In the ordinary practice of hypnotism now, the patient is placed sitting on a comfortable chair and the operator on one side facing prepares the mind of the subject by proper assurances. The patient must be brought into a thoroughly assured and comfortable state of mind and must be quite ready to submit to hypnotism. Then in most people, if the finger is held rather close to the patient and well above the line of sight, requiring special effort {158} on the part of the superior recti muscles as well as of the power of convergence, a tired feeling will come over the subject with a tendency of the lids to droop. When this happens the subject is asked to allow the lids to drop and to quietly concentrate the attention on the idea of sleep so as to permit the drowsy feeling gradually to increase. On a first seance this may take ten minutes, subsequently much less time will be needed, and, as a rule, in five minutes the subject is quite predisposed to sleep. In more difficult cases a much longer time may be needed, and repeated efforts may have to be made. Great patience is required. The operator soon learns to adjust himself to certain peculiarities of individuals in predisposing them to the hypnotic condition.
Hypnotism Simple, Natural, Not Mysterious.—The most important thing to know about hypnotism is the fact that any one who wishes can hypnotize. There may be need for favoring circumstances, but there is no need for any special faculty in the operator. If he has confidence in himself so as to take up the question of hypnotizing seriously, if the subjects are reasonably susceptible and if they are persuaded that they may be hypnotized, or even if they are not, so long as they take the operator seriously a hypnotic state will result. Nothing is more surprising to the operator himself, the first time he succeeds, than his success. This at once gives him renewed confidence, and future hypnosis becomes a comparatively simple matter. To have this idea widely diffused would do much good, since it would at once strip the charlatans, who abuse hypnotism, of most of the mystery that surrounds them. The general diffusion of such knowledge would also do good in another way. It would expose the supposed wonderful power that some people are presumed to possess. Hypnotism works no wonders; it is a mere natural manifestation not unlike sleep, and probably not a whit more mysterious.
Stages.—A number of divisions of the hypnotic state have been suggested, but probably the simple division into three stages is the best for ordinary teaching purposes, and helps to the understanding both of the conditions themselves and of many things that are written about hypnotism.
The first stage consists of a subdued, dreamy condition, in which the patient is not asleep and yet not thoroughly awake to all that is going on around him. He has his mind so concentrated on certain thoughts that he is preoccupied, and suggestions are much more efficient than under ordinary circumstances. This is really only a state of intense attention to the suggestions that are being made, with the banishment of all distracting thoughts. It is rather difficult for any one to keep from being distracted, and whenever this is accomplished, the ideas that then enter the mind penetrate more deeply and, above all, seem to affect the will more forcibly than when they are merely superficially considered. This first stage of hypnotism would not be considered hypnotic by most people who associate the idea of sleep with hypnotism.
In recent years it has been found that most of the good that is accomplished, especially for nervous people, by hypnotic suggestion, can be attained almost, if not quite as well, in this first stage, and without the hypnotic trance. The first stage is much less liable to the dangers of hypnotism in many ways, and it represents one of the most interesting phases of psychotherapy.
The second stage of hypnotism is the hypnotic sleep. The patient loses consciousness of his surroundings, though his senses are still open to suggestion from the operator. Practically all that happens in the room apart from what is brought to the subject through the operator's direction remains unnoticed. If the sleep is very deep, even the suggestions of the operator do not penetrate after a time, so it may be quite difficult to awaken the subject. It may be even some hours before the person hypnotized will come out of the lethargy which has been induced in these cases. Under these circumstances, this second stage partakes somewhat of the nature of the deeper trance condition that characterizes the third stage.
The third stage of hypnotism consists of a profound trance-like condition in which there is catalepsy—that is, firm contracture of muscles all over the body—and as the extensors are stronger than the flexors, this contracture takes place in the extended position. The cataleptic condition is really a nervous spasmodic seizure rather than a true stage of hypnotism. It is probably always harmful for the patient to have it induced. Its occurrence as one manifestation of hysteria, apart from hypnotism, shows its real character. It is with this stage of hypnotism that professional hypnotists, who give exhibitions, make their demonstrations—that is, of course, when their demonstrations are really hypnotic and are not merely, as is often the case, performances by actors trained for the purpose. Catalepsy is entirely pathological; experiment with it then is eminently undesirable, and certainly should not be undertaken except under the most careful precautions and by a physician. One of its dangers was very clearly pointed out by the death of a young man, who in a cataleptic condition was subjected to certain strains upon his thorax which brought about the rupture of an aortic aneurism. Catalepsy never permits of suggestion in such a way as to be helpful to the patient. It always leads to further functional deterioration of the nervous system, and yet it has unfortunately come to mean for many people the most essential characteristic of hypnotism. Its production is supposed to represent the acme of skill in the hypnotist. Nothing could possibly be less true nor be more likely to do harm.
