III. SUICIDE…

III. SUICIDE

In spite of the gradual increase of comfort in life and its wide diffusion--far beyond what people enjoyed in the past--there has been a steady progressive increase in the number of suicides in recent years. It is as if people found life less worth living the more of ease and convenience there was in it. This increase in suicide is much greater (over three times in the last twenty years) than the increase in the population. Surprising as it may seem, prosperity always brings an addition to the number of suicides. Stranger still, during hard times the number of suicides decreases to a noteworthy degree. It is not those who are suffering most from physical conditions who most frequently commit suicide. Our suicides come, as a rule, from among the better-to-do classes of people. While suicide might seem to be quite beyond the province of the physician, it is a duty of the psychotherapeutist to prevent not only the further increase of suicides in general but to save particular patients from themselves in this matter. A careful study of the conditions as they exist, moreover, will show that he can accomplish much--more than is usually thought--and that it is as much a professional obligation to do so as, by the application of hygienic precautions and regulations, to lessen disease and suffering of all kinds and prevent death.

The same two modes of preventive influence that we have over disease in general can be applied to suicide. The physician can modify the mental attitude in individual cases and thus save people from themselves and then he can, by his influence in various ways upon public opinion, lessen the death rate from suicide. For this purpose, just as with regard to infectious disease, it is important for him to appreciate the social and individual conditions that predispose to suicide, as well as the factors that are more directly causative. The more he studies the more will he be convinced that what we have to do with in suicide is a mental affliction not necessarily inevitable in its results and that may be much influenced by suggestion. Indeed, unfavorable suggestion is largely responsible for the increase in suicide that has been seen in recent years. Favorable suggestion might be made not only to stop the increase, but actually to reduce the suicide rate. For this purpose it is important to know just what are the conditions and motives that predispose to suicide and, above all, to realize that it is not the result of insufferable pain {714} or anguish, but rather of the concentration of mind on some comparatively trivial ailment, or exaggeration of dread with regard to the consequences of physical or moral ills.

Suicides are often said to be irrational; in a certain sense they are. No one who weighs reasonably all the consequences of his act will take his own life. This irrationality, however, is nearly always functional and passing, not of the kind that makes the commission of suicide inevitable, but only produces a tendency to it. This tendency is emphasized by many conditions of mind and body that the physician can modify very materially if he sets about it. Many of the supposed reasons for suicide are founded on the complete misunderstanding of the significance of symptoms and dread of the future of his ailments, often quite unjustified by what the individual is actually suffering. Indeed, the desperation that leads to suicide is practically always the result of a state of mind and not of a state of body. It is exactly the same sort of state of mind which sometimes proves so discouraging in the midst of diseases of various kinds as to make it impossible for patients to get over their affections until a change is brought about in their ideas. This makes clear the role of psychotherapy with regard to suicide, and there is no doubt that many people on the verge of self-murder can be brought to a more rational view and then live happy, useful lives afterwards. For this purpose, however, it is important that the physician should come to be looked upon as a refuge by those to whom the thought of suicide has become an obsession.

A well-known social religious organization not long since established a suicide bureau, that is, a department to which those contemplating suicide may apply with the idea that they would there find consolation and perhaps some relief for their troubles and thus the idea of suicide might be dissipated. Many a suicide would be avoided if the reasons that impelled to it had been known to one or two other people beforehand, so that some relief might have been afforded to what seemed an intolerable condition. This suicide bureau is said to have done much good. There is no doubt that the mere act of giving one's confidence to another is quite sufficient of itself to diminish to a marked degree a burden of grief and trial. If anything in the world is true, it is that sorrows are halved by sharing them with another, while joys are correspondingly increased. The fact that there is someone to whom they might go, who would look sympathetically at their state of mind, who would appreciate the conditions, who had been accustomed to dealing with such cases, would be enough to tempt many people from that awful introspection and concentration of mind on themselves which, more than their genuine sufferings and trials, whatever they may be, make their situation intolerable.

There has always been a suicide bureau, however, in the office of every physician who really appreciates the genuine responsibilities of his profession. More than any others we have the opportunity to alleviate physical sufferings, to lessen mental anguish and to make what seemed unbearable ill at least more or less tolerable. Unfortunately in recent years the change in the position of the physician in his relations to the family has somewhat obscured this fact in the minds of the public. The old family physician occupied to no slight extent the position of a father confessor, to whom all the family secrets were told, from whom indeed, as a rule, it was felt that they should not be kept; to whom father went with regard to himself and mother, to whom mother {715} went with regard to all the family as well as herself, to whom the boy confided some of his sex trials and the girl some of the secrets that she hid from almost everyone else, so that to go to him for anything disturbing became the first thought. We must restore something of this old-fashioned idea of the doctor's place in life if all our professional duties are to be properly fulfilled. If those contemplating suicide learn to think of us as persons to be appealed to when all looks so black that life is no longer tolerable, we shall soon be in a position to confer increased benefits on this generation that needs them so much.

Physical Factors.--As a rule there is a physical element as the basis for nearly all suicides. With the unfortunate, unfavorable suggestion that has come from the supplying of details of pathological information--the half-knowledge of popular medical science--without the proper antidote of the wonderful compensatory powers of the human body for even serious ailments, a great many nervous people are harboring the idea that they have or soon will have an incurable disease. Physicians have abundant evidence of this. All sorts of educated people come to us to be reassured that some trivial digestive disturbance does not mean cancer of the stomach, or, when they are between forty and fifty, come to make sure that some slight disturbance of urination is not an enlarged prostate. Brain workers of all classes come over and over again to be reassured that they are not breaking down because of organic brain disease, of which they show absolutely no sign. Sometimes they have been making themselves quite miserable for a long period by such thoughts. It is easy to understand, then, how many less informed people, yet provided with the opportunities of quasi-information that modern life affords, are apt to think the worst about themselves.

So-called Insomnia.--The correction of such preconceived notions will always greatly alleviate the mental sufferings of these patients. For this purpose there are many chapters of this book which point out how various symptoms and syndromes that are often amongst the factors in the production of suicide may be managed. Perhaps one of the most frequent of these is so-called insomnia. Most people are insomniac, mainly because they are overanxious about their sleep. A few of them are wakeful because of bad habits in the matter of work and the taking of air and exercise. Essential insomnia is extremely rare and symptomatic; insomnia is not mental, but is usually due to some definite physical condition that can be found out and, as a rule, treated successfully. There is always some other symptom besides loss of sleep. If men will live properly and rationally there is no reason why insomnia should be a bane of existence, nor even any reason why the morphin or other drug habit should be formed which is so likely to come if inability to sleep is treated as if it were an independent ailment. In the forms in which it incites to suicide it owes its origin to a nervous superexcitement with regard to sleep in people whose daily life in some way does not properly predispose them for the greatest of blessings on which there is no patent right. Additional suggestions as to these insomniac conditions are made in the chapters on Insomnia and Some Troubles of Sleep which make it clear that suicide, because of insomnia is due to a delusion.

Headache.--Persistent supposedly incurable headache is another prominent feature of the stories of suicides and here once more we have to deal rather {716} with a delusion of over-attention of mind and concentration of self on a particular part than a real physical ailment. Most of the so-called headaches that are supposed to be so intractable are really not headaches but pressure feelings and other queer sensations in the head originally perhaps partaking of the nature of an ache but continued through over-advertence. Severe pain within the head occurs in cases of congestion and brain tumor, and without the head in cases of neuralgia, but most of these are only temporary and long-continued headaches are rather neurotic than neuritic or due to any real disturbance of the nervous system. This is discussed in the chapter on Headaches. People commit suicide who have for a long time been sufferers from headache because they fear that they may go crazy. There is absolutely no reason in the world to think this probable, and in the one case of continuance of severe intermittent headaches for years already mentioned--that of von Buelow, the Austrian pianist and composer, in which we have the autopsy record--it was found, after a long life, that his severe intracranial headaches were due to the pinching of a nerve in the dura and not to any organic change in the brain itself.

Mental Factors.--While physical factors enter into the suicide problem to a marked degree, it would be a great mistake to think that physical conditions or material circumstances are the main causes or occasions in suicide. It is supposed, as a rule, to be due to depression produced by incurable disease, oppressive weather, financial losses and the like. There is no doubt that these are contributing causes, but the physical conditions have very little influence compared with the attitude of the patient's mind toward himself. As a rule, it is not those who are in absolutely hopeless conditions who turn to this supposed refuge of a voluntary exit from life in order to get out of trouble, but rather those who are momentarily discouraged and who have not sufficient moral stamina to face the consequences of their acts. There was a time when it was considered brave to fight a duel and cowardly to refuse to do so. Looking back now, we know that they were the real brave men who dared to refuse when a barbarous civilization would force them into a false position and who, in spite of disgrace, ventured to be men and not fools. There are those who used to say that it was brave to take one's own life rather than bring disgrace on loved ones, but the mitigation, if there be any, of the disgrace that suicide brings with it, comes from that lowest of all motives, pity for the survivors, and the cowardly suicide leaves to others the thankless task of making up for his faults.

Suicide and the Weather.--An investigation of suicide records shows, as we have said, that it is not nearly so often bodily or material hardships that lead men to it as mental states. These mental states are not mental diseases, but passing discouragements in which men are tempted beyond their strength and do irretrievable things for which there is no rational justification. It is not in dark damp weather that men commit suicides most, though this was supposed to be a commonplace in our knowledge of suicide. Recent investigations show that quite the contrary is true. Professor Edwin T. Dexter of the University of Illinois published a very important study of this question in a paper entitled "Suicide and the Weather." [Footnote 55] He followed out the records of nearly 2,000 cases of suicide reported to the police in the City of New York {717} and placed beside them the records of the weather bureau of the same city for the days on which these suicides occurred. According to this, which represents the realities of the situation, the tendency to suicide is highest in spring and summer and the deed is accomplished in the great majority of cases on the sunniest days of these seasons.

[Footnote 55: Popular Science Monthly, April, 1901. ]

His conclusions are carefully drawn and there is no doubt that they must be accepted as representing the actual facts. All the world feels depressed on rainy days and in dark, cloudy weather, but suicides react well, as a rule, against this physical depression, yet allow their mental depression to get the better of them on the finest days of the year. Prof. Dexter said:

The clear, dry days show the greatest number of suicides, and the wet, partly cloudy days the least; and with differences too great to be attributed to accident or chance. In fact there are thirty-one per cent. more suicides on dry than on wet days, and twenty-one per cent. more on clear days than on days that are partly cloudy.

What is thus brought out with regard to the influence of weather can be still more strikingly seen from the suicide statistics of various climates. The suicide rate is not highest in the Torrid nor in the Frigid zones, but in the Temperate zones. In the North Temperate zone it is much more marked than in the South Temperate zone. Civilization and culture, diffused to a much greater extent in the North Temperate zone than in the South, seem to be the main reason for this difference. We make people capable of feeling pain more poignantly, but do not add to their power to stand trials nor train character by self-control to make the best of life under reasonably severe conditions. With this in mind it is not surprising to find that the least suicides occur in the month of December, when the disagreeable changes so common produce a healthy vital reaction, though the many damp dark days that occur would usually be presumed to make this the most likely time for suicides. On the contrary, it is the month of June, the pleasantest in the North Temperate zone, that has the most suicides. It is important to remember this in estimating the role of physical influences on the tendency to suicide.

Social Factors that Restrain Suicides.--War.--A most startling limitation of suicide is brought about by war. For instance, our Spanish-American war reduced the death rate from suicide in this country over forty per cent. throughout the country and over fifty per cent. in Washington itself, where there was most excitement with regard to the war. This was true also during the Civil War. Our minimum annual death rate from suicide from 1805 (when statistics on this subject began to be kept) was one suicide to about 24,000 people, which occurred in 1864 when our Civil War was in its severest phase. There had been constant increase in our suicide rate every year until the Civil War began, then there was a drop at once and this continued until the end of the war. In New York City the average rate of suicide for the five years of the Civil War was nearly forty-five per cent. lower than the average for the five following years. In Massachusetts, where the statistics were gathered very carefully, the number of suicides for the five-year period before 1860 was nearly twenty per cent. greater than for the five-year period immediately following, which represents the preliminary excitement over the war and the actual years of the war. This experience in America is only in accordance {718} with what happens everywhere. Mr. George Kennan in his article on "The Problems of Suicide" (McClure's Magazine, June, 1908), has a paragraph which brings this out very well. He says:

In Europe the restraining influence of war upon the suicidal impulse is equally marked. The war between Austria and Italy in 1866 decreased the suicide rate for each country about fourteen per cent. The Franco-German War of 1870-71 lowered the suicide rate of Saxony 8 per cent., that of Prussia 11.4 per cent. and that of France 18.7 per cent. The reduction was greatest in France, because the German invasion of that country made the war excitement there much more general and intense than it was in Saxony or Prussia.

Great Cataclysms.--Even more interesting than the fact that war reduces the suicide rate is the further fact that a reduction of the number of suicides takes place after any severe cataclysm. The earthquake at San Francisco, for instance, had a very marked effect in this way. Before the catastrophe suicides were occurring in that city on an average of twelve a week. After the earthquake, when, if physical sufferings had anything to do with suicide, it might be expected that the self-murder rate would go up, there was so great a reduction that only three suicides were reported in two months. Some of this reduction was due to inadequate records, but there can be no doubt that literally hundreds of lives were saved from suicide by the awful catastrophe that levelled the city. Men and women were homeless, destitute, and exposed to every kind of hardship, yet because all those around them were suffering in the same way, everyone seemed to be reasonably satisfied. Evidently a comparison with the conditions in which others are has much to do with deciding the would-be suicide not to make away with himself, for by dwelling too much on his own state he is prone to think that he is ever so much worse off than others.

If life were always vividly interesting, as it was in San Francisco after the earthquake, and if all men worked and suffered together as the San Franciscans did for a few weeks, suicide would not end ten thousand American lives every year, as it does now.

Individual Restraints.--Religion.--It seems worth while to call to attention certain factors that modify the tendency to suicide and limit it very distinctly, because it is with the limitation of it that the physician must be mainly occupied. There seems to be no doubt that certain religious beliefs, which affect the individual profoundly and occupy his thoughts very much, furnishing, both by tradition and heredity as it were, sources of consolation for evils in this life by the thought of a future life, notably lessen the suicide rate. All over the world the Jews who cling to their old-time belief have perhaps the lowest suicide rate of any people. This is true in spite of racial differences. People who retain the confidence in prayer, that used to characterize members of all religions a century or more ago, are likely to be able to resist the temptation to suicide. This is true particularly for the more or less rational suicide. Oppenheim has recalled attention to the power of prayer against depression and in the insane asylums of England its efficiency in this way is well recognized.

