure so easy that there will be no trouble involved or only a passing period of struggle required to accomplish it. There have been many claims made in this matter. We have wanted such remedies and methods of treatment so much that it has been rather easy to persuade us sometimes that they have been discovered. It is like the question of specifics in medicine. For centuries men devoted themselves to trying to find a specific remedy for each disease. It was thought they must exist in nature. Now we know that they probably do not exist, though those who claim to discover them find an easy livelihood exploiting the credulity of those who still cherish the belief in them. Scientific students of medicine have practically given over the search for them in order to devote themselves to strengthen the patient to resist the disease rather than spend more time trying to find something to give him that cures it.

Treating the Patient rather than the Habit--This principle holds with special force with regard to drug addictions. We do not treat the patient's habit, but we treat the patient. He must be braced up, must be made to understand that if he wants to quit the habit, no matter how slavishly he is addicted to it, he can do so. He must be told of men who had habits like his, often of longer duration and to a greater degree, yet gave them up when firmly resolved and properly stimulated. It is not hard to find such examples, since medical and even ordinary literature abound with them and every physician's experience furnishes him with instances. The first and {708} most absolutely necessary preliminary of the treatment is to lift up the patient in his own eyes and make him understand that, low as he has sunk, his case is not hopeless, that his degradation is not at all uncommon nor so rare as he might think, and that men and women have succeeded in lifting themselves out of conditions worse than his. The psychotherapeutist must, above all, not be of those who insist that human nature is degenerating and that people are much weaker physically and morally than they used to be, though of course he must be thoroughly aware that drug habits are more frequent than they were and are quite alarmingly on the increase. This is not due to any deterioration in human nature, however, but mainly to the excitement of modern life and its inevitable reaction, the strenuousness with which men now take existence and the consequent craving for artificial relief from over-activity, and then, above all, the facility with which the habit-forming drugs can be obtained.

Prophylaxis.--This last point accounts for the frequency of drug habits in our time more than anything else. Men have always been ready to do something for the sake of novelty and excitement. Everyone is curious to experience for himself the effects produced by drugs that can make people such slaves to them. We hear too often of the intense pleasure that the drug habitue gets from his use of drugs. The curiosity thus aroused constitutes the suggestion that has led many to try the effect, confident that he or she would be able to resist any craving just before it became seriously tyrannous. Psychiatrists agree that one of the worst elements in modern social conditions is the impression generally maintained that there is such intense pleasure in the taking of drugs. A clear statement of the reality of the case is eminently desirable. It is not positive pleasure that the drug habitue has, but mere negative pleasure, as a rule. His "dope" does not so much add to his good feeling as take away the bad feelings that he has because of depression or ennui at the beginning and later because of the craving for the drug.

Physicians to whom many drug habitues have told their experience frankly are not at all inclined to think that the usually accepted opinion of pleasure in drug taking is true. It is not that it is heaven to have the drug so much as it is hell to be without it. The patient's system has learned to crave it so much because of the surcease of painful consciousness of self it gives and this it is that compels these unfortunates to go back to ever-increasing doses. The pleasant side is a very dubious affair at all times, accompanies only the earliest steps of the formation of the habit at most, and usually whatever agreeable feelings there are are accompanied by such a nightmare of solicitude and anxiety as a background that the pleasure is more poignant than agreeable. As a prophylactic against the formation of drug habits this aspect of the experience of drug habitues deserves to be emphasized and knowledge of it widely diffused. Of course, the morphin fiend brightens up after his dose of morphin, his eye lightens, his expression becomes happy, and his nerves get steadier, but that is only because the depression in which he was sunk before has now been stimulated away, the struggle with his worst feelings is over and the consequent reaction has developed. Of course, the cocain-taker is pitiably helpless and downcast without his "dope," but it is only by contrast with this previous state that his succeeding condition can be said to be pleasant or agreeable, even to himself.

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Favorable Suggestion.--One of the most helpful sources of favorable suggestion for these patients is to be found in the stories of cured drug habitues. These may be used tactfully to bring confidence to patients that they, too, can be broken of their habit if they are willing to take the pains to do so. De Quincey, taking his thousand drops of laudanum a day, represents one of the most encouraging examples of this since he succeeded eventually in breaking away from his habit. Coleridge succeeded, also, in breaking his habit more than once, but unfortunately returned again and again, and illustrates the danger of the almost inevitable tendency to relapse, if the patient permits himself to think that now that he has once conquered the habit he is too strong ever to let it get hold of him again. If he ventures to think complacently of his self-control and that consequently he may with impunity--always for some good reason--take a dose or two of his favorite drug in order to tide him over some crisis of mental worry or some spell of physical pain, relapse is certain. The tendency of patients to fool themselves in this way is too well known to need special emphasis, but it is as well to say that there is scarcely a single cured case that does not relapse. The relapse is due not so much to craving for the drug, as to the memory of its previous effects in relieving discomfort and the unfortunate confidence that the patient has developed that now, knowing the dangers, he will be able to resist the formation of the habit before it gets a strong hold of him.