Susceptibility.—As to the number of people who are susceptible to hypnotism, there are great differences of opinion. Liebault declared that practically every one is susceptible in the hands of a patient operator. In a carefully made series of cases his failures were less than three per cent. Van Rentergehem and Van Eeden, in a series of over 1,000 persons, failed only with fifty-eight, or little more than five per cent. Schrenk-Notzing's statistics, collected from many countries, seem to show that only about six per cent. were uninfluenced. Bernheim, at Nancy, was not nearly so successful as Liebault, his master, and his failures amounted to twenty-five per cent. at the beginning and at least twenty per cent. later. I remember that when I was at the Saltpêtrière fifteen years ago, they were inclined to discount the enthusiasm of the Nancy school with regard to the value and significance of hypnotism. They insisted that probably not more than one out of two of the persons presenting themselves at a nervous clinic could be hypnotized to the extent that is ordinarily associated with the word—could be brought beyond the drowsy stage. There are other workers in the subject who have insisted that not more than one out of three ordinary individuals can be so {160} deeply hypnotized as to exhibit the ordinary symptoms. These symptoms consist of complete neglect of surroundings and absolute absorption in the suggestions of the operator.
Some people can be hypnotized to the extent of being thrown into sleep and yet walk and talk under the absolute control of the operator. These are so-called somnambules, the class of persons who are exhibited by professional hypnotizers who want to attract popular attention, and, indeed, the class usually exhibited by physicians before medical societies, and even by professors before their classes. This extreme susceptibility is, however, quite rare. Even the most ardent advocates of hypnotism and of the susceptibility of humanity to it do not claim that more than one in ten of average individuals can be influenced to this degree. There are milder degrees of hypnotism than this, until we reach a state in which all the patients feel is a certain dreamy sense of well-being and a heaviness of the eyes, with a readiness to respond to suggestions. Most people who think of the somnambulistic stage as representing hypnotism would not consider these latter to have been at all subjected to the hypnotic state.
Repeated Efforts.—As to this question of susceptibility, much depends on how often the operator has tried to hypnotize the particular subject, for susceptibility develops with repeated trials, not only where there is a manifest impression at first, but also where there is not. It is not uncommon to find that a patient who cannot be brought at all under the influence of hypnotism in the first or second or third trial, will, at the fifth or sixth trial, yield to the suggestion to go into a hypnotic sleep. A dozen unsuccessful efforts may be followed by the development of a very satisfactory hypnosis. Those who have practiced hypnotism much tell of having tried a score or even two score of times before finally bringing on a hypnotic condition. Dr. J. Milne Bramwell, one of the English authorities on hypnotism, tells the story [Footnote 20] of having tried sixty or more times to hypnotize patients before finally succeeding. It is this persistence that enables successful hypnotic operators to accomplish results where less confident physicians fail. It is also the frequency of trial that makes all the difference in the statistics as to the susceptibility of patients to hypnotism in the hands of different individuals. There must be the confidence of the patient in the physician's power to hypnotize, but, above all, there must be the physician's own confidence in his power to bring on the hypnotic sleep so that he tries and tries again, even to seventy times.
[Footnote 20: "Hypnotism. Its History, Practice and Theory," by J. M. Bramwell, 2nd edn. London, The De la More Press, 1906.]