It is well-known that Roman Catholics the world over have much less tendency to suicide than their Protestant neighbors living in the same {719} communities. It is true that where the national suicide rate is high many Catholics also commit suicide, but there is a distinct disproportion between them and their neighbors. The suicide rate of Protestants in the northern part of Ireland, as pointed by Mr. George Kennan, is twice that of Roman Catholics in the southern part. He discusses certain factors that would seem to modify the breadth of the conclusion that might be drawn from this, but in the end he confesses that their faith probably has much to do with it and that, above all, the practice of confession must be considered as tending to lessen the suicide rate materially. It is the securing of the confidence of these patients that seems the physician's best hope of helping them to combat their impulse and Mr. Kennan's opinion is worth recalling for therapeutic purposes:

In view of the fact that the suicide rate of the Protestant cantons in Switzerland is nearly four times that of Catholic cantons, it seems probable that Catholicism, as a form of religious belief, does restrain the suicidal impulse. The efficient cause may be the Catholic practice of confessing to priests, which probably gives much encouragement and consolation to unhappy but devout believers and thus induces many of them to struggle on in spite of misfortune and depression.

Disgrace as a Restraint.--It is curious what far-fetched motives, that appear quite unlikely to have any such influence, sometimes prove able to affect favorably would-be suicides and prevent their self-destruction. Plutarch tells the story, in his treatise on "The Virtuous Actions of Women," of the well-authenticated instance of the young women of Milesia. Disappointed in love, they thought life not worth living. Accordingly there was an epidemic of suicide among the young women and it even became a sort of distinction to prefer death to matrimony. Some perverted sense of delicacy entered into the feeling that prompted the suicides, as if sex and its indulgence were something belittling to the better part of their nature. The authorities in Milesia must have been psychologists. They issued a decree that the body of every young woman who committed suicide would be exposed absolutely naked in the market-place for a number of days after her death. This decree, once put into effect, immediately stopped the suicides. The young women shrank from this exposure of their bodies, even though it might be after death, and the suicide fashion came to an end.

It might be thought perhaps that this incident represented ancient feeling and that a similar condition in the modern times would not have a corresponding effect. It so happens that something similar has been tried. In some of the cities of South Central Europe in which the suicide rate is almost the highest in the world, it was decided about a generation ago by the Church authorities of the towns that suicides would not thereafter be buried in the cemeteries near the bodies of those who died in the regular course of nature, but must be interred in a separate portion reserved for themselves. Strange as it may seem, just as in the case of the young women of Milesia, this proved a great deterrent to suicide. The suicide rate was reduced one-half the next year.

As a matter of fact, it only takes some reasonably forceful countervailing notion to set a train of suggestions at work that will prevent suicide. If those contemplating suicide are made acquainted with some of these curious facts we know, then the notion of suicide loses more than half its terrible {720} attraction by being stripped of all of its supposed inevitableness. Almost any motive that attracts attention, even apparently so small a thing as disgrace after death, makes these people realize the littleness and the cowardice of the act.

Favoring Factors.--Psychic Contagion.--A prominent factor in suicides that must constantly be borne in mind is the influence of example or, as we have come to call it learnedly in recent years, psychic contagion. It is discussed more in detail in the chapter on Psychic Contagion, but its place here must be emphasized. It has often been noted that certain peculiar suicides are followed by others of the same kind. If a special poison has been used, others obtain it and put an end to their lives in that way. Even such horrible modes of death as eroding the jugular vein by drawing the neck backward and forward across a barbed-wire fence have been imitated. If the story of jumping off a high building is told with lurid details, special care has to be taken in permitting unknown people to go up to the same place for some time afterwards. The imitative tendency is evidently a strong factor. Plutarch's story of the young women of Milesia brings this out, and it has been noted all down the centuries.

In any discussion of the prophylaxis of suicide the effect of newspaper descriptions of previous suicides must be looked upon as very important. The influence of suggestion of this kind on people who have been thinking for some time of suicide is very strong. There comes to them the impelling thought that the suicide's miseries are over and they wish they were with him. From the wish to the resolve and then to the deed itself are only successive steps when suggestion is constantly prodding the unfortunate individual. If we are going to reduce the suicide rate materially or, indeed, keep it from increasing beyond all bounds, this question must be squarely faced. Accounts of suicides are not news in the ordinary sense of the word and while they might find a place for legal and other purposes in a few lines of an obituary column, the present exploitation of them by the papers makes them a constantly recurring source of strong suggestion to go and do likewise. These suggestions come to persons already tottering on the edge of disequilibration in this matter, and it is like tempting children to do things that they know are wrong, but that look irresistibly inviting when presented under certain lights. The very fact that their death will produce a sensation and will give them so much space in the newspapers attracts many morbidly sensation-loving people. Physicians must work as much for this prophylaxis as we have for the prevention of infectious diseases.

Child Suicides.--Probably the worst feature of the suicide statistics of recent times in all countries is the great increase of self-murder among children. Arthur MacDonald in discussing the "Statistics of Child Suicide" [Footnote 56] has shown that there is a special increase of young suicides everywhere. In France there are nearly five times as many suicides at the end of the nineteenth century as there were at the beginning of it. In England there is almost as startling an increase. Though the statistics are not as well kept, child suicide has increased not only in proportion to the increase of suicide among adults, but ever so much more. In Prussia the condition is even worse.

[Footnote 56: "Statistics of Child Suicide," Transactions of American Statistical Association, Vol. X., pp. 1906-1907. ]

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The French child suicide rate is especially interesting and disheartening. In the Paris Thesis for 1906 Dr. Moreau discusses the subject of suicide among young people and shows how rapid has been the growth of the number of such suicides in the last 100 years. The first statistics available for the purpose that, in his opinion, are exact enough to furnish a basis for scientific conclusions, are from 1836 to 1840. Altogether during that period in France there were 92 suicides under the age of seventeen years, 69 of whom were boys and 23 girls. In 1895 this number had increased to such a degree that in a single year there were almost as many suicides (90) as there had been in five years, only fifty years before. In 1895 the proportion of suicides less than ten years of age was a little more than one in twenty of the total number of suicides in France. There are countries in Europe in which the suicide rate among such children is even higher than it is in France. In every country it has gone on increasing and the awful thing is that the suicide rate is increasing more rapidly among children than it is among adults, though among adults it doubles every twenty years.

Causes at Work.--The causes for the increase in suicide among children were pointed out even by Esquirol, the great French psychiatrist, nearly a century ago. They are the same to-day, only emphasized by the conditions of our civilization. He attributed it to a false education which emphasizes all the vicious side of life, makes worldly success the one object of life, does not properly prepare the child for constancy in the midst of hardships, nor make it appreciate that suffering is a precious heritage to the race, that has its reward in forming character and fixing purpose. He thought that there were two very serious factors for the increase of suicide among children not usually realized. They were in his time literature and the theater. He said: "When the theater presents only the triumphs of crime, the misfortunes of virtue, when the books that are in common circulation because of the low price at which they are issued, contain only declarations against religion, against family ties and duties towards our neighbor and society, then they inspire a disdain of life and it is no wonder that suicide rapidly increases even among the very young." He was commenting on the case of a child of thirteen who had hanged himself, leaving this written message: "I bequeath my soul to Rousseau and my body to the earth."

Cowardice of Suicide.--Of course, the strongest motive for dissuasion from suicide is the utter cowardice of the act. As a rule, the man who contemplates suicide is not a sufferer from inevitable natural causes, but one who for some foolish act has put himself into what seems to him an intolerable position out of which escape without disgrace is impossible, and he is afraid to face the consequences of his own acts. It is from the fear of mental worry and of the condemnation of others rather than from any dread of physical suffering and pain that men commit suicide. The suicide leaves those who are nearest and dearest to him to face the battle of life alone, with all the handicaps that have been created by their foolishness. Running away in battle is as nothing compared to the cowardice of the suicide. The deserter is deservedly held in deepest dishonor, and if there is some little pity for the suicide, it is because of the supreme foolishness of his act and the feeling that it only can have been dictated by some defect of mental equilibrium. A frank recognition of these conditions in their real significance probably will do more than anything {722} else to make the prospective suicide realize the true status of his act better than anything else.

Men sometimes seem to persuade themselves that it is a brave thing thus to face death. The shadowy terrors of what may come after death are too little realized to deter a man from his act when compared with the real disgrace that he is so familiar with and that he has often witnessed in actual life. It is the man, as a rule, who has most condemned others when something has gone wrong, who has found no sympathy in his heart for the slips of his fellows, who discovers no courage in himself when he has to face disgrace. He does not realize that for most men there are so many extenuations of any evil that a man may do, that the large-minded man is ready to forgive and eventually to forget almost anything that happens. "To know all is to forgive all," and the more we know of men the readier we are to forgive them. Little men do not forgive and cannot forget the failings of their fellows and they think that everyone else looks upon men's failings in the same way. It is only the small, narrow man who contemplates suicide as a refuge from disgrace, and the fact that he can complacently plan the abandonment of others not only to the disgrace which he himself is not ready to face, but to all the suffering consequent upon it, is the best proof of his littleness of soul. The utter pusillanimity of suicide is the best mental antidote for the temptation to it.

Besides, the thought that deterred Hamlet may well be urged:

There's the rub; For in that sleep of death what dreams may come. When we have shuffled off this mortal coil, Must give us pause; . . . who would fardels bear, To grunt and sweat under a weary life; Cut that the dread of something after death.-- The undiscovered country, from whose bourn No traveller returns.--puzzles the will; And makes us rather bear those ills we have. Than fly to others we know not of?

It is sometimes said that this is the argument of a coward, but such cowardice is as reasonable as the dread of touching a wire that may be carrying a high charge of electricity. Besides it is only such an argument that will properly suit the man who, in his cowardice, is ready to let others bear the brunt of his disgrace, flying from it himself. [Footnote 57]

[Footnote 57: Is life worth living? How old this argument as to suicide is can perhaps best be appreciated from the fact that it is discussed very suggestively in a papyrus of the Middle Kingdom the date of which is probably not later than 2500 B. C, which is now in the Berlin Museum and is recognized to be the most ancient text of its kind that has been preserved in the Nile Valley. I have referred to this in the initial historical chapter. I think that I have more than once turned men's thoughts from the serious contemplation of suicide--always a dangerous thing--by discussing with them this fact that men have at all times in the world's history argued just the same way on these subjects. Men prefer not to resemble the dead ones, and a motive is all that is needed. ]

There has sometimes been an erroneous tendency to confuse suicide and heroism, but Chesterton, in "Orthodoxy," [Footnote 58] has well expressed the difference:

[Footnote 58: "Orthodoxy" by Gilbert K. Chesterton, New York, John Lane Co., 1909. https://www.gutenberg.org/ebooks/130]

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A soldier surrounded by enemies, if he is to cut his way out, needs to combine a strong desire for living with a strange carelessness about dying. He must not merely cling to life, for then he will be a coward, and will not escape. He must not merely wait for death, for then he will be a suicide, and will not escape. He must seek his life in a spirit of furious indifference to it; he must desire life like water and yet drink death like wine. No philosopher, I fancy, has ever expressed this romantic riddle with adequate lucidity, and I certainly have not done so. But Christianity has done more: it has marked the limits of it in the awful graves of the suicide and the hero, showing the distance between him who dies for a great cause and him who dies for the sake of dying. And it has held up ever since above the European lances the banner of the mystery of chivalry: the Christian courage, which is a disdain of death; not the Chinese courage, which is a disdain of life.

The feature of incidents in life that bring with them disgrace and punishment which needs to be insisted on for those to whom the thought of suicide comes, is that the sensation which the revelation of such acts causes is but a passing phase of present-day publicity, and that after all it is not even a nine-days' wonder, but a two- or three-days' wonder, and then it is forgotten and replaced by something else. The facing of the condemnation for the moment may seem an extremely severe trial. The world's blame, however, is largely a bogey, a dread that is phantom-like and that disappears, or at least diminishes, to a great degree as soon as it is bravely faced. Besides, as practically every man who has been carrying around a guilty secret with him for years is free to confess, there is an immense sense of relief once the worst is known. At last the effort at concealment, the nervous tension, the fear of the moment of exposure are all past and a new set of thoughts can be allowed to come. Those may be unpleasant and yet they are not so bad as the dread of discovery that hung over the unfortunate. If a man can be braced up to meet exposure, usually he will find in a very few days that there are sources of consolation that make it much easier for him to live than he thought possible before.

Real Suffering a Tonic.--Probably the best remedy for a man or a woman who talks of suicide and seems to fear lest the temptation should overcome them is, if possible, to give them an opportunity to see some real suffering. I have on a number of occasions had the opportunity to note the effect on a discouraged man or woman of the sight of a cancer patient suffering severely, yet bearing the suffering patiently, wishing that the end might come, yet ready to wait until it shall come in the appointed order of nature. Suffering, like everything else, becomes much more bearable with inurement to it. The old have learned the lesson of not only not looking for pleasure in life, but of being quite satisfied with their lot if no pain comes to them, and they even grow to consider that they have not much right to murmur if their pain is not too severe. It is not among those who have to suffer severe pain that one finds suicides as a rule. It is true that young, strong, healthy persons who suddenly find that pain is to be their lot for a prolonged period may grow so discouraged and moody over it as to take their lives. The patients that I have seen suffering from incurable diseases have expressed no desire at all that their life should be shortened, except during the paroxysms of their pain, unless they feel that they are a serious burden on others when they may express the wish to be no more.

Euthanasia.--Every now and then there is a discussion in the newspapers {724} of the justifiableness of euthanasia, that is, the giving of a pleasant death to those who are known to be incurably ill and who are doomed to suffer pain for most of what is left of their existence. The question usually discussed is whether patients have the right to shorten their own existence and then, also, whether their physician might have the right or, even as some people say, the duty, to lessen human suffering by abbreviating existence for such incurable cases. The discussion has always seemed to me beside the realities of things, because physicians do not see many patients, I might almost say any patients, who really want to shorten their lives or would want to have them shortened. I have known many physicians die of cancer, but very seldom is it that one tries to shorten his own existence, or that even his best friend in the profession would consider that he was justified in doing this for him. This, it seems to me, should be the test of the problem. It is true that not infrequently, in the midst of their paroxysms of pain, patients wish they were dead, but there come intervals of surcease from discomfort to some degree at least that make life quite livable for a time again and even occasionally there is real happiness in these intervals, deep, human, natural happiness in heroic forbearance and example.