It is curious how even highly intelligent patients will slip back into their old habits, sometimes deeper than before, on this reasoning, in spite of the lessons of experience, even their own as well as others. Like the drunkard, they persuade themselves that just this once will not count, and when it would have been comparatively easy for them to say no they yield once or twice and make self-denial for the future increasingly difficult. This is especially true if patients have the drug near them, so that it is not difficult for them to have recourse to it. Hence doctors and nurses are not hard to cure of such habits, as a rule, provided they are away from their professional duties, but they almost inevitably relapse when they go back to work. Every time the relapse is due to the fact that tired feelings, because of irregular hours or some physical pain, prompt them to seek relief and they yield to the temptation of taking the old drug, sure that they need it, only for the moment. They will all assert that they could just as well resist as not, that, indeed, had not the drug been so handy, they would not have taken it, and that if anyone had been near to help them by a word in the matter even then they would not have indulged in it.

If patients are to be kept from relapsing, all this must be set before them frankly. After they have been told once or perhaps twice or perhaps many times and yet relapse into their habits, they must simply be told it again a little more emphatically, more encouragingly, up to seventy times seven, if necessary. Patience is needed more than anything else in taking care of these cases. Over and over again their confidence in their power to overcome their habit, if they really wish to do so, must be reawakened. Without this confidence in themselves success is hopeless. It matters not how often they have relapsed, they can still break off the habit, and if they will not fool themselves into over-confidence in their power to keep away, they need never be slaves to the habit again. There will be quite as many disappointments in {710} treating drug addiction as in the treatment of alcoholism. Those who have most experience insist that there are even more, but there are some wonderfully encouraging examples of men and women who have broken from their habit, even after a number of bad relapses, and have for many years lived absolutely without any of their drug and, though still not over-confident in their power to resist if once they should yield (such confidence, it cannot be repeated too often, is always fatal), do actually keep away from the drug without any other bother than the necessity of living a regular hygienic life and exercising a little self-control.

In drug addictions as in alcoholisms, the question of sanitarium treatment comes up in every case. Much more rarely than in the case of the alcohol habit is it necessary to send a drug habitue to a sanitarium. Here once more, however, the patient's circumstances and the possibility of diversion of mind with reasonable freedom from temptations to take the drug and from ready access to it, are the most important considerations. If a patient really wants to break off the use of a drug, it can be done gently and without much bother in the course of three or four weeks. I have seen cocain fiends who have tried many remedies and many physicians completely cured in five or six weeks without serious trouble. The important thing is perseverance in the effort and in the treatment and the definite persuasion of the patient that it is not only perfectly possible to get rid of the habit, but that it is even easy with good will on his part. If certain other milder stimulants are supplied for a time so that all the symptoms due to the physiological effects of the excessive use of the drug are minimized, the physical trial need not be severe. The patient's mind, however, must be occupied. Time must not be allowed to hang heavy on his hands and all physical symptoms must be treated promptly. Drug addictions are indeed more curable than alcoholism and the danger of relapse is not quite so imminent. The social temptations do not exist for drug habitues as they do for alcoholics. As I have said, however, in the cases of nurses and physicians almost a corresponding state of affairs obtains and in them the danger of relapse is great.

Early Treatment.--It is quite as important for drug victims as it is for alcoholics that the case should be taken under treatment early. Every physician knows how curiously easy it is for some people, indeed for most people, to acquire a drug habit. I have seen one of the solidest men I ever knew, with plenty of character that had been tried by many a crisis in life, recommended cocain for a toothache when he was past fifty years of age and in the course of ten days acquire a thorough beginning of the cocain habit, so that he was taking several grains a day. He had no idea that he was unconsciously slipping into a drug habit. When the druggist refused any longer to supply the cocain solution without a prescription he was quite indignant. It was not until he had forty-eight hours of nervous symptoms and craving that he realized that he had created a need for stimulation of his nervous system by the mere taking of cocain by application on his gums. This habit was broken up at once and there has never been any tendency to its recurrence. He had his warning, fortunately, without evil effects.

If the cocain habit can be formed as unconsciously as this, there should be little difficulty in treating it. It is not a profound change in the organism, but only a habit. It is not the habit itself that is hard to break, but the effects {711} upon the nervous system of the patient are such as to create a series of symptoms that can only be soothed by the drug. It is these symptoms of depression, irritation, sleeplessness, lack of appetite, constipation and the rest that it is the physician's duty to treat in order to help the patient. The patient breaks the habit by his will-power when properly persuaded and when it is made clear to him that it is neither so difficult as he thought, nor is he so likely to fail in the matter as he has imagined, and as has perhaps been suggested to him even by physicians. The mental treatment consists in making him realize that he can do it and that if he wants to get rid of his habit he must do it for himself. With this must come the assurance that every annoying symptom will be met, that he need not recur to his favorite drug for this purpose, that his appetite will be gradually restored and that, though perhaps for a week he will have considerable inconvenience to bear, after that it will be plain sailing. Usually three days can be set as the term at which his craving ceases to be so disturbing as to make the possibility of his relapsing into the habit a positive danger. As in alcoholic and sex habits, the patient to be helped in breaking the habit should be seen once a day at least, usually oftener. If he can be made to understand that whenever the old tendency seems about to get the upper hand is the time to see his physician, and if something physical as well as moral is done for him, the breaking of the habit is comparatively simple.