The hypnotization of animals shows that only a very low grade intelligence is needed for the production of this state. The famous experiment of Father Kircher with the hen, which any one may repeat at any time, is a good illustration. The fascination exerted upon birds by snakes is another familiar example. The bird is paralyzed with terror at the sight of the snake, and so cannot escape from its enemy, fairly glueing its eyes on the terrifying object, and thus loses power to control its wings. Stories of snake {161} fascination are usually told as if the eye of the snake attracted the bird, who thereupon proceeded to approach the snake. These are, however, doubtful stories. The paralysis of motion seems to be the main effect. The rabbit is affected in nearly the same way. There is a tremor of horror in anticipation, and then the animal stands perfectly quiet, though ordinarily he would be quite able to escape, while its enemy approaches. The underlying mechanism is evidently a concentration of attention, which completely precludes the possibility of the exertion of any spontaneous energy except that involved in the one act of watching the awful object.
There are many and various opinions of the dangers of hypnotism. Some of those who have given it a fair trial have insisted on its dangers. Some of those who have had very large experience have declared emphatically that there is no danger at all. Occasionally it has seemed that such a declaration must be considered as having been dictated by such intensity of interest as sometimes leads men to overlook the darker side of things with which they are much occupied. Certain moral aspects of hypnotism are at least dubious, and, it must be admitted, present opportunities for abuse. There are certain dangers connected with its effect upon nervous patients, and especially with its influence upon character, that have become more and more clear in recent years. Dr. John K. Mitchell, in his "Self Help for Nervous Women," a series of familiar talks on economy in nervous expenditure, [Footnote 21] has dwelt on certain of these dangers of hypnotism for nervous patients in a passage that deserves to be recalled. As a representative of a school of thought that is worthy of special regard from American physicians his expressions must carry weight:
[Footnote 21: Philadelphia, Lippincott, 1909.]
The greatest danger of all is the use of hypnotism in any form or
degree, a two-edged sword, capable indeed of usefulness, but more
capable of harm. After years of study, beginning with too easy an
approval of it, hypnotism, whether called by that name or by the
unsuitable one of suggestion, has been laid aside by the medical
profession as a means too dangerous for ordinary use, involving
great risk of deterioration of character in the subject if often
repeated, and putting a terribly tempting tool in the hands of the
user, fascinating in the ease with which it can produce superficial
and temporary good results and equally capable of being used for
harmful ones.
A susceptible person, once hypnotized, is more and more easily
thrown into the hypnotic state until even the slightest hint
suffices to bring about the condition. It is not necessary for the
hypnotization to go so far as deep sleep; this more advanced stage
is indeed seldom required, and to say that persons are not
hypnotized because they are not put into a sleep or a trance shows
ignorance of the subject.
I am not asserting that very slight degrees of the hypnotic
condition are as dangerous as the deeper, but I do say that all
degrees of it are dangerous to the integrity and healthy action of
the subject's nervous system. The danger of harm increases with
every repetition of the hypnotization.
In suggestible, that is, over-susceptible, individuals, who are
almost universally neurotic persons, to fix the eyes on a small
point, especially a bright one, sometimes even to fix the mind on
the one idea of going into the hypnotic state (mild or deep), is
enough without further intervention from any one to put them into
that state.
In an article on the "Danger and Uses of Hypnotism" Prof. Forel, of Zurich, twenty years ago, while frankly admitting that hypnotism is by no means a panacea for all nervous affections and unfortunate habits, found it to be an extremely valuable help in the treatment of many forms of functional nervous disease. He suggests that some of its many dangers are due to the fact that hypnotism is practiced by men who are too distrustful of it, and this distrust, unconsciously communicated to the patients, produces an unfortunate effect. On the other hand, fear and distrust on the part of the subjects seriously disturbs the process of hypnotization, interferes with its effect and sometimes leads to unfortunate results.
In some cases it seems that the state of dependence on some one else, at least by suggestion, that had been created during the hypnotic experience, resulted in a diminution of will power and caused a less hopeful state on the patient's part than before. I found personally that suggestion in the waking state might in most cases be used quite as efficiently as hypnosis itself, and that when improvement came under these circumstances, the patient always felt more confidence in himself and less in the operator. Anything that restores self-confidence and gives patients the feeling that they can conquer inclinations, tendencies, even habits, if they only will, merely by firmly resolving to do so, is the best possible mental influence for them. The hypnotic relief is always easier, but nothing that is easy is likely to be of lasting value. The enduring effect of gradual cure by suggestion means much more than the hypnotic miracle that these patients are so prone to crave.