We can recall AEsop's fable of the old man who, gathering wood for the fire in the winter that he needed so much, finds the burden of his labor and the wood too much for him and calls loudly for death to come to him. Promptly Death makes his appearance and asks what the old man wants. "Oh! nothing," is the reply; "only I would like you to help me to carry this bundle of sticks." This is the attitude of mind of practically all who have grown old in suffering. They have learned to bear with patience, and that patience gives even something of satisfaction. After all, it is not so often the pleasant things in life that we look back on and recall with most satisfaction as the difficulties and trials. Virgil said long ago, "Forsan et hoc olim meminisse juvabit"--perhaps at some future time we shall recall these, our trials and pains, with pleasure. It is the conquering of difficulty that means most for men and even the standing of pain is not without an aftermath, if not of pleasure, at least of broad human satisfaction. When we talk about euthanasia, then, it would be well to ask some of these old people whether they want it or not. Seldom will the answer be found to be that which is so often presumed, by those in good health and strength, to be inevitable under such conditions.

Physicians have all seen incurable cancer patients who were approaching their end inevitably and with the fatal termination not far off, have hours and days of alleviation of suffering and even of enjoyment that made up for the prolongation of life almost in the midst of constant agony. The distinguished New York surgeon who had the pleasure a few years ago of listening once more to his favorite singer and fairly seemed to get renewed life from the inspiration of her voice and who for days after had the pleasant consciousness of smooth running life in improvement so characteristic of convalescence, is a typical example of what may happen under such circumstances. I shall not soon forget Dr. Thomas Dunn English, the well-known author of "Sweet Alice, Ben Bolt," saying at an Alumni dinner of the University of Pennsylvania, that, like Bismarck, he used to think that all the joys of life's existence were in the first eighty years of life, but of late years he had found {725} that many of them were also in the second eighty years of life. He was at the time 83. He made the most joyous and happiest speech on that occasion. He was quite blind, was almost deaf, had been reported dying some months before, and had gone through prolonged suffering, yet he was by his cheeriness and whole-hearted gaiety on that occasion a joy and inspiration to all the younger men at the table.

Dread of Suicide.--There are patients who come to the physician worked up because they fear they may commit suicide. Every now and then the thought comes to them that some time or other they will perhaps throw themselves out of a window, or be tempted to drop in front of a passing train, or over the side of a steamboat, or impulsively take poison. Some nervous people become quite disturbed by these thoughts. Every physician is sure to have some patients who must be reassured, every now and then, that they are not likely to commit suicide. Their nervousness over the fear of this may serve to make them supremely miserable and it evidently becomes the doctor's duty to reassure them. It is not difficult to do this, as a rule, provided the physician will be absolutely confident and unhesitating in his declaration that there is no danger that they will commit suicide, since it has almost never been known that patients who dread it very much and, above all, those who dread it so much that they take others into their confidence in the matter, take their own lives. The very fact that the thought produces so much horror and disturbance in them is the best proof that they will not impulsively do anything irretrievable in this way.

Prof. Dubois has discussed this subject in his usual thoroughly practical way and his words serve as an authoritative confirmation of what has been already said, though as a matter of fact the expressions and experience of nearly every nervous specialist thoroughly justify the position here assumed. Besides, it must be realized that this confident assurance is the best possible prop that doubting patients can have with regard to the actions they dread, and by positive declarations the physician will accomplish more than in any other way.

There are patients who are subject to strange obsessions. They are afraid that they will throw themselves out of the door of a car, or climb over the parapet of a bridge. They are afraid that they will throw their relatives out of a window, or will wound somebody with a knife or a gun. There are some with a strong impulse to open their veins. But if there is a certain attraction in such things, it is really a phobia. It tends to make one shrink back and not to act.

Nothing quiets these patients like the frequently repeated statement that they will not do anything. It is necessary to show them the vast distance there is between the impulse toward suicide and murder and the phobia which, however distressing it may be, is a safeguard. One must keep at this education of the mind with imperturbable persistence and use the most forceful and convincing arguments that one can think of to correct the judgment of his patient, in order to make the strings of moral feeling and reason vibrate in unison.

It is through lack of courage and perseverance that we err in the treatment of these psychoneuroses. We wait too long to distinguish the morbid entities that bear on a certain etiology or a different prognosis. We do not see clearly enough the bond which unites these different affections.

It may seem to some physicians as though they would be assuming too much responsibility in giving patients such positive assurance that their dreads {726} will not be fulfilled, but as a matter of fact the experience of physicians is quite sufficient to justify the confident statements here suggested. It is true that occasionally a person who afterwards commits suicide talks the matter over and hints at the possibility of taking his own life. He does not, as a rule, speak of it with dread, however, but as one of the alluring solutions of his difficulties that he sees ahead of him. He is much more likely to write a letter to his physician telling him that all his arrangements are made and that by the time this letter reaches him he will be already dead. The prospective suicide is usually quite secretive about this purpose, not only to friends, lest he should be prevented from accomplishing it, but even with his physician, in whom he has had absolute confidence and to whom he has told practically everything else. The patients who fear the possibility of committing suicide, who tell how much they dread the horror of it, and who rush to consult the physician to help them against themselves, show by the very fact the unlikelihood of action on their part.

The Physician and Suicide.--By mental influence, then, the physician may lessen the tendency to suicide in the individual and in the community. To do this is to save suffering and to help in the solution of one of the most serious social problems in modern times. It can only be accomplished by a sympathetic attitude towards the whole subject and a tactful understanding of each individual case. Every effort in the matter, however, is well worth while, for there is no more hideous blot on our modern civilization than the startling increase of suicide. It is particularly important to bring about improvement in this regard among young suicides, and fortunately it is here that the influence of the physician for good is likely to be most felt. The saving of life is the noblest part of the mission of the physician and nowhere, perhaps, can this be accomplished more successfully than with regard to some of these patients whom a rash resolution, due to a momentary fit of depression and a sense of suffering exaggerated out of all proportion to their actual pain, is hurrying out of life.

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IV. GRIEF

Grieving would seem at first glance to be one of the conditions for which the physician, especially if the etymology of the name of his profession be taken strictly, should not be called upon to minister, nor his remedies be expected to relieve. Grief is usually supposed to be due to moral ills and, therefore, at most to come under the care of the alienist, with the feeling that even he can accomplish very little for what is an affective rather than a true mental disorder. There is no doubt at all, however, that grieving, especially in the excess that shows it to be pathological, is always associated with certain physical and mental conditions for which the physician can accomplish much. Indeed more often than not the physical condition of the grief-stricken person is a prominent factor in the production of the state of feeling which causes grief to be exaggerated, while, on the other hand, this state of mind {727} itself reacts upon the physical being so as to make it more sluggish in all its functions, and as a consequence a vicious circle of cause and effect is formed affecting unfavorably both the mental and physical conditions. It is when patients are run down in health that grief becomes extremely difficult or apparently impossible to bear and grief itself still further brings about a deterioration of health that makes the mind's reactionary power against its gloomy feelings still weaker than they were.

Viewed in this way, grief is an ailment that should properly come to the physician for treatment and with regard to which that important principle is eminently true that the physician cannot always cure, but he can nearly always relieve, and he can always console his patients. On the one hand, an improvement in the general health always make grief easier to bear because it increases the resistive vitality of both mind and body. On the other, any diversion of mind that lifts the burden of grief even to some degree, releases new stimuli and physical powers for the restoration of bodily function to the normal and this brings about an immediate lessening of the depressive condition. In a word, for the vicious circle of unfavorable influences ever pushing the victim farther into depression, a virtuous circle, in the Latin sense of the word virtue, meaning courage, favoring strength, must be formed, that brings about an immediate improvement in the patient's mental and physical well-being. This is not a pretty bit of theory but is the result of the experience of every physician who has ever taken seriously the problems of caring for the grief-stricken.

Natural and Pathological Grief.--It is, of course, not easy to distinguish between grief that may be called morbid in the sense of a melancholy, that is, more than natural--a true mental disease--and that which represents only an affective state accompanied by depression from which there will be complete reaction. A mother loses a favorite, it may be an only son, and is plunged into grief. For days, even weeks, she refuses to take any interest in life, she thinks moodily about the awful affliction that has come to her and how blank the future is, and she cannot be aroused to attend either to her own affairs or to the duties of life around her. Such a grief is, in many cases, not more than the normal depression incident to such a loss. If after months, however, the mother still continues to refuse to take interest in life and the things around her, especially if, besides, she now talks of having been visited with this punishment because of some unpardonable sin in her own life, or because the Deity has been offended beyond all hope of propitiation, then the case verges over into one of true melancholy in which the mental depression is not merely a symptom of a passing condition, but partakes of the nature of a mental disease, or is the consequence of a profound neurotic condition.

It must not be forgotten that there is always the danger that exaggerated grief, as it seems for the moment to be, may be only the first symptom of a true melancholic condition. Only too often friends and physicians have been deceived by this. Some of the sad cases of self-destruction and a few cases of homicide and suicide have followed a condition that seemed to be only abnormal grief for the loss of a relative.

Etiology.--The cause of exaggerated, prolonged grief is, in a considerable proportion of the cases, a melancholic tendency, that is, a failure on the {728} part of the mind to react against depression. The weakness of mind that predisposes to this may be inherent or acquired. Sometimes no special loss is needed to produce melancholia in susceptible individuals, while occasionally it is precipitated by some misfortune, inasmuch as this is a mental disease, very little can be done directly, and yet the patient can be helped and diversion of mind may bring a good measure of relief. More often, however, the reason for persistent grieving is that before the disturbing loss came into the life of the individual there had been a serious deterioration in health. This was due to the conditions preceding the unfortunate event. Wives sometimes have worn themselves out physically and mentally while nursing husbands, or mothers their children, and this has produced a lack of physical force which prevents them from reacting with healthy mentality against the subsequent shock of loss.

Prophylaxis..--For the melancholic tendency prophylaxis cannot be special, but must be general. We cannot prevent people from suffering serious losses, but we can foresee the possibility of a loss proving very depressing, and can, therefore, try to keep the individual in reasonably good physical condition. If this is done the subsequent depression will be much less than it otherwise would be. Very often there is little or no recognition of the fact that there is a definite tendency in some patients to too great an inclination toward melancholic thoughts, and it is not until an exaggerated manifestation of it comes that the danger is realized. It is not easy to make patients realize the dangers, but where the physician talks with assurance and points out definite things to do in order to prevent serious developments, patients, or at least their friends, can be made to appreciate the dangers.

The best demonstration that I know of the value of work as a remedy for grief is my experience with members of religious orders. For them, as a rule, there is no interruption in life no matter what the loss may be. Their work goes on the day after the funeral just as before. This is the most precious possible arrangement, time and occupation of mind are the two factors that will dull the edge of grief and while humanly we may resent the consolation that is thus brought by such conventional things as the passage of time and humdrum occupations, they represent nature's resources. Above all, patients must be given something to do and if that something concerns other suffering human beings, there is every reason to expect relief.

Treatment.--The most important element in the treatment of grief cases is to prevent physical running down as far as possible and to build up the physical condition. Depression that comes to patients who have lost considerable weight, even though it may show some of the signs of melancholia, is always hopeful. Where patients are twenty or thirty pounds under weight the recovery of weight up to the normal condition will often mean the relief of their depressed condition. The one hope lies in this physical improvement. Mental treatment by diversion of mind must, of course, be practiced. This does not mean getting the patients interested once more in trivial things, but to be successful it means arousing the deeper feelings of their nature. Above all, the solace of tears will often save depressed and grieving persons from themselves. An interest in the sufferings of other people that awaken their sympathy will do the most to end exaggerated grieving over their own loss. The self-centeredness of their grief is the principal reason for its exaggeration. {729} It is because of overestimation of their own importance and of the importance of their loss that these people suffer severely.

Motives of Consolation.--The main resource of the physician who would employ psychotherapy for the treatment of those who are grieving beyond the limit of what is normal, is to supply motives by which they can understand the real significance of their loss. Very often, especially in young folks, there is no proper estimation of values in life and no recognition of the fact that human life was evidently not meant for happiness since that comes to but few, while suffering and partings are inevitable. They come to all, and apparently will always continue to do so. It is the young or, at least, those under middle age, who are most likely to be affected by exaggerated depression over losses and disappointments. Older folks have grown more accustomed to such incidents. These patients must be made to see how many motives there are to take their grief philosophically and while permitting themselves the luxury of sorrow, not to let this interfere either with their physical condition or their mental state to such a degree as to prevent them from taking the proper interest in their duties in life.

The ethical motives that may be urged to keep people from grieving over-much are many, but there is sometimes the feeling in the physician's mind that it is scarcely his business to emphasize them in any way. It is supposed that to the clergyman must be committed the task of consoling people for losses in life. This has always seemed to me a serious mistake. As physicians we know how much the mind influences the body and since it is our duty to care for the body, we must, above all and first of all, care for the mind as far as we can. Mens sana in corpore sano is a very old motto and is usually taken only in the sense that to have a healthy mind one must have a healthy body. In its Latin form, however, it might very well also be taken to mean that to have a healthy body one must have a healthy mind. Since grief has an untoward influence on the body, physicians are bound to learn what to do for it in any and every possible way and to exercise every faculty they have for its relief. This is all the more true because in recent years many persons have no regular religious attendant who would come to offer them consolation or to whom they would go in their trouble. It is not at all with the idea of infringing on the rights of the clergy or invading his territory that I would insist not only on the right of the medical man, but even his duty, to afford consolation to the mind as well as relief for the body.

The Family Physician.--In older times the family physician was a friend of the family to whom people turned in all troubles where he might possibly be of aid, with just as much confidence and as promptly as they did to their religious attendant. Unfortunately, in the progress of medicine, though still more because of the social vicissitudes that have taken place in recent years, this relationship of the family physician has been largely diminished, but that constitutes only one more reason why every physician, to whose attention the grief of a patient for any loss is presented as a cause of ill-health, should know all the means and be ready to employ them for the amelioration of the condition. As a matter of fact, there is often a feeling on the part of patients that it is more or less the business of the clergyman to afford consolation and that the performance of his duty in this matter is somewhat conventional, not {730} as if he performed it less thoroughly because of this, but as if the feeling of the routine practice detracted from its effectiveness. Some of the motives for consolation advanced by the clergyman, then, lose in significance, in some persons' minds at least, because of this feeling, while motives presented by the physician rather gain in weight because of the impression that he is a thoroughly practical man, deeply interested in life's problems from a common-sense standpoint, and who knows the motives for consolation because he has realized that losses are inevitable, suffering unavoidable, and grief sure to come, though somehow we must learn to bear up bravely under life as we find it.