This method of treatment looks too simple to be quite credible to those who have so often tried and failed in the cure of drug habits. It is not the doctor, however, who fails, but the patient. We cannot put new wills into a patient, but we can so brace up even an old and tottering will as to make it possible for the worst victims of drug habits to reform. The doctor, too, easily becomes discouraged. He has not confidence enough in his own methods to make assurance doubly sure for the patient as to his cure. This is what many of the pretended specific purveyors of drug habit cures have as their principal stock in trade. They assure patients with absolute confidence, while the physician only too often says the same thing, but half-heartedly. A half-hearted physician makes a hesitant patient, and success is then very dubious from the beginning. Every patient can be cured. They may relapse, but then they can be cured again. This is the essence of the psychotherapy of drug habits, but it is also the only successful element in any treatment of the drug habit that is really effective. Specifics come and go. Sure cures cease to have their effect. The only really effective element in any cure is the absolute trust of the patient.

In his "Drugs and the Drug Habit" (Methuen, London) Dr. Harrington Sainsbury, Senior Physician to the Royal Free Hospital of London, has emphasized all these points that can only be touched on very briefly here. He has called particular attention to the fact that the victim of one drug habit is rather prone to acquire another if by any chance he should once begin to take another habit-forming drug. The original drug habit has broken down the will. It is not so much the craving for a particular drug as the lack of will power that proves unfortunate for the patient. He suggests "incidentally, if this explanation hold good, it proves the solidarity of the will that it works as a whole and not by compartments." He has dwelt on recoveries from the most discouraging depths and insists "we must teach that {712} no one is ever so enslaved by a habit as to be incapable of relief--this alone is right teaching, justifiable moreover by records well substantiated of recoveries from desperate plights."

Heredity and Unfavorable Suggestion.--As to the suggestion, sometimes encountered, of the influence of heredity and its all-powerful effect in making it practically impossible for the son of a man who has taken drugs to keep from doing the same thing, we must recall very emphatically here the principles discussed elsewhere. So far as concerns heredity, opium and the other drugs are exactly in the same position as alcohol in their effect upon the human race. Instead of being justified in saying that by heredity individuals of succeeding generations are rendered more susceptible to them, just the opposite is true and, if anything, an immunity is produced. This is not only racial and general but is personal and actual. In recent years we have come to realize that individuals born of tuberculous parents who care for themselves properly are much better able to resist the invasion of the tubercle bacilli than those who come from stocks that were never affected by the disease. They are the patients who, in spite of the fact that their disease reaches an advanced stage, sometimes live on for years with proper care. Just this is true for drug addictions so far as we know anything about it. The whole subject is as yet obscure, but heredity rather favors than hurts the patient in these cases.

Hereditary Resistance.--Instead of being discouraged by the fact that his father took a drug to excess and that therefore he is weaker against this than other people, a man should rather be encouraged by the thought that a certain amount of resistance to the craving has probably been acquired by the particular line of cells through which his personality is manifested. Dr. Archdall Reid has said that "the facts concerning opium are very similar" (to those that concern alcohol). Then he continues:

That narcotic has been used extensively in India for several centuries. It was introduced by the English into China about two centuries ago. Quite recently the Chinese have taken it to Burma, to various Polynesian Islands, and to Australia. There is no evidence that the use of opium has caused any race to deteriorate. Indeed it happens that the finest races in India are most addicted to its use. According to the evidence given before the late Royal Commission on Opium, the natives of India never or very rarely take it to excess. When first introduced into China it was the cause of a large mortality; but to-day most Chinamen, especially in the littoral provinces, take it in great moderation. On the other hand. Burmans, Polynesians and Australian natives take opium in such excess and perish of it in such numbers that their European governors are obliged to forbid the drug to them, though the use of it is permitted to foreign immigrants to their countries. In exactly the same way alcohol is forbidden to Australians and Red Indians in places where It is permitted to white men.

After-Cures.--I have said so much about the after-cure of alcoholism that applies directly to drug addictions also, that it does not seem necessary to repeat it here. Patients must be warned that if they become overtired, if they lose sleep, if they are subject to much excitement, if they put themselves in conditions of anxiety and worry, if any form of recurrent pain develops--headache, toothache, stomach-ache--they are likely to be tempted to take up their old habit. If they are in a position where they can easily get the drug it is almost inevitable that something will happen to make them feel that {713} they are justified in taking one or two doses and from this to the reestablishment of the habit is only a small step. Often these patients need a change of occupation. Some of them are over-occupied, some of them have not enough to do. In either case it is the doctor's duty to know enough about his patient to be able to give directions. We do not treat a drug addiction with the hope of curing it, but we treat a patient suffering from a particular drug habit and we try so to modify that patient's life that after we have succeeded in getting him away from his habit, which is never difficult, he will not relapse into it. The after-cure is the more important of the two.

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