At present there is a very general feeling among those who have had considerable experience with hypnotism, that in spite of the claims of certain votaries for it, there is no justification for its frequent or habitual use. It has a definite place in diagnosis, in certain difficult cases, and at the beginning of the treatment of certain forms of the psycho-neuroses. When repeated frequently it is not therapeutic, but is likely to produce serious results in a certain lack of self-control and tendencies to auto-hypnotization with deterioration of character. There is very seldom need of a repetition of deep hypnosis, and, as a rule, all the diagnostic benefit can be secured in one or two seances. Its continued use only illustrates the tendency noted at all times, in the history of medicine, for the unthinking or unprofessional to persist in the application of supposed remedial measures after they have been shown to be useless or even harmful. The subject well deserves further study, but investigations should be carefully made by men who realize the dangers, and who are not likely to be tempted to exploit patients and curious psychological phenomena for the sake of sensational reputation. The use of hypnotism for exhibition purposes, by men who are not physicians, is an unmixed evil, producing entirely wrong impressions on the public, and doing untold evil to the subjects employed.
The most important element in Psychotherapy is the individual patient. Old Dr. Parry of Bath said a century ago, "It is much more important to know what sort of a patient has a disease, than what sort of a disease a patient has." Mental influence is not of the slightest avail against pneumonia or typhoid fever, nor constipation nor rheumatism as such; mental influence may be, and often is, of the greatest possible help to the patient suffering from any of these diseases.
We recognize frankly now that for most diseases we can do nothing to counteract the disease directly or to cure it specifically. The idea of specifics in medicine has to a large extent disappeared. Two or three of them possibly we have, but even with regard to these, there are certain doubts as to the essential modes of their activity. We have learned, however, to help the patient to overcome disease. We know how to conserve his forces, to increase his vital reaction, to maintain his nutrition without disturbing his general condition, and to secure elimination in such a way as to prevent nature from being interfered with in her curative purposes. To this, psychotherapy would enable us to add such encouragement of the patient as would tap new sources of energy in him according to the law of reserve energy, and would prevent discouragement and the inhibition of favorable nerve impulses that so often follow. The outcome of any disease depends on two factors. One is the condition of the patient at the time the infection was acquired, the other is the virulence of the infection. We can do nothing to modify this latter element, once the disease manifests itself. We can, however, do much to enable the patient to throw off the disease and, above all, by securing a favorable attitude of mind, we can enable him to use his forces to the best advantage.
Anyone who has noted the difference between the patient's state just before and just after his physician has called, though absolutely no physical remedy has been employed, is able to realize very well how much psychotherapy is able to accomplish. One who did not know, would be sure to assume that some potent remedy had been administered—and there has been. This potent remedy is psychotherapy. Whether the personal magnetism necessary to produce therapeutic effects of this kind can be learned or not depends on the individuality of the physician. Undoubtedly, however, everyone can add to whatever of personal influence he has by definitely recognizing its place, by {164} making every effort to employ it, and then by regular systematic effort in securing as much personal information as possible with regard to the patient. This personal relationship of physician and patient makes instruction easier and suggestion more effective.
The securing of personal information is of the utmost importance in determining the affections that psychotherapy will relieve, because very often details of life and habits are discovered that can be so modified by instruction as to bring about a disappearance of unfavorable physical influences. It is indeed surprising to find how many unreasonable things people do from habit, from unfortunate persuasion, or from lack of knowledge. In many of the minor chronic ailments that are the source of so much mental discomfort to patients, the physician finds that a change in the patients' habits, not necessarily of marked degree, may make all the difference between cheerful health and rather despondent low-spirited feeling. Now that epidemic disease has become rarer, a physician's practice, especially among the better classes, is much more taken up with these minor ailments than with the typical classical diseases.
The ordinary history of their ailments, as patients commonly present them, especially when there are neurotic elements, is likely to be meager in what is objective, but consists mostly of the subjective. Such patients have much to say of their sensations, their feelings, their dreads, their surmises, their conclusions as to their particular condition, and especially the hereditary elements in it, but comparatively little of the objective realities of their ills and of their environment. What the physician needs to know about them is their habits of life, their daily routine of existence, just as minutely as it is possible to obtain the information. There is just one way to get the latter details, and that is to inquire particularly with regard to actual happenings. In chronic conditions of many kinds, it is so helpful that it will always be worth the physician's while to get at these details, especially in supposedly puzzling cases for which various forms of treatment have been already tried.