Physicians have always done this in the past, but in more recent years either they have lost the habit, or have considered it unworthy of their profession, or else, perhaps, only too often they themselves have had no motives to offer that might seem sources of consolation for those in suffering and especially those who are grieved for the loss of friends. If life were a mere chance, if there were not an evident purpose in it, if, as Lord Kelvin insisted, science did not demonstrate (not "suggest" but "demonstrate" is the word he used) the existence of a Creator and a Providence, Who, while caring for the huge concerns of the universe, can just as well employ Himself with the little details of human life, then there would be some reason for physicians thinking that their science kept them from seeking consolation from the ordinary motives. Even if they occupy an advanced agnostic position, however, they may still find sources of consolation that, if not so effective as those attached to the old beliefs, at least will provide something for the forlorn to take hold of, that will mitigate their grief and sense of loss and make the present and the future look not all too blank.

Few men have been so thoroughly agnostic as Prof. Huxley, yet on the death of his wife he found that some of the thoughts of the old beliefs might prove a source of consolation. Huxley had loved his wife very dearly and their separation by death meant very much. The epitaph that he wrote for her sums up his doubts yet plucks out of them something to console, expressed in old Scriptural language:

And if there be no meeting past the grave. If all is darkness, silence, yet 'tis rest. Be not afraid, ye waiting hearts that weep. For God still giveth His beloved sleep; And if an endless sleep He wills, so best.

Attitude Toward Death.--The ordinary attitude of people toward death is a very curious one. Death is the one absolutely certain thing in life after birth, yet most of us live our lives without much regard to it, and whenever it comes and under whatever circumstances, at whatever age, it is always a shock to us. No matter how old people are it always comes a little before it is expected. When death comes it is always a shock and all that can be said of it is what Hamlet resents when the commonplace consolations for the loss of his father, who also lost a father and so on all down the course of history, are offered to him. Perhaps, however, as much the reason for his resentment was the person who offered the consolation as the form of the consolation itself, which, after all, exhausts nearly all that we can say in this matter for grief for near and dear ones:

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King. 'Tis sweet and commendable in your nature, Hamlet, To give these mourning duties to your father: But, you must know, your father lost a father; That father lost, lost his; and the survivor bound In filial obligation, for some term To do obsequious sorrow: but to persevere In obstinate condolement, is a course Of impious stubbornness: 'tis unmanly grief: . . . Fie! 'tis a fault to heaven, A fault against the dead, a fault to nature. To reason most absurd, whose common theme Is death of fathers, and who still hath cried, From the first corse, till he that died to-day, "This must be so."

Death and Pain.--One of the most effective consolations in our day for all classes of people, quite apart from religious affiliations or beliefs, is the sociological import of death and suffering in the world. Life, without suffering and death in it, would be a riot of selfishness. Men, as a rule, would not care for others at all, the weak would go to the wall, the individuals who possess less efficiency than others would simply have to make out as best they could, and bad as social conditions are now, they would be intolerably worse. As it is the young and strong and vigorous have very little of true sympathy. Nothing makes a man feel for others like having gone through some suffering himself. On the other hand, nothing makes him feel the impotence of struggling ceaselessly for vain success and the futile rewards of life than to lose near and dear friends whose share in that success and joy over the rewards would constitute their only real value and justification. As a man grows older and has gone through some of the sufferings and has had to bear the losses of life, he learns more and more to feel for others, he is ready even to make sacrifices that others may not have to suffer as he has suffered, he has charity for them for the sake of his own suffering and that of near and dear ones, and things are much better than they could possibly be without suffering and death.

Therapy by Example.--Many men have taken losses so seriously as to think that life held no more for them, and have foolishly given up their occupations, yet have found that Time, the great healer, could work his marvels in their case as well as in most others and that new interests and, above all, their life work, could arouse them to a sense of duty and bring them back to the old routine of life. Dr. Mumford, in his "Sketch of Sir Astley Cooper," tells the story of how even that veteran surgeon gave up everything at the death of his wife and yet found, after a year of idleness, that he had to come back to the old life again. Dr. Mumford says: "Sir Astley Cooper was an emotional man. In 1827 his wife died, and the event prostrated him with grief. He felt that all the interests of life were over for him. He fell into an acute physical decline, sold his town house, threw up his practice and other professional employments, and retired to his country place to pass his last days. Within a year of the sad event he had returned to town, taken another house, resumed practice with increased vigor, and married again. He was then sixty years old, he lived on until 1841, and died in his seventy-fourth year."

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A typical example of how much a strong man whose diplomatic ability had stamped him as one of the large men of his generation may yet be afflicted beyond measure by a loss of this kind is to be found in the life of the second Lord Lytton. I have told it somewhat in detail in the chapter on Periodic Depression. After the death of his boy Lord Lytton, who for more than a week of anguish had watched unceasingly at the death-bed of his dying son, came to the conclusion that God was not in His world or, at least, that the arm of Providence was shortened if such (as it seemed to him) needless suffering was permitted. The boy had probably suffered much less than the bystanders thought and much less than he seemed to, for in these cases nearly always there is a merciful deadening of the senses that to a great extent eliminates suffering, but Lord Lytton could not understand and refused ever to look at life from the same standpoint afterwards. This is, of course, only what happens in many cases, but it represents an exaggeration of grief since death and suffering have always been in the world and sometimes they will come to those near and dear to us, much as we may resent it.

Neither profound intelligence nor the sympathetic genius of the poet or artist is sufficient to safeguard men against the severer forms of griefs for loss. Louis, the distinguished French physician (to whom we in America are indebted so much as the Master of the Boston and Philadelphia schools of diagnosis, and, above all, for his teaching of the differentiation between typhoid and typhus fever), suffered so much from the loss of his son that he could scarcely be consoled. Dante Gabriel Rossetti was so much affected by the death of his wife that he put into her coffin the only manuscript copy of his poems that he possessed. It is interesting to learn that some years later he had the coffin exhumed and took out his manuscript at the urging of friends, and published the poems. Many other examples of this kind might be given, for exaggeration of grief affects all classes and conditions in life. They are practically always pathological, usually on a basis of somewhat disturbed mentality, though often the real underlying and predisposing condition is the physical exhaustion that has preceded the loss and which makes patients unable to bear the strain of it after weeks of care, solicitude, anxiety and neglect of eating and sleep.

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V. DOUBTING

In recent years the attention of physicians has been called to the fact that many people are made profoundly miserable by an unconquerable tendency to doubt about nearly everything that has happened to them, or is happening, or is about to happen. This is not a new phenomenon, but introspection has emphasized it, leisure gives more opportunity for it, and so physicians hear more of it now than they did in the past. This doubting tendency sometimes makes serious inroads on the peace of mind of sufferers from it because they cannot make up their minds to do things, even to take exercise, to eat as {733} they should in quantity or quality, and to share the ordinary life around them sufficiently to get such diversion of mind as will keep their physical functions normal. The state used to be described as a neurasthenia (nervous weakness), but in recent years has come better to be designated as in the class of psychasthenias (lack of mental energy). It is always a mental trouble in the sense that it is difficult for these patients to make up their minds about things, yet it is not a mental disease in the ordinary sense of the term, and these people are often eminently sane and thoroughly intellectual when their attention has been once profoundly attracted. They may even, under favorable circumstances, be active and useful helpers in great causes, yet there is always to be observed in them a certain noteworthy difference in mentality from the normal. The physician can do more for an affection of this kind than is usually thought, and he is probably the only one who can thoroughly appreciate and sympathize and, therefore, be helpful in the condition.

Sufferers are often laughed at by their friends and relatives and are likely to be the subjects of at least a little ridicule if they take their troubles to their physician. As a matter of fact, however, doubting is a typical case for psychotherapeutics and not only can much be done for its relief, but it can be kept from disturbing the general health, which it is prone to do if neglected, and by mental discipline and acquired habits of self-control, the doubting habit may be almost completely eradicated.

Exaggeration of Ordinary State of Mind.--The first thing absolutely necessary to impress upon the minds of these victims of their own doubts is that their condition is by no means unique, it is not even very singular, but is only an exaggeration of that hesitancy and tendency to put off making decisions that practically every person finds in a lifelong experience. This frame of mind is rather cultivated by education and by a large accumulation of knowledge. The less one knows the easier it is to come to decisions about difficult problems and to form conclusions without hesitancy. The young man will decide anything under the sun, and a few other things besides, almost without a moment's hesitation, and after but slight consideration. Twenty years later he looks back and wonders how he did it, and having done it, how he succeeded in turning the practical conclusions to which he came to advantage. The scholar is eminently a doubter and a hesitater, and we recognize that he loses certain of the qualities that would make him a practical man of affairs, though he gains so much more that broadens and deepens life's significance that there can be no doubt about the value of his liberal education.

"Hamlet" is just the story of one of these doubters and hesitaters. He saw his duty clearly and that duty was imperative. In spite of cumulative evidence, however, he refused to go on to the performance of that duty, urging to himself now one and now another reason of delay, until finally he wonders whether it would not be worth the while to take his own life, rather than try any longer to solve the problems that lie around him demanding solution. When he finally does something, his hand is forced and circumstances have so arranged themselves that instead of one clean-cut punishment for a great crime, there is the tragedy that involves six lives, including his own. The play seems to involve such exceptional characters and to be written around such an unusual set of circumstances that it might be thought {734} that it would prove uninteresting for men and women generally. As a matter of fact, however, "Hamlet" is the most popular of Shakespeare's plays and probably the most popular play, both for readers and auditors, that was ever written. There are commentaries by the hundred on it in nearly every modern language. Men have been more interested in this figment of Shakespeare's imagination than in any man that ever lived. Caesar and Napoleon have not attracted so much attention. Only Homer and Dante have been perhaps more written about than Hamlet.

Shakespeare has emphasized the condition of Hamlet by showing us an eminently well educated man. His deep interest in literature, and especially in dramatic literature and all that relates to the stage, can be appreciated very readily from his speech to the players. No one but a man of profound critical ability and deep intellectual interests could have so summed up the actors' relation to the drama. Of course, this is Shakespeare himself talking and unthinking people have said that this was a purple patch fastened on the play because it gave the author an opportunity to express his views with regard to actors and their ways. Instead of that, it is of the very essence of the development of Hamlet's character and shows us the scholarly amateur who knows so much about many things that he has become quite unable to make up his mind about the practical problems that lie before him. James Russell Lowell says that Shakespeare sent Hamlet to Wittenberg, though Wittenberg was not founded until centuries after Hamlet existed--and Shakespeare probably knew that very well--because Wittenberg in Shakespeare's time, on account of its connection with Luther and the religious revolt in Germany, had the widespread repute of occupying men's minds with doubts about many of the things that had been deemed perfectly settled before, and its popular reputation serves to give an added hint as to the character of Hamlet as the dramatist saw it.

Once those who are perturbed by doubts learn that the reason for the universal human interest in Hamlet is that there is a large capacity for doubt of self in every man and woman, that we all put off making decisions whenever possible, sometimes refuse to open letters when they come if we fear that they will contain some disturbing news, put off writing letters because we have to state ideas definitely, apparently hope that the day and the night will bring us counsel and that somehow the decision will be made for us without the trouble of making up our minds, then they lose their sense of discouragement over their condition and appreciate that they are suffering only from an exaggeration, probably temporary and quite eradicable, of a state of mind that comes to practically every human being.

This is the important thing, because on it can be founded the only really hopeful therapy of the condition. Doubting is a habit that may be increased by yielding to it, but that can be diminished to a very great extent by constant discipline, which refuses to permit doubts and hesitancy and bravely makes decisions, even though there may be the feeling that they may prove to be wrong.

Extent of Affection.--If such discipline is not instituted, then the lengths to which the doubting hesitant habit may go are almost incredible. I have had patients tell me that they doubted about nearly everything in the past. A very dear friend once confided to me that it was always a source of bother {735} to him that he was not quite sure whether he was married or not. His marriage I knew had been a public ceremonial, and he had led his bride down the aisle to the strains of the "Wedding March" in quite conventional style, but he was hesitant of speech, especially under excitement, and he was not sure that he had ever said "I will" to the question of the clergyman, for there was a constriction at his throat at the moment and he could utter no sound. The absence of any audible sound from the groom is not so unusual as to attract attention and, of course, his intention and his bodily presence and everything else gave the assent without the necessity for the word, but he could not get out of his mind the thought that possibly he was not married and at times it gave him poignant discomfort. He was a thoroughly intelligent man, a teacher and a writer, with no abnormalities that attracted attention, and his tendency to doubt was only known to very near friends who laughed at it and had no idea at all of the annoyance that it often gave its unfortunate victim.

I have a clergyman friend who has had some serious scruples with regard to his ordination. He is a Catholic priest and at a certain part of the ceremonial of ordination it is considered necessary for the candidate for orders to touch at the same moment the paten, the small metal plate on which the Host is placed, and the chalice. This clergyman is not sure that he had done this simultaneously. As a rule, great care is exercised in seeing that all the details of the ordination ceremonies are carried out very exactly and as there are a number of attendants on the altar whose duty it is to see that the absolutely necessary details are properly fulfilled, it is quite improbable that any mistake in this matter was made. The young clergyman, however, had not made an act of conscious attention at the moment when he was supposed to do this, and consequently he could not be sure afterwards whether he had done it or not. He thought of it as the very essence of his ordination and he feared that all his subsequent acts as a clergyman might be impaired by this negligence.

Trivial Doubts.--It is not alone with regard to important things, however, that people may doubt and are disturbed by doubts, but with regard to every trivial thing in life, if they permit the habit to grow on them. Doubting is, after all, one of the phobias, that is to say, it is the fear that something may happen if the decision they make is wrong, that causes people to hesitate so much. There is a tendency in all of us which, if undisciplined, may make us put off the doing of things until the last moment. It is easy to resolve the night before that we will do certain things the next day, but when the next day comes we find excuses to put them off. I have already suggested as a symptom that some people put off the opening of letters. There are probably more who do this than anyone has any idea of. Delay in answering letters is probably much more often due to hesitancy of decision than to actual laziness. We doubt as to what we should say about certain things, and we do not care to take the trouble of making up our minds, and we fear if we do make up our minds it may be wrong, so we adjourn the whole matter to another time and keep on adjourning it. Many people are quite ready to confess that they do not do things until they have to, though few are ready to acknowledge that it is due to hesitancy or doubting about themselves and their decisions.

{736}

Of course, the man who doubts whether he has locked the door of his house after he gets to bed can only satisfy himself by getting up and actually investigating the state of affairs. Then there is the man who doubts whether he has locked his safe at the office. He may get his doubts just as he reaches the foot of the elevator and then if he is wise he will go back and determine the matter. If he is wise with experience he will also deliberately determine while he is there whether the office window is closed and locked and will make a conscious act when he comes out as to the locking of the office door. If he does not do all this he will have further doubts on the way up town and at his home during the evening which will make the doing of anything else a matter of discomfort and he will spoil the restfulness of his after-dinner hours. Some men conquer their first doubt, make their way home only to be beset by so many doubts that at the end of an hour they go back to their office and determine whether the safe is locked or not. Finding it locked they may forget to notice other things about the office and then they will surely have doubts about these, and they may have to go back again and see about them.

Then there is the man who doubts whether he posted a letter or if he did post it, who doubts whether it found its way down to the bottom of the mail box, or whether it may not have caught on a projecting screw or bolt or some portion of the upper part of the box and so fail of collection; he may go back several times to determine this. Doubts about even more trivial matters than this, however, annoy some people. I have known widows on whom the responsibility of managing the financial affairs of the household had been thrown for the first time after their husbands' death, who constantly doubted whether they could afford to spend this or that, though they were regularly saving money from their income. Over and over again they would have to go over all their recent expenditures to decide whether they could afford certain expenses. Such little things as the sort of paper to use in their correspondence, the wages they paid their servants, the amount of waste in the food in the household, all aroused in them doubts and set them to calculating once more just what was the relation of their income to expenditure, all to no purpose, for they would have the same doubts the next week or month.

Then there are people who doubt whether their friends really think anything of them. They think that though they treat them courteously this may be only common politeness and they may really resent their wasting their time when they call on them. They hesitate to ask these people to do things for them, though over and over again the friends may have shown their willingness and, above all, by asking favors of them in turn, may have shown that they were quite willing to put themselves under obligations. They doubt about their charities. They wonder whether they may really not be doing more harm than good, though they have investigated the cases or have had them investigated and the object of their charity may have been proved to be quite deserving. They hesitate about the acquisition of new friends, and doubt whether they should give them any confidence and whether the confidences that they have received from them are not really baits. This is, of course, a verging on suspicion as well as hesitancy and doubt, but the stories of how these people try to conquer themselves, yet have to make decision after decision, each one requiring time and a certain resolution of mind, are quite {737} pitiable. It gets worse rather than better unless a definite discipline of opposition and control is organized.

What ordinary people do habitually and easily and without any effort of mind, these people must waste time and mental energy over so that it is extremely difficult for them to accomplish anything. Training of mind, as of hand, consists in making certain actions so habitual that they are accomplished quite automatically. If we have decided that we are to get up at a certain hour we get up at that hour and do not have to make up our minds about it again, though this is one of the actions in which we all have the most lapses and the most need of renewal of resolution and habit. We make up our mind what we are going to eat and gradually acquire the habit of eating a certain quantity and a certain variety at meals and then we do not have to make up our minds about it every time. We go out, to do whatever must be done in our occupation quite automatically and there is no need of wasting mental energy over decisions about it. It is this that the doubter cannot do. He or she calls every trifling act before the supreme court of last decision, the bar of intellect, to decide whether it is worth while doing, whether it is to be done or not, how it is to be done, and then there is a doubt whether after it is done it may not prove to be quite the wrong thing to have done. This adds so much to the friction of life that all the surplus energy is used up in the settling of trivial matters, and nothing worth while is accomplished.

Sir James Paget once expressed all the realities of the situation of many of these people in a few terse phrases. It is probably the best explanation of its kind that we have and it deserves to be in the notebook and often before the mind of physicians who treat neurotic patients. Sir James said: "The patient says 'She cannot'; her friends say 'She will not'; the truth is she cannot will."

The expression, of course, applies to many other phases of so-called nervous disease besides doubting and especially to the psychasthenias. It represents, indeed, the keynote of many of these puzzling affections. The fact that it was uttered more than half a century ago shows how much better these affections were understood two generations before ours than we are likely to think, and how well physicians then got to the heart of them. From this to the re-education of will, that mental discipline and relearning of self-control which constitutes the essence of the treatment of them, is but a short step.

Prophylaxis.--Serious Occupation.--Of course, the real way out of the trouble is to have to do certain important things that occupy the mind and require the doing of many other things as subsidiaries which must be accomplished in order to carry out the greater resolution. Men who have important affairs on their hands seldom are bothered by doubts and hesitancy. Women who have not much to do make mountains out of the molehills of their little occupations and every trifle must be adjudged. The larger interests must be cultivated, the smaller ones must be turned over to the automaton which every one of us can develop in our persons if we only set about it resolutely. Each thing that comes up must be settled at once and action must replace contemplation. The Hamlet in us all must be put down and resolution must not be allowed to be sicklied over with the pale cast of thought. We must do {738} things and not think about them too much. The doubters can learn this lesson. They will never be entirely without hesitancy, but they can remove many of their difficulties, and live to accomplish much in spite of their make-up.

Physical Treatment.--The physical treatment of the doubting state consists, of course, in bringing the individual's physical condition as near as possible up to the normal. When the state occurs in people who are under weight its betterment is rather easy. The special feature of the physical condition that needs seeing to is an ample supply of fresh air. People who live in ill-ventilated places, or who do not get out into the air enough, are almost sure to suffer from the tendency to avoid the making of decisions. The man of decision usually is a vigorous outdoor-air individual. Even the perfectly healthy man who has been in the house for some reason for days together gets into a state of mind where the making of decisions becomes objectionable. He wants to push things away from him. In individuals who already have a natural tendency this way this is greatly exaggerated by confinement. Arrangements must be made, therefore, that will ensure getting out for some time, not once but twice every day. The regular making of decisions for this purpose is of itself a good mental discipline. It must not be omitted even for rain or snow, unless there are additional reasons of some kind. An abundance of fresh air in the sleeping-room is extremely important and must be secured.

Mental Treatment.--The mental treatment consists in diversion of mind. Usually the doubters have no interests that appeal to them deeply and in which they have to make prompt regular decisions. If possible, these must be secured. They must form habits of doing things regularly and of making up their minds to do them, and then not have to repeat the adjudication and resolution. In recent years people realize, quite apart from its religious significance, the value of what older religious writers called examination of conscience. Regularly before they go to sleep these people must be told to call up what they have done during the day and to note their faults in the matter of putting off doing things and making decisions slowly. They must, however, not only realize their faults, but they must make up their mind to correct them during the following day. They must not leave the arrangement of what they shall do next day to chance, but must decide just how and when they shall do things and then, as far as possible, keep to this program. The program must, of course, be sensible and considerate. This preliminary arrangement can be made to mean much more than might be thought. Some people thus learn to correct entirely their tendency to doubt whether they should do things or not and lessen greatly the difficulties they have in making decisions.

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VI. RESPONSIBILITY AND WILL POWER

The development of science (meaning by that term knowledge with regard to physical nature in contradistinction to philosophy or the relation of nature to man) in modern times has brought about in some minds a hesitant, if {739} not frankly contradictory attitude towards the question of free will. There are many scientists who not only doubt the existence of free will, but insist that there cannot be such a thing. For them, man like the animals is determined to do things from without rather than from within. The stronger motive compels him. There may be a weighing in the balance of motives, but that is a question of intellect and not of will. It is true that the stronger motive may be one that is less alluring to nature or to sense than some of the others which clamor for a hearing, but it is eventually the stronger motive that compels. A man may desire something that does not belong to him very much, but the consciousness that it does not belong to him and that to take things that do not belong to him is unworthy of him will override his covetousness and so he remains honest if he has been trained to regard things that way. After all, the old maxim, "Honesty is the best policy," is founded on some such reasoning as this, since only one who is at heart dishonest would consider men as swayed by the thought that to be honest is the most profitable, instead of being the right, and therefore the only proper thing.

The argument for free will that appeals to most men is the consciousness that we are free and that at any given moment we can do a thing or not do it, just as suits us. If two things are presented to us we can do that one which seems right to us to do, or we can do both of them, or we can permit ourselves to be led into the wrong, though always acknowledging to ourselves that it is the wrong and feeling downcast, or at least disturbed, that we should let ourselves be led away from higher motives. Even in this case the determinist insists that we are determined from without by motives due to our training, to our education along certain lines with the influence of the environment in which we live, to the special sentiment that we have within us as a consequence of the influences of preceding life. Such determination, however, does not come from without us, but from within. It is the result of the formation of our wills in a particular direction. The argument is, therefore, a begging of the question. A man may have formed the habit of doing evil things and then finds it easy to do them without compunction. On the other hand, the exercise of his will in doing what he considers right, in spite of the fact that it may not be pleasant at the moment, is a training of the will founded on its essential freedom. There is an essential distinction between right and wrong, and we have it in our power, as many a man has done, to follow the right even though it costs our life.

Bad Temper.--A typical example of supposed determinism, which proves exactly the opposite of what is sometimes urged, may be noted with regard to exhibitions of temper. As Clouston declares in his "Unsoundness of Mind" (Methuen, London, 1911), "an uncontrollable temper is in many cases very like and nearly allied to an unsoundness of mind. It is certain that bad temper may gradually pass into technical insanity and that a considerable number of persons who are passing or have passed into insanity exhibit as the most marked symptom morbidness and violence of temper. 'It's just temper. Doctor,' is one of the most common remarks that I have heard made to me by patients' friends. I think that it is quite certain that in most cases much might be done in youth to establish a reasonable control over temper where it is inclined to be uncontrolled, so preventing serious discomforts in life both to its possessor and to others. In many cases I am satisfied that {740} this education would have the effect of preventing unsoundness of mind also, arising out of uncontrolled temper." There are many examples in the literature of hagiology particularly, from which it is clear that men have learned to control even violent tempers and by self-discipline and training in self-control have even become rather quiet, gentle individuals. The truth of such examples is attested too well to be discredited. This question of training, then, is extremely important.

It has been pointed out that the consciousness of freedom to which an appeal is made in this argument for free will is shared with us by the insane even in the performance of many acts that we know are compelled in certain ways. Insane persons reason themselves into a peculiar state of mind, in which they represent to themselves that they have been persecuted, for instance, by a particular person and then they become persecutors in turn and do harm. As they see their act, it is often a species of self-defense. They themselves have no consciousness, or, at most, a very dim and hazy realization of the inner compulsion to which they are subjected at the time of the act and sometimes talk quite rationally and discuss the motives which impelled them to do things, just as if they were free. We recognize, however, the distinction between this delusion of the insane and the rational state of mind of the sane. We have no definition for insanity, that is, no formula of words, which will absolutely include all the insane and at the same time exclude all the sane, but we have a practical working knowledge that enables us to judge rather well between those who are compelled to do things by delusions, and those who do them from motives that are rationally weighed and that influence a will that is free to follow them as it pleases. We hold the rational man responsible for his acts because he knows he was free not to do them. We punish him partly because he should not have done them and partly because we want him not to do them again, and we know that punishment will help him to keep from committing crime, because it will support his free will against his inclinations, when the time of trial comes again.

Above all, we are conscious of our own responsibility. We know that when we do wrong we are worthy of blame. We know that when we allow covetousness to lead us into the appropriation of what does not belong to us we are deserving of punishment, because we need not have done it, but we yielded to unworthy motives. We know that while anger may be blind we can control it, at least those of us who are fully in possession of our intellectual and voluntary powers, so as to keep from doing violence, even in the heat of it. This dealing with ourselves is the best proof that we have of our recognition of our freedom of will. We are responsible, and what we genuinely do not will to do is not accomplished. Our will may be bent by many attractions, but we know that these motives are not compelling unless we allow them to be. When a child tells us that he did something because he could not help it, we either feel sorry for him because he is not yet in possession of his full faculties or else we laugh at this excuse. There is a tendency to admit this excuse as having a meaning, but only by those who themselves come into court with hands assoiled in some way and who are looking for pardon from others for offenses, and who, above all, want to feel that they can pardon, or at least excuse, themselves.

In recent years we have seriously impaired the idea of responsibility in {741} the minds of the general public by a foolishly sentimental mercifulness to criminals. If a man under indictment for murder can show that he has ever previously in his life acted even slightly irrationally, or if he has been peculiar in certain ways, provided, of course, he has money enough to pay for the opinions, there will be an abundance of expert testimony to declare that he is irresponsible and should not be punished. As a consequence, in many cases justice fails. We are reaping the harvest of this pseudo-scientific invasion of law. Human life is cheaper in no country in the world than it is in America. Our murder rate is going up by leaps and bounds, while that of Canada remains almost stationary, and the reason is that while nine out of ten of all our murderers do not receive the death penalty and many of them escape serious punishment of any kind, nearly as large a proportion of Canadian murderers are punished by death. A man may have his responsibility somewhat impaired and yet retain sufficient free will so that he deserves to be punished for serious crimes. It is hard to decide in certain cases, but in most cases the decision is not difficult if, with the right sense of justice, morbid sentimentality is put aside.

[Footnote 59, the following lengthy citation is from an article on "Responsibility and Punishment," in the American Journal of Medical Science, 1909.]

While the doctrine of free will is so clear it is still true that the question of responsibility for actions, and above all for criminal actions, is not so simple as many people used to proclaim it in the past. No two men are free to perform an act or not to perform it in quite the same way. Familiar examples are ready to hand: One man finds no difficulty at all in resisting the inclination to take spirituous liquor to excess; another finds it a most difficult feat, often apparently impossible for him to refrain from indulging to excess almost whenever the opportunity offers, or at least whenever he gets a taste of liquor. This difference between the two men is founded in their very nature. It would be utterly a mistake to praise the one for his abstinence or to blame the other under certain circumstances for his indulgence. Between these two classes there are others quite different individually. Some of them have a slight tendency, and, fearing the worst, do not indulge in it; some of them have a marked tendency which they are able to resist under most circumstances without very much difficulty once they have made up their minds; some are sorely tempted, fall occasionally, yet never become habitual drunkards. For each of these men there is a different responsibility, and so far as they are to be punished a different punishment must be meted out, for it is our effort in the modern time to make the punishment fit the criminal and not the crime.

This same thing holds true for many other forms of crime. Some men readily lose sight of the distinction between mine and thine, and possess themselves of their neighbors' goods almost without realizing that they have done wrong. They are rare, and we have been accustomed to call these people kleptomaniacs. Between these and the man who hesitates to steal, even when starving or for his starving children, there are many degrees of inclination and disinclination toward stealing. The same thing is true to a more noteworthy degree with regard to anger. Anger, the old saw says, is a brief madness. In America we say very frankly that a man who is very angry is mad. In this brief madness he may be led to do things which he would not do at all in his sober senses. Some men easily get into one of these awful fits of anger in which their responsibility is lessened, while others have a calm phlegmatic disposition from which they are scarcely aroused even by the worst forms of abuse or injury, or even physical suffering.