In spite of every precaution in this matter, the physician sometimes finds, after a series of consultations, that some point which when brought to light he considers to be of great importance, has been thought so trivial by the patient that it was never mentioned, in spite of the most careful questioning. In all medical practice the rule is that mistakes of diagnosis are much more due to neglect in eliciting necessary information than either to lack of expertness in diagnosis, or lack of knowledge of the significance of symptoms.
In the affections that can be relieved by psychotherapeutics, the most important element for diagnosis, besides a minute knowledge of the patient's habits, is just as detailed information as possible with regard to his ways and modes of thought as to his ills. Practically every motive, as well as every action of the day, must be scrutinized, and often it will be found that little things mean much for the individual. "Trifles make perfection, but perfection is no trifle," as said by Michelangelo, might well be changed for the physician to, "Trifles make all the difference between health and discomfort, though health is no trifle."
In getting the history of patients for diagnostic purposes the safest way is to begin with the getting up in the morning and then to follow out the various actions of the day. The hour and mode of rising should be inquired into. Practically all nervous people, and nearly all those beyond middle life, feel less fit in the morning hours than at any other time in the day. Apparently as a consequence of their will having been allowed to lose its hold during sleep, it does not secure thorough command over the organism for some time. Nervous people, as a rule, wake up with a tired feeling, a dread of the day, wondering whether life is worth living. They dread—for it is a real dread—to get up and tackle the daily round of life once more.
If they have nothing very definite to do, then slight tired feelings or discomfort, even of very minor degree, may lead them to think that they cannot get up. Any yielding in this matter is almost sure to do harm. When there are no objective signs, that is, when there is no fever recognizable by the thermometer and there has been no diarrhea or any physical weakness, nervous patients should get up promptly at a particular hour every morning, because, as a rule, within a half hour after getting up they feel better, and by the time they are washed and have had their breakfast, life has grown not only quite possible but even plausible, and the day's work does not seem such a nightmare as it was at first. It is not advisable to tell people all this as soon as they confess their habit of dawdling in the morning, for they must be gradually brought to discipline themselves. The detail emphasizes the necessity of knowing how they get up as well as when.
Mode of Awaking.—It is often valuable to know how patients awake. Sometimes it will be found that they are anxious and solicitous to be at work at a particular hour, or to catch a train at a particular time, and that as a consequence their sleep is disturbed in the early morning hours. At best it may be fitful and when they awake they fear to go to sleep again lest they oversleep. An alarm clock will sometimes remedy this state of affairs. Better still is an arrangement by which someone, who can be depended on, will wake them at a particular time. Occasionally patients cannot content themselves in spite of the assurance that they will be waked. They dread that the alarm clock may not go off, or that the awakener may make a mistake, and so they go to bed with a dominant idea, which is more or less constantly present in their mind during all their sleeping hours, disturbing sleep and preventing complete rest. It may be necessary to insist on a change of occupation for such persons, or a change of residence that will do away with the necessity for early rising. When this is done, many a neurotic condition that has before proved intractable will disappear.
Amount of Sleep.—It is of cardinal importance to know how long patients sleep. In our large cities most people have too little sleep. A comparison of the hours when they get to bed with those when they get up will often show that at least three or four nights in the week some patients who are complaining of nervous symptoms, especially nervous indigestion, are {166} sleeping less than seven hours. There are but few men, and still fewer women, who will retain their health under such conditions. Some men have been able to do it, but they are comparatively rare. King Alfred's rule of dividing the day into three eight-hour periods—one for sleep, one for work, and the third for bodily necessities and recreation, still remains the best for human nature. Whenever people try to live the strenuous life and get along on less than eight hours of sleep, they are almost sure, sooner or later, to render themselves uncomfortable, to make themselves liable to all sorts of neurotic symptoms and, above all, to detract from their efficiency for whatever work they are engaged in. Whether they sleep or not, they should be in bed for nearly eight hours.
Bathing.—Morning Bath.—In our larger cities at least, many of the inhabitants begin the day with a bath. In this matter one finds all sorts of harmful fads that need to be corrected. Many men take a cold bath, and unless they are particularly strong and vigorous, this is rather an exhausting experience for the beginning of the day, when the last nutrition the body absorbed is twelve hours before. On the other hand, large, athletic men who manufacture a great deal of heat, their muscles—the heat-making organs—being well developed, will be benefited by having a cold bath because of the abstraction of heat that it involves. It is not, however, infrequent to find that the man for whom it will be good is not taking it, while the thin, neurotic individual, already exhausting more of his vitality by worry and dieting and in various fads with regard to his health than is good for him, is regularly taking his cold plunge or douche. Unless especially asked about it, few men give particulars in this matter, yet they are extremely important.
Women, on the other hand, are likely to take hot baths more frequently than is good for them. Especially when they have maids to assist in dressing and undressing, it is not unusual to find that women take two, and sometimes even three, hot baths in a day. They take them in the early morning when they first get up, and in the evening before dressing for dinner. I have known cases where some took a third hot bath before going to bed and sometimes even put in a fourth before luncheon in case they had had any exercise in the morning hours—tennis, or horseback riding, or the like—that made them perspire. These are details which the physician will learn only if he asks particularly about them. Until he has actually had the experience of finding that they play an important role in some ailment he is almost sure not to think of it. It is probable that even two hot baths a day are too many. I have known women to begin at once to get better of neurotic symptoms that before had proved quite intractable, when their hot baths were limited or when they were changed for a single warm bath with a cold rub after it in the morning, or sometimes just before dinner.
Bathing is more liable to abuse than is usually thought to be possible. While the habits of modern life call for it often, and many people are quite sure that they would not be healthy without it, the people who live longest, and who have had the best health far beyond three score years and ten, have usually not been noted for bathing proclivities. The human body is composed of nearly seven-eighths water, and so our cells are constantly bathed in it, but the making of the whole organism a marine animal once more, as seems to be the definite tendency of some people, is not nearly so hygienic as {167} it is often thought to be. Enough bathing for thorough cleanliness, but not for luxury, must be the rule for people who have active work and want to retain their health.
Bathing Fads.—While such mistakes are usually made only by the wealthy and leisure classes, the physician will sometimes be surprised to find that women who have no maids for personal service are indulging themselves in these over-frequent bathing practices. They have heard that it softens the skin and renews youth, or they have heard that the Japanese take hot baths and are revivified when they are very fatigued, and so they go to great lengths in bathing. Often this is the main reason for the relaxation of muscle tissue and the sense of prostration that has come over them. Neurotic people are constantly going to extremes. Even delicate women will sometimes be found to take very cold baths which are surely doing them harm. Over frequent washings of hands and face are sometimes responsible for skin lesions, especially if the soap used is one of the varieties so scented that the manufacturer is enabled to conceal the impurities in its ingredients. Some women easily run into what is really a misophobia, an exaggerated morbid fear of dirt, and need to be restrained from washing themselves over frequently. Many a chapped hand would be saved by avoiding unnecessary washings, and especially in warm water just before one goes out, for it leaves the skin without its proper oily protection.
Clothing.—Then comes the question of clothing. It is curious how irrationally many people clothe themselves. People complain of cold hands and feet when they are wearing thin cotton undergarments, and who need only to have these changed for wool for their feelings to be at once improved. In the meantime they have been persuaded that they have a defective circulation. The usual excuse for not wearing wool is that it produces hyperemia of the skin with itchy discomfort, but this, as a rule, is only passing and is due to unaccustomedness. The coarser wools should not be worn by the sensitive. A thin cotton garment may, if absolutely necessary, be worn next the skin. There is too little variety in the underclothing that people wear. Some change from light to heavy weight and only that, but there should be a medium weight worn, and occasionally, when there is a spell of mild weather in the winter time, even during the season when heavy weight is usually worn, medium weight should be substituted for comfort's sake.