It is evident in all these cases that in order to measure how much of punishment ought to be meted out for acts committed it is more necessary to know the individual than his act. This often becomes an extremely difficult matter, for {742} after the commission of crime every effort is made to make out as little responsibility as possible for the criminal. The easiest way to do this has been to use the insanity plea. As already stated, we have no definition of insanity. It is easy to understand then that there will be a disagreement among physicians as to who is or is not insane, and the result is almost sure to create doubt which tends to obscure the principles on which are based the proper punishment of crime. Now this system is founded on certain wrong principles as regards the administration of Justice. While it is difficult to decide with regard to a man's insanity or sanity, it is not difficult to decide with regard to his punishment when the ordinary purposes of punishment are kept well in view.

The old idea of punishment used to be that of revenge. A man had done a wrong, and what would ordinarily be held a wrong had to be done to him in order that the scales of Justice should be maintained level. At the present time we have no such idea at all. Punishment has two main purposes--the prevention of further disturbance of social order by the particular criminal, and the deterrence of others from like acts. If a man takes away the life of another we do not take away his because thus Justice will be obtained, but we take it away to prevent him from ever doing anything of the same kind again. A man who has committed murder is more likely to do it again than another. He has committed one breach of social order; we shall prevent him forever from committing another of the same kind. This is the very best deterrent to such crimes that there is. It will be said, of course, that these men could not refrain from doing their acts. It is doubtful, however, whether this contention is true in the great majority of cases, and the proper punishment of such as occur furnishes the best possible motive to help others from the commission of like acts.

This holds true for children at a time when their sense of responsibility for their acts is as yet undeveloped. They can be taught, even very early in life, by properly applied punishment, that need not be severe, that they must not do certain things, and then they will not do them, or at least, will do them much less. This is true not only for perfectly rational children, but also for those that are to some degree irrational. Punishment is of great importance in the training of children of low grade intelligence, and there is scarcely any child, however wanting it may be in intellect, that cannot be disciplined into conduct that makes it much less bothersome than would ordinarily be the case. This is well known and it is also well known that the attempt to manage such children without punishment would be extremely difficult, not to say impossible. They do not reason about the thing, they are not quite responsible for their acts; but they do connect punishment with what they have done, and are in many cases deterred from doing it again, especially while they realize that authority is near them and that punishment is inevitable. These are the principles on which the adjudication of punishment for crime must be measured. There is nothing else that can be done if society would preserve itself and its members from those who are irresponsible even in minor degrees.

In this matter practical experience is well worth the while. The lower order of creatures, the animals, we do not consider responsible for their acts in the same way as human beings. We know the value, however, of punishment in deterring them. A dog, for instance, by being whipped a few times when he is young, can be taught not to steal things to eat, and taught that there is an inevitable connection between the taking of such things and the infliction of such punishment. I shall not soon forget my first lesson in philosophy from a dear old professor, who, talking of the memory of animals, demonstrated that they had a memory, from the ordinary experience of mankind with regard to them. "If a cat does something naughty in your room," he said, "you rub its nose in it, and it will not do it again." The cat had no idea that it was doing wrong. According to its way of life it was not doing wrong. It learned, however, from sensory experience that it must not do this sort of thing under special circumstances, and after the lesson has been once thoroughly learned there is no more trouble of this kind.

Individuals who are of less mental stability than normal require, indeed, more careful discipline than average men. The rational may be managed by sweet reasonableness. The defective child must be made to realize that certain actions {743} will surely be followed by painful punishment, though, of course, the main purpose of modern care for such children is to watch over them so diligently as to prevent them getting into mischief. This is after all what we do with the animals, and we realize the necessity for it. Defective human beings approach the animal in their lessened power to resist impulses, and they must be treated in the same way. If we were to save the animals in an excess of tenderness toward them, because we held to the notion either that they did not know any better or else could not resist their impulses, and then permitted them to do things without punishment, we should either have to get rid of animals entirely, or else life would be one continuous readjustment of things to animal ways. Since defectives occur in the general population, it must be realized that far from being less rigid with them in the matter of meting out punishment for things they do that are harmful to others, we must be even more strict with them. Otherwise, we will have to take the bitter consequences of our own foolishness.

It does not make so much difference if the thoroughly rational individual occasionally escapes punishment for something done, but whenever the subrational escapes, he is encouraged to do it again. More than that, the example of his punishment is needed for others. So far as possible, punishment must inevitably follow crime in the world, in order to impress the subrational and deter them from yielding to impulses. Far from being less deserving of punishment in every sense in which a modern penologist cares to inflict punishment, these individuals are more impressed by it, and, above all, need to be more impressed by it. When the subrational know that they can do things without being severely punished for them, they will always abuse that state of affairs. The thoroughly rational man may be depended on to do his duty as a rule without the need of punishment hanging over him. This is not true for the others, and hence the greater increase in crime, and above all in murder, which has made human life cheaper in this than in any other country in the world, as the direct consequence of recent abuses in our penal system.

It has become very clear now that in recent years we have come to take entirely too lenient a view in these matters, and that many criminals who deserved to be punished, both because in this way they would be prevented from future crime and others deterred by the knowledge of their punishment, have been allowed to escape Justice. The tendency is toward too great mercifulness, which spoils the character of the nation, just as leniency to the developing child spoils individual character. Men may very well be insane, in the broad meaning of that term, in the sense that they have done irrational things, but then there is almost no one who has not. The responsibility of most men for a definite action is quite clear in the sense that if they are punished they will not do it again, or will be less likely to do it again, while if they are not punished their escape becomes a suggestion to themselves and to others to repeat such acts. It is for the subrational that we most need to insist on punishment. The cunning of the insane is proverbial, and this extends also to the subrational, and many of these folk realize that their difference from others, their queerness, as their folks call it, is quite enough to make a verdict of insanity in their case assured with the present lax enforcement of law. If the present state of affairs continues in this matter, we are simply allowing ourselves to be led by the nose by these cunning people into the perpetuation of a state of affairs in which they may do what they like because we have become foolishly oversensitive in the matter of inflicting punishment.

On the principle that punishment deters, a man who has killed another man, even under conditions that seriously impaired his responsibility for the act and with evidence of previous lowered mentality, must never again be free to live the ordinary life of men. He must be under surveillance, and should be confined for life in an institution for the criminally insane. For the subrational such a sentence, if known to be inevitable, would usually be more deterrent than even imprisonment in an ordinary prison for life with all the possibilities for freedom which are presented by executive clemency, pardoning boards, and the like. It is absurd to say that a man may have such an attack of mental unsoundness as will lead him to do so serious an act as taking away human life, and then be expected to get over his mental condition so as not to be likely to do the same thing again. {744} Every alienist knows that this is not true. Such acts, when really due to mental instability, occur either in depressed or maniacal conditions, and these, as is now well known from carefully collected statistics, inevitably recur, or in weakened toxic conditions in susceptible subjects, and a return to the old mode of life may at any time bring recurrences.

It is in the treatment of disorders of the will of various kinds that the physician is brought to realize how much harm is done by the teaching that determinism and not free will rules life. It is true that we often find cases in which men and women cannot use their wills or at least seem not to be able to use them. They are lacking in some essential quality of human mentality. We find many human beings, however, doing things that are harmful for them and that are so inveterated by habit that it is extremely difficult to get away from them. In every case the sane person can conquer and break the habit, no matter how much of a hold it may have obtained.

We have heard much of the born criminal and of the degenerate and his inevitable tendencies, but most of the theories founded on this phase of criminal anthropology have gradually been given up as a consequence of more careful and, above all, more detailed observation. Many criminals bear the stigmata of so-called degeneration. Many of them have irregular heads, uneven ears, some fastened directly to the cheek and some with the animal peak, many have misshapen mouths and noses, but, on the other hand, many people having these physical qualities are good men and women, perfectly capable of self-control, honest, efficient members of society, and it is evident that the original observations were founded too exclusively on the criminal classes, instead of on the whole population. It is important, then, to get away from the notion of irresponsibility in these cases.

While men are free, yet each in a different way and the freedom of their wills is as individual as their countenances, it must not be forgotten that the freedom of the will is a function of the human being, and, like all other functions, can be increased or decreased by exercise or the lack of it. The old idea of "breaking the will" was as much of a mistake as that other old-fashioned notion contemporary with it of "hardening" children by exposing them to inclement weather and severe physical trials. The will may be strengthened, however, by the exercise of it and if not exercised it may not be expected, by analogy, at least, to be as weak and flabby as muscles would be under similar circumstances. The training of the will by self-denial and self-control is extremely important. When there is an hereditary influence, a family trait and not merely an acquired character, by which the will rather easily passes out of control, there is all the more need for the training of it in early youth. Without such training men may find it impossible to make up their minds to deny themselves indulgence of many kinds, but this is not because they have not free will, but because this function has never been exercised sufficiently to enable them to use it properly. A man who attempts to do gymnastic feats without training comes a cropper. A man who is placed in circumstances requiring hard muscle exertion will fail if his muscles have not been trained to bear it. The same thing will happen with the will.

Unfortunately this training of the will has been neglected to a considerable extent in modern education, and, above all, in modern families, where the presence of but one or two children concentrates attention on them, {745} over-stimulating them when young, leading to self-centeredness and, above all, discouraging self-denial in any way and preventing that development of thorough self-control which comes in the well-regulated large family. Besides, unfortunately it is just the neurotic individuals who most need thorough training in self-control and whose parents suffer from the same nervous condition (for, while disease is not inherited, defects are inherited), that are deprived of such regular training in self-control because of the inability of their parents to regulate either themselves or others properly. Here is the secret of the more frequent development of neurotic symptoms in recent years. It is not so much the strenuous life as the lack of training of the will so that the faculty of free will can be used properly. Lacking this, hysterical symptoms, unethical tendencies, lack of self-control become easily manifest. The training that would prevent these should come early in life, and when it does not it is very difficult to make up for it later. Just as far as possible, however, it is the duty of the psychotherapeutist to supply by suggestions as to training and discipline for the education of the will that has unfortunately been missed.

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SECTION XX

PSYCHOTHERAPY IN SURGERY

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I. PSYCHOTHERAPY IN OLD-TIME SURGERY

Surgery, a name derived from chirurgy--handwork--might seem to be dependent almost entirely on mechanical and technical skill, yet there has always been the conviction that the patient's attitude of mind towards an operation is almost as important a factor in the success of surgery as the surgeon's skill.

Astrology in Surgery.--From the earliest history of surgery we, find that astrology was mainly employed in order to determine what days were likely to be favorable, and what unfavorable, for the practice of such surgical procedures as were in vogue at that time. Certain conjunctions of the planets were declared to be particularly unfavorable, and some of them, indeed, were declared almost absolutely fatal; others were said to be especially favorable. As astronomical and anatomical knowledge grew, more and more details were added in this matter. Definite portions of the body were supposed to be under the occult influence of certain constellations. It was only with careful reference to these constellations then that surgical procedures or, indeed, the application of remedies of any kind, might be undertaken. All remember the picture in old almanacs of a man with the signs of the zodiac around him, and the indications that referred certain of these signs and the corresponding constellations to the different parts of the body.

Venesection and the Stars.--When venesection became a frequently used remedy, the question of the favorable and unfavorable influence of the stars was an important element in it. In old Babylonia, noted for its knowledge of astronomy, which was then called astrology without any of our derogatory meaning in the word, certain positions of the planets were absolute contraindications for the performance of venesection. Indeed, astrology often furnished the best possible excuses for the failure of what were thought to be absolutely specific remedies. When the remedies did not succeed, their failure was attributed to their being taken at unfavorable times and not to the remedies themselves. These astrological ideas continued to influence medicine, and, above all, surgery, down almost to our own time. Galileo and Kepler made horoscopes, and Mesmer wrote a thesis on the influence of the stars on human constitutions. In fact, very few important patients of the seventeenth and even eighteenth centuries were treated medically or surgically without due reference to the stars at the time. All this had a profound influence on {747} the patient's mind. He felt that every precaution was being taken to preclude the possibility of failure and assure favorable results, and he, therefore, submitted to the operation absolutely confident that so far as human knowledge could go, everything was favorably disposed in his regard.

Mental Influence in Old Hospitals.--It is rather interesting to realize how much the history of medicine illustrates the profound attention that was given in the old times to the question of the occupation of patients' minds as an eminently helpful factor in the treatment of disease and, above all, in convalescence. In the great health resorts, the temple hospitals like that at Epidaurus, or even the city hospital, the AEsculapeum at Athens, the question of recreation of mind was evidently considered very important. At Athens, the two city theaters, the larger one seating perhaps 50,000, and the smaller, Odeon, were not far from the hospital. At Epidaurus, a theater seating probably 12,000, in which the great Greek classic plays were given; a Stadium, seating nearly 10,000, in which athletic contests were conducted, and a Hippodrome, seating 6,000, in which animal performances might be witnessed, were all in connection with the temple hospital. Outdoor sleeping apartments were provided; that is, the patients slept under a colonnade, and, in general, the mental and physical hygiene of modern times was thoroughly anticipated. All of this was considered particularly important for convalescents. Patients were occupied, while in bed, with various interests. Just as soon as they could be moved, their minds were occupied with all sorts of interests external to themselves, and especially such as had the readiest appeal to humanity. (See bird's-eye view, facing p. 9.)

Medieval Hospitals and the Mind.--It is not difficult to trace the development of similar conditions in the hospitals of the Middle Ages. While we are inclined to think of these older hospitals as surely lacking in everything that we have developed in our modern hospitals, they prove, on the contrary, to have anticipated most of our hospital improvements. They were of single story construction, with large windows high up in the wall so that there could be no drafts, with a balcony on which patients could sit in the sun, with arrangements for procuring privacy rather easily by means of sliding partitions, with tiled floors, and, above all, with pictures on the walls, some of them the products of the brush of the great artists of the old time and which would serve to occupy patients' minds. Probably nothing is worse for patients who are convalescing from illness or operation than to be left to their own thoughts. Often they must not be talked to overmuch, or permitted the exertion of conversation or of reading, yet they must have some occupation of mind. The frescoes painted directly on the walls of the old hospitals were eminently psychotherapeutic in this respect, and we shall probably have to imitate them. Besides, the patients had the opportunity every morning to hear Mass, which was said at an altar at an end of the ward, and certain religious exercises were conducted by the sister nurses each afternoon. How much of consolation this was to believing patients at a time when all were believers is rather easy to understand.

Medieval Surgeons and Mental Influence.--Some of the insistence on this favorable state of mind for operations during the Middle Ages is extremely interesting. One of the great surgeons of the fourteenth century was Mondeville, whose text-book has recently been published in both France and {748} Germany. I have translated in "Old-time Makers of Medicine" [Footnote 60] some of his emphatic expressions, which show how important he deemed it to keep the patient in as favorable a state of mind as possible before and after operations. He went so far as to suggest that someone should be deliberately called in to tell him jokes. He said, "Let the surgeon take care to regulate the whole regimen of the patient's life for joy and happiness by promising that he will soon be well, by allowing his relatives and special friends to cheer him, and by having someone to tell him jokes, and let him be solaced also by music on the viol or psaltery. The surgeon must forbid anger, hatred, and sadness in the patient, and remind him that the body grows fat from joy and thin from sadness. He must insist on the patient obeying him faithfully in all things." He repeats with approval the expression of Avicenna that "often the confidence of the patient in his physician does more for the cure of his disease than the physician with all his remedies."

[Footnote 60: Fordham University Press, 1911.]

Mondeville was but one of the great surgeons of the medieval period who dwelt on this. It would not be hard to find corresponding expressions in the books of such men as Guy de Chauliac, Hugh of Lucca, Theodoric, or even earlier among the great Arabian physicians and surgeons. Rhazes, for instance, declared that "physicians ought to console their patients even if the signs of impending death seem to be present, for the bodies of men are dependent on their spirits." He considered that the most valuable thing for the physician to do was to increase the patient's natural vitality. Hence his advice: "In treating a patient, let your first thought be to strengthen his natural vitality. If you strengthen that, you remove ever so many ills without more ado. If you weaken it, however, by the remedies that you use, you always work harm." Another of his aphorisms seems worth while quoting: "The patient who consults a great many physicians is likely to have a very confused state of mind." For him a confused state of mind evidently meant a lessened tendency to recovery.

Surgical Lesions Influenced.--The King's touch in England, which so often proved beneficial for scrofulous patients, illustrates very well how much strong mental influence may avail even in cases where surgery seems surely indicated. Many cases of epilepsy were also greatly benefited by the King's touch, and, indeed, in this matter there are probably many more cases of the cure of epilepsy, or at least relief of the worst symptoms of the affection, reported as following the King's touch than after operation in the modern time. In both sets of cases we are now confident that the good effects produced came through the minds of the patients. When, during the eighteenth century, Mesmerism began to attract attention, investigators and experimenters on the subject were able to show that many pains and aches could be greatly benefited by psychic treatment. The painful conditions following fractures and sprains proved to be particularly amenable to mental influence exerted in this special way. As we approach the modern time, there comes to be a definite recognition of the fact that the mind may produce many pains and aches which seem due to purely physical conditions that might be expected to yield only to physical treatment. A corresponding recognition of the power of the mind to lessen and even suppress actual physical pain is almost a corrollary of this.

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Sir Benjamin Brodie declared, as I have quoted in the section on "Diseases of the Muscular and Articular System" that a large proportion of the painful joint conditions that he saw among his better-to-do patients were of the hysterical or neurotic type. Sir James Paget thought this expression of Brodie an exaggeration, but acknowledged that one-fifth to one-fourth of all his cases in both hospital and private practice were due to hysteria. In those days most of the painful conditions were considered to belong rather to surgery than to medicine, so that these opinions represent very well the practice of medicine in these cases during the early nineteenth century.

During the nineteenth century great practical surgeons, and especially those who have taught us how to treat individual patients rather than their diseases--for it is quite as true in surgery as in medicine that the patient is more than his disease--have made distinct contributions to the department of psychotherapy in surgery. Dr. Hilton's great book on "Rest and Pain" is full of psychotherapy. His cases illustrate the fact that when patients' minds and bodies are set at rest, all sorts of serious conditions proceed to get better. The rest of mind, the cessation of worry, the presence of a feeling of confidence in recovery, is quite as important as the physical measures. Young surgeons particularly probably could not do better than follow the advice of the old Scotch surgical professor at Edinburgh who suggests to his pupils that they should read Hilton's "Rest and Pain" at least once a year.

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II. MENTAL INFLUENCE BEFORE OPERATION

Much may be done during the preparation for operation to put the patient in the most suitable condition for the manifestation of healthy reaction of tissue and of normal convalescence. Many patients do not come for operation until their health has been somewhat impaired at least by the condition requiring operation. Not infrequently a good proportion of this impairment of health is due not so much to the lesion that is present as to the worry over it and the anxiety and solicitude which its development has occasioned. If the lesion is in connection with the digestive tract, this is particularly likely to be true, and nutrition will often have been sadly interfered with, not so much by direct influence of the pathological condition as by the unfavorable mental influence developing in connection with it. We know now that it is perfectly possible for an indigestion which is entirely above the neck to make rather serious inroads upon the health of the patient, by producing dislike for food or at least such loss of appetite as leads to considerable reduction in weight. In such cases there are often complications, such as tendencies to constipation, that still further impair health or at least reduce vitality and therefore hamper that healthy reaction which should occur after operation in order to assure normal convalescence.

Accessory Neuroses.--In many of these cases, even where there is a definite lesion present, the patient can be brought up to normal weight, or at least his condition can be greatly improved by medical treatment accompanied {750} by such attention to his state of mind as will neutralize its unfavorable influence. If he can be made to understand that a definite effort to increase weight and to bring back his strength will be of assistance in recovery from the operation, and that the reestablishment of certain habits of eating and caring for himself will do much to help in this, very desirable changes for the better in his general health may be brought about. This is illustrated very well by what happens in certain incurable cancer cases. The patients often have lost considerable weight, even thirty to forty pounds, before an operation is decided on, and then when the operation is performed their cancer is found to be inoperable. After the exploration the patient is not told this, but is mercifully spared and is assured that now he ought to get better, since an operation has been performed. Such patients have been known to gain twenty, thirty, and in one case I believe over forty pounds as the result of the mental influence of this suggestion and the resumption of former habits of life to some extent at least, consequent upon the neutralization of the unfavorable state of mind into which they had sunk before through over-solicitude about themselves. If even the depressing effect of the toxins of cancer can thus be overcome, it is easy to understand how much can be accomplished when there is no such physical factor at work.

Dominant Ideas.--As a general rule, it must be recognized that patients may be, and indeed frequently are, besides their definite pathological conditions, under the influence of dominant ideas which must be recognized and as far as possible neutralized. Some of them have persuasions with regard to food and the amount that they can eat, others have removed many important nutritious articles from their diet and are quite sure that any attempt on their part to take such articles is sure to be followed by indigestion, and still others have habits with regard to the amount and the kind of fluids that they take at meals and between meals and, above all, the lack of fluids in their diet which need to be overcome. Unless such ideas are counteracted there is difficulty even in convalescence, and very often they have brought patients into physical conditions in which whatever pathological condition is present is emphasized by that over-attention which the nervous system is so prone to give to even slight sensations when the organism is in a state of lowered nutrition.

In not a few of these cases the bringing of the patient up to the normal condition of weight and health, and the removal of the influence of dominant ideas, will perhaps also remove many of the indications for operation. There are many patients, and especially such as are reasonably educated and have some leisure, who get certain of their organs on their minds and produce symptoms or emphasize such symptoms as are present until it seems as though an operation is the only thing that can lift their burden of discomfort and permit them to go on again with their work. We have all known of physicians who felt sure that they ought to be operated on for such conditions as gastric ulcer or duodenal ulcer, though subsequent developments in the case, when they were persuaded to put off operation and made to reform certain ill-advised habits, proved that no such lesion as they suspected had ever been present. Indeed, some of these physicians and even surgeons have insisted so much that surgical friends occasionally have operated on them and have found nothing to justify the operation.

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Some of these states in connection with discomfort of various kinds in the abdomen have been discussed in the chapter on Abdominal Discomfort, and some illustrations of useless operations given. We must not forget that there is a constant stream of pathological suggestion in the air at the present time, not only in medical journals, but even in the secular press, and that this concentrates the attention of patients on comparatively slight discomforts and leads to the exaggeration of them until even an operation seems a welcome relief for them.

Operative Persuasions.--While surgical operations are in practically all cases mutilations, they are absolutely necessary under certain circumstances, are often, indeed, life-saving, and there is no doubt that they have saved mankind a great deal of discomfort. Surgeons are agreed, however, that they are not to be performed unless they hold out a definite promise of physical relief. It is extremely important, then, that patients must not become persuaded of the need of an operation in their cases unless surgical intervention is really necessary. This is as true for physicians and even surgeons themselves, as I have said, as it is for the general public. Women are much more susceptible than men to operation suggestions, and since it has become fashionable to talk about their operations, not only has the deterrent idea of surgical mutilation been greatly lessened, but there has actually developed in many of them a morbid fascination for a similar experience with all its attraction of attention and promised occupation of mind for the woman of leisure.

This phase of the necessity for favorable mental influence has been especially emphasized in the chapters on Gynecology. Unless, therefore, there are very definite indications, operations must not be performed, for they will relieve, as a rule, only for the time being, and further operations may have to be done to no purpose. Any physician of reasonably large experience has seen such cases. Patients get the idea of an operation as their one hope, and then nothing less than that will produce such diversion of mind as will bring relief of symptoms. It is important in these cases that such patients should not have operations suggested to them. Once the suggestion takes hold, they do not use their reserve energy in such a way as to help out effectively other remedies that may be given. They distrust all remedial measures, think that at most they can be only palliative, and so do not add to other forms of therapeutics the power of psychotherapy to cure them.

Besides the abdominal conditions, there are certain tuberculous conditions with regard to which this seems to be particularly true. I have seen enlarged cervical glands disappear without discharge when patients have taken up the outdoor life, and, above all, when they have gone out of the city and have lived the regime proper for those in whom tubercle bacilli are growing. If such patients, however, once become persuaded that their glands must be operated on, they are likely to need, if not active intervention, at least the discharge of material from their tuberculous lesions before they get well. Operations of a radical character for tuberculosis used to be much more popular than they are now, when we are likely to think that nature can do more for tuberculous lesions in nearly all cases than the most skillful surgery.

Fractures and the Mind.--In such surgical conditions as fractures and dislocations, a change has come about in the mode of treatment, at least in many hands, that seems entirely physical in its effect, yet has undoubtedly {752} exerted important psychic influences favorable to recovery which deserve to be noted. In dislocations and fractures, and particularly the latter, it was the custom in the past to do the fractured limb up in bandages and then leave it until knitting of the bones, or, in dislocations, healing of the soft tissues, had taken place. Apparently it was forgotten that this eminently artificial condition was not conducive to that healthy reaction of tissues for reparative purposes which must be expected in these cases. Circulation was not so good because of the constrictive effect of the bandages; vitality not so high because of failure of nervous activity in absolute immobility; the return venous circulation was somewhat hampered because there were no contractions of muscles; and all the conditions were distinctly unfavorable, though nature was expected not only to maintain the health of the part, but bring about the added functions of repair. In spite of the more or less unfavorable conditions, nature was able, as a rule, to do so. Prof. Lucas Championere reintroduced the older method of treating fractures and dislocations more openly and of even using certain manipulations, passive movements, and massage in order to encourage the circulation and the natural vitality of the limb.

There is another phase of the influence of this mode of treatment that deserves to be recalled. When the fracture is hidden away for many days and the patient is not absolutely sure whether it is getting on well or not, solicitude or anxiety is awakened in some minds that prevents, or at least delays, normal healthy repair. It is well known by surgeons that fractures do not heal so well after accidents in which there has been considerable shock, or in which the simultaneous death of a friend seriously disturbs the patient's mind. Nor do fractures heal so well if the patient is worried about business affairs or seriously disturbed over family matters. Among sensitive patients, a state of mind not unlike that produced by worry or shock may develop as a consequence of the dread that the fracture may not heal properly, or that there may be deformity, or that when the surgeon removes the bandages he may find it necessary either to break it again or do something that would involve considerable discomfort. These patients need reassurance. If the surgeon sees the broken limb occasionally, and, by manipulation and passive movements such as may properly be used, assures himself as to its condition, the patient's mind is much better satisfied and that inhibition of trophic processes which otherwise sometimes occurs is prevented.

Incisions and Suggestion.--Something of this same psychotherapeutic influence is noted with regard to the healing of incisions when these are not left without inspection too long. The newer surgical customs of comparatively few dressings, so that the wound may easily be inspected and the patient may be completely assured with regard to it, has undoubtedly had a good influence in bringing about more rapid repair. Air is the best environment for a healing as well as a healthy skin, and mental trust is best for the patient's power of repair. In vigorous individuals such repair will occur anyhow. It is in those of delicate health, neurotic disposition, and psychoneurotic tendencies, that reassurances are needed. Often their physical condition is such that they need every possible aid in bringing about complete repair. Their state of mind, then, must be noted carefully, and any inhibitory ideas that may be present because of over-anxiety as to how the incision is getting on must be removed. This does not mean that patients' whims should be yielded {753} to in the matter of over-solicitude about their condition, but that proper care should be taken to prevent inhibition of trophic influences through unfavorable mental states just as far as is possible. Most surgeons of experience do these things in the proper way by instinct from the beginning, or by a tactful habit, which develops in their surgical experience of adapting themselves to individual patients. It is well to realize, however, that such mental attitudes are extremely important and must be deliberately treated by the surgeon.

Pseudo-rabies.--Certain conditions usually treated of as surgical have mental relations that are very interesting. There seems no doubt that in a certain number of cases pseudo-rabies occurs; that is, persons are bitten by a dog, become seriously disturbed over the possibility of rabies developing, and after brooding over this for a time their mind gives way and there is either a neurosis simulating many symptoms of true rabies, or a state of collapse from fright in which even death may take place. These cases are not frequent. Their occurrence is taken by some of those who are opposed to animal experimentation as a proof that rabies is always some such delusion, and that it is due to the exaggeration of the significance of dog-bites by the medical profession that the symptom complex known as rabies has come into existence. This is, of course, nonsense, and many true cases of rabies occur. Since, however, these other cases provide the opportunity for argument in the matter, it is all the more necessary that they should be recognized for what they are. When a patient has been bitten by a dog that has not died from rabies within three weeks after the bite, there is practical certainty that the animal did not have and could not communicate rabies. The cases of hydrophobia with long incubation periods are rather dubious, and the general impression now is that there has been subsequent infection. Patients who are in the midst of overwhelming dread of the development of rabies must be taken seriously and their cases treated by mental influence. Suggestion, instruction, and the neutralization of wrong ideas by reference to authorities in the matter, must be used to overcome the unfortunate state of mind which may, if allowed to continue and, above all, to develop, prove serious for the individual.

Pseudo-rabies is but a type, though the most serious and perhaps most frequent of what may be called surgical psycho-neuroses. There are others. Imaginary syphilis is an affection that often causes worry and trouble to patient and physician. Herpes preputialis with mental symptoms is almost as bad. These are mental infections of various kinds. There are many neoplastic persuasions and toxic suggestions that must be treated with tact and firmness.

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III. MENTAL INFLUENCE IN ANESTHESIA

Nowhere in the domain of surgery is the influence of the mind more important than in the production of anesthesia for surgical purposes. It is well known that intense preoccupation of mind will make an individual completely anesthetic even for very severe injuries. In battle men frequently are severely wounded, yet do not know it, or at least have no idea of the extent of the wound and of the pain that ordinarily would be inflicted by it. In the {754} midst of panics, as during fires, or when crowds are trying to get out of buildings rapidly, people often suffer severe injuries and know nothing about them. The story of the woman who lost her ear in the theater panic and was quite unaware of it until her attention was called to it, is only one of many striking examples. Men have been known to walk round even with a broken leg, or with a dislocation with which it proved quite impossible for them to move, once their mental preoccupation for others ceased and they had time to think about themselves. Anesthetic incidents under conditions in which great pain might well be expected are not uncommon. It is evidently possible so completely to occupy the mind that pain sensations cannot find their way into the consciousness.

Pain and Diversion of Mind.--From very old times, attempts have been made to use this power of the mind to prevent pain, and often with some results. In preanesthetic surgery, minor operations were performed rapidly, beginning just after the patient's attention had been attracted to something else besides the thought of the operation. Pain is, of course, much less tolerable and seems to the sufferer at least to be much more severe whenever the attention is concentrated on it. Specialists in nervous diseases, during the process of eliciting complaints of pain or tenderness while employing movements or manipulations, usually try to attract the patient's attention as much as possible to something else, in order to determine just how much genuine pain or tenderness is present. Often it is found that, while a part of the body is complained of as exquisitely tender or it is averred that a joint cannot, be touched or a limb moved without severe pain, when the patient's attention is attracted strongly to something else, deep palpations may be practiced and rather extensive manipulations can be made without complaint. In these cases very often the pain is not imaginary, but is slight, due to some physical basis, and has been very much increased by the concentration of attention on it. This part, at least of the pain, may be removed by an appeal to the mind. The principle is valuable when there is question of minor operations.

Surgeons have often taken advantage of this power of distraction of attention to relieve pain in surgical manipulations. The story is told of the French surgeon, Dupuytren, that he was called one day to see a lady whom he knew very well in order to determine the form of injury from which she was suffering. He found that she had a dislocation of the shoulder, and during the manipulations, in order to make his diagnosis, he almost inevitably inflicted considerable pain. She complained very bitterly and told him that she understood that he was very rough with his hospital patients, but he must not be rough with her. He had hold of her hand at the moment, and, just before grasping the arm in such a way as to make the manipulations necessary to reduce the dislocation, he slapped her face and told her that she must not talk to him while he was treating her. Needless to say, she was deeply shocked. Before her shock had passed away, Dupuytren had completed the reduction of the dislocation, and in her preoccupation of mind she felt almost no pain. She remarked afterwards, however, that she had suffered so much mental anguish from his unexpected roughness that she was not sure whether, after all, she had been really spared in her feelings.

Hypnotic Anesthesia.--When, in the first half of the nineteenth century, {755} scientific attention was seriously attracted to hypnotism, it was hoped that this would prove an effective means of producing anesthesia during surgical operations or at least of greatly lessening pain. The hope was not disappointed. There was a discussion on the subject before the Medical Chirurgical Society of London in 1840, and in 1843 Dr. Eliotson wrote a work with the title, "Numerous Cases of Surgical Operations Without Pain in the Mesmeric State." In 1846 Sir John Forbes wrote in his Review that "the testimony as to the value of hypnotism as an anesthetic is now of so varied and extensive a kind as to require an immediate and complete trial of the practice in surgical cases." At the end of that same year, ether as an anesthetic was introduced into England, and the first case was reported under the caption "Animal Magnetism Superseded," which shows how much attention the previous attempts at hypnotic anesthesia had attracted. After this, hypnotism was given up for anesthetic purposes except by a few enthusiastic students of it. These, however, succeeded in accomplishing much with it. Dr. Esdaile, in India, succeeded in doing all sorts of operations under hypnotism. Dr. Milne Bramwell, in "Hypnotism, Its History, Practice and Theory" (London, 1906), lays down the rules for hypnosis for anesthetic purposes. They are eminently practical.

While hypnotism can be used to produce anesthesia, it has many disadvantages. The length of the hypnosis cannot always be arranged so as to assure anesthesia during the whole of an operation, while in some cases it will continue after the operation for some time in spite of every effort on the part of the hypnotist to bring the patient to himself. Besides, the depth of the hypnosis cannot always be assured, and sometimes some sensation remains. Patients will groan and wince and move, though, of course, under ether or chloroform such manifestations may take place, yet the patient afterwards will give every assurance that not the slightest pain was felt. In some cases, however, even where the pain sensation is not severe during an operation under hypnosis, it may, nevertheless, prove sufficient, when continued for some time, to bring the patient out of the hypnotic state.

For short operations of minor character, undoubtedly hypnosis can be employed successfully. As we explain in the chapter on Hypnotism, anyone can produce hypnosis who has confidence in his own power and in whom the patient has trust. There is no need of a special hypnotist, and there is no special faculty required. There should be some familiarity with procedures, but any man has just as much hypnotic power as another. The influence does not pass from the operator to the subject, but is due to the subject's concentration of his attention so that there is a short circuiting of association tracts within the brain very probably, which does not permit the entrance into consciousness of sensations through any path except one or two, usually that of hearing, and sometimes of sight, less frequently of other sensations.

Concentration of Attention.--In a great many cases of minor operations, such as the opening of a boil of a small abscess, the pulling of a tooth, the lancing of a gum, or other such procedures, a surgeon who is confident in his own mental power over his patient can rather easily produce a state of mind in which the discomfort of the surgical procedure is greatly minimized. There are certain physical helps for this. For instance, if patients are asked to breathe rapidly and deeply for a few minutes, there is a hyperoxygenation {756} of the blood which seems to obtund sensibility. If patients are told of this, and then made to breathe rapidly for a half a minute in order that they may continue consciously their deep, rapid breathing even when pain is noted, a state of mind is produced from concentration of attention on their breathing in which painful sensations are greatly obtunded. The effect is probably more mental than physical, and is well worth while trying because of the amount of pain it often saves.

Waking Suggestion.--Without resort to hypnotism, much can be accomplished by mental suggestion in the waking state to lessen the pain of surgical operations and maneuvers. This is particularly true as regards nervous persons, who will otherwise emphasize their discomfort, and for those of lesser intelligence, children, and the like. Esdaile's experiences in India show how much can be done in this way. Often the hypnosis was so slight that the patients were perfectly cognizant of everything that went on around them, yet under the compelling influence of the assurance of Dr. Esdaile, whom they trusted completely, they did not complain of pain nor wince even when considerable surgical intervention was practiced, and they always assured their friends afterwards that they had felt nothing. I know an American physician who has an almost similar power over negroes. Ordinarily it requires more of an anesthetic to produce insensitiveness to pain in the negro than in a white person. By personal assurance, by the absolute securing of their confidence, and through their trust in him, this man is able to produce anesthesia without the use of more than a minimum quantity of the anesthetic. He is able to do the same thing with children, and, of course, it is well known that mental influence over them is extremely important in limiting the amount of anesthetic that will be necessary.

Personality of Anesthetist.--Some anesthetists by their personal influence are able to bring patients under the influence of an anesthetic with much less excitement and, as a consequence, with the use of much less of the anesthetic than others. It is the same question of personal influence that extends through all medicine. Some men seem to have it naturally, and others not, though to some extent, at least, it may be cultivated. Of course, it is now well understood that, under no circumstances, should a patient be forced to take an anesthetic. This is as true for a child as for any other patient. Only a little management is required to secure the cooperation of even a young child. Above all, there must be no struggling, and while there may be a passing stage of excitement, which cannot be entirely controlled, this can be eliminated by those who are skillful. It may be necessary, especially in the case of children, for the little patients to become familiar with the anesthetist. They should see him on several occasions and should be made to feel that they know him. The presence of a stranger is enough of itself to excite children and make them suspicious and resentful of any manipulations. It may be well for them to have breathed through the cone on several occasions and to play a sort of game with it. In this way children will often go under an anesthetic without any struggle or excitement.

It seems a little childish to suggest similar procedures with grown patients, but even surgeons of long experience with the older methods who have insisted on the trial being made on their patients have found much benefit from it. Familiarity with the anesthetist and even with the inhaler {757} and the breathing through it on several occasions beforehand, when no anesthetic is being administered, helps many patients not a little. This preliminary is particularly of help with regard to nervous patients and especially women. It is very seldom necessary to use nitrous oxide as a preliminary to ether if this mode of procedure is practiced.

Mental Diversion.--It is well to concentrate the mind of the patient on something else besides his sensations. One element that is extremely important for anesthesia is deep breathing. The patient must then have his attention called to the necessity for deep breathing and should frequently have the suggestion to this effect repeated in his ear as he comes under the anesthetic. There should be some practice in deep breathing deliberately beforehand, with the idea of accustoming the respiratory mechanism to take deep breaths by habit even when not entirely under the control of the will. This may be done with the inhaler on a few occasions at least. The occupation of attention necessary for deep breathing during the taking of the anesthetic lessens the concentration of mind on the feelings, and actually makes the discomfort much less. Besides, deep breathing distributes the anesthetic over the lungs, leads to its absorption more rapidly, and makes the irritation of the anesthetic less by diffusing it over a larger surface. On the contrary, short, rapid breaths lead to an intensity of irritation and much slower absorption.

Skilled anesthetists have found it of decided advantage to keep the patient's mind fixed on something else besides the breathing. Perhaps the easiest recommendation is that of locking the hands over the abdomen just above the umbilicus and asking the patient to hold tight. This gives something very definite to think about and to occupy the mind with. I have seen patients of rather nervous organizations go under the influence of even a very small quantity of an anesthetic when required to hold their hands thus and when the command was constantly repeated, "Hold your hands tight," whenever there was the slightest sign of struggle or excitement. Where this was done tactfully and regularly, I have seen patient after patient go into anaesthesia without struggle or excitement and usually without any noise or even a loud word. I realize how much the personality of the anaesthetist means in such cases, and I feel sure that anyone who is confident in his own power in the matter will produce a corresponding feeling of confidence in the patients.

Fright in Anesthesia.--There seems good reason to think that occasionally the deaths reported from anesthesia have really occurred from fright or at least have been greatly influenced by emotional factors. It has often been noted that these deaths occurred particularly at the beginning of the administration of an anesthetic and before anything like a sufficient quantity to produce a toxic effect had been administered. In other cases it has been noted that patients were allowed to come out partially from under the anesthetic, and as they recovered consciousness were disturbed by some incident. Sometimes the pain seems to act as an inhibitory agent on the heart. In more than one reported case the patient told afterwards of hearing very distinctly some remark that seemed to be of bad omen. In one case in my own experience the breathing and heart stopped (though the patient fortunately was resuscitated) as a consequence of hearing a series of rather loud goodbyes said at the door of the elevator leading to the operating room during the {758} course of an operation just at a moment when the anaesthetic influence was very much lessened for a while. In some cases where there has been great fear of the anesthetic which has been talked over beforehand by the patient, even a few whiffs of the ether or chloroform have given rise to serious symptoms from stoppage of the heart. It is evident that it is extremely important properly to predispose such patients.

The well-known surgical warning not to make remarks during the course of an operation that might prove disturbing to the patient, needs to be emphasized. By a very curious psychological anomaly some patients, though thoroughly anesthetic as regards pain, are able to hear and understand very well remarks that are made near them. Fortunately, such patients are few in number, but they are sometimes rather seriously disturbed by chance observations that for the moment at least seem to have an unfavorable bearing on their case. Besides, certain patients sometimes have their special senses come out from under the influence of the anesthetic before their sense of pain. They may also hear and be disturbed. These cases illustrate very well the place of mental influence and how much deliberate attention should be given to this phase of the treatment of surgical cases coming out of anesthesia, as well as while more or less under its influence.

Local Anesthesia.--In local anesthesia it has come to be generally recognized in recent years that the personality of the operator is one of the most important factors for success. A number of local anesthetics have been introduced, and in some hands only comparatively small quantities of them are needed in order to produce complete absence of pain during operations. In other hands, however, considerable and even toxic quantities may have to be employed and sometimes without entire satisfaction. Infiltration anesthesia depends for its success largely on the personal influence of the administrator over the patient. It is extremely important that the patient should have complete confidence and not have that confidence disturbed in any way. For instance, he needs to be warned that he will feel the slight prick of the needle when it is first introduced, for otherwise he will be disturbed by even so slight a pain at the very beginning and will magnify subsequent feelings until satisfactory local anesthesia becomes impossible. Without thorough command over the patient and complete trust, local anesthesia never succeeds except in very minor operations. There are some men, however, who can do even severe and extensive operations with comparatively small amounts of local anesthesia. Others cannot perform satisfactorily even minor operations with large amounts. It is the operator, his personality, and mental influence over the patient that counts.

Vomiting After Anesthesia.--The vomiting that comes after anesthesia, especially with ether, often constitutes not only an annoying but sometimes a seriously disturbing complication. It must not be forgotten that vomiting in neurotic individuals, and especially women, may be largely due to a neurosis. In the section on Psychotherapy in Obstetrics we discuss the vomiting that occurs in connection with pregnancy and suggest that it is nearly always neurotic in character. The best-known European obstetricians are now agreed in this. While ether produces a tendency to vomit in everyone, in some the actual vomiting is very slight or completely absent. If patients expect that there is to be vomiting, if they are of the neurotic temperament that not only {759} vomits easily but has a tendency to secure sympathy by fostering this symptom unconsciously perhaps, then the vomiting may become even a dangerous complication. If there is no expectancy in the matter, however, but if, on the contrary, it is made clear to these patients before the anesthetic is administered that, while there may be some nausea, there need be no vomiting unless they yield too readily to their feelings, much can be done to lessen the vomiting. A single suggestion may not mean much in this matter, but a series of suggestions properly given beforehand, especially if the patient has seen others vomiting after operations and is worrying about it, may prove of excellent contrary suggestive value.

If there is no expectancy, the physician must be careful not to arouse it by over-solicitous anxiety in the matter. A plain statement should be made on several occasions, however, so that the patient will have in mind a good basis for contrary suggestion when coming out of the anesthetic. Many remedies have been suggested for this post-anesthetic vomiting, but, just as with regard to the vomiting of pregnancy, the most important element in all the cures that have been reported has been the influence upon the patient's mind. Whenever we have a number of remedies for an affection, it is almost sure that it is not their physical but their psychic effect that is of most importance.

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