It is even more common to find that neurotic individuals, who fear to catch cold, wear too much clothing, especially around the chest. Very often they alternate from this during the day to next to nothing in the evening, and by so doing subject themselves to special risks of internal congestions. When the skin is covered with too much clothing it loses the habit of reacting, and the warmth and the irritation of wool keep up an artificial hyperemia which gradually lowers the tone of the peripheral vessels. Many people wear "chest protectors," as is evident from the prominent display of these abominations in the drug-store windows. By leaving certain portions of the chest unprotected while other parts are kept over-warm, these add greatly to the risk of such disturbances of circulatory equilibrium as predispose to the infections grouped under the term "taking cold." It is not heavy clothing that keeps people warm so much as the layers of non-conducting air between the skin and the outer air. It is better, therefore, to wear three thin {168} garments than two heavy ones because of the additional layers of air that are thus confined. A paper vest, if one is driving in the wind, will probably protect better than the heaviest woolen garment worn. The wearing of chamois garments is not, as a rule, advisable because chamois does not permit free access of air and it hampers transpiration.
Before Breakfast.—After dressing comes breakfast, with regard to which it may be advisable to ask many questions. It is well to begin with a query as to whether liquids are taken before breakfast. Many people have taken to the fad of drinking a large quantity of warm water, sometimes as much as a pint, before breakfast. Surely this never does any good and, in most cases, just as surely does harm. Plain water will not dissolve mucus that may have collected in the stomach, and warm water merely dilates that organ, relaxes its fibers, and renders the whole gastric digestive system atonic. If cold water can be borne, it will often be found that a glass of cold water the first thing in the morning stimulates peristalsis, and serves to lessen the necessity for laxatives. Many people complain that cold water is too much of a shock. Usually, if they are reminded that when we want to warm our hands we rub them vigorously with cold water and that the reaction after this gives a healthy glow, the effect of the supposed shock, which was merely an unfavorable suggestion, will disappear. Sometimes delicate people cannot drink cold water. If there is any reason to suspect an accumulation of mucus in the stomach, a small bouillon cup of very hot water, just as hot as it can be borne, in which a pinch of salt and a pinch of bi-carbonate of soda have been dissolved will prove an excellent aperitive for the day. This is physiological and appropriately chemical, as well as naturally stimulating. Mucus does not dissolve in ordinary water but dissolves readily in an alkaline salt solution, and this is just what is thus recommended. This drink is quite grateful to the palate. Indeed, it tastes very much like clear soup, and, if the eyes are closed, cannot, as a rule, be distinguished from some of the bouillon commonly served. I have known this cup of hot water to stimulate an appetite when drug tonics had failed.
It is better to take the glass of cold water from fifteen to twenty minutes before the morning meal—say immediately on rising. If, instead, the small cup of hot water is chosen, it should come immediately before eating, and will usually prove an appetizer.
Breakfast.—The exact details of the amount of breakfast taken and how it is eaten should be known. Nervous people eat little breakfast. When ordered to eat, they find it difficult at first, but the habit is easily formed, and then they want their breakfast like anyone else. It is surprising how often physicians will find that nervous persons, who are under weight, are not taking enough breakfast. They will ordinarily say that they are eating breakfast about as other people do and will, perhaps, mention eggs and rolls, but it will be found that their ordinary breakfast consists of a roll and piece of toast and coffee, and only occasionally do they have any of the other things mentioned.
Breakfast is ordinarily the meal which those who work are likely to eat too hurriedly. Those who are neurotically inclined are especially victims of the habit. They lie abed until there is only a few minutes left to get the train so as to reach their place of occupation in time, and thus their breakfast is {169} skimped. Their oatmeal or other soft cereal is fairly shovelled in, coffee is gulped, toast is unchewed, the coffee softening it; if they have creamed potatoes they are swallowed in such large pieces that, as every physician knows, if for some reason they vomit they are surprised, beyond all measure, at the large portions they have been able to pass down into their stomachs. A breakfast thus eaten makes a bad beginning for a nervous man's day, and the more that is so eaten the worse for the victim. With a habit like this, it will be utterly impossible by means of drugs or directions as to diet to relieve the discomfort of neurotic indigestion, or to keep the patient from suffering that stomach discomfort so often complained of in the morning.
Working Women.—Working women are even more prone than are men to take a hurried breakfast, and having, as a rule, less appetite than men, their meal is likely to be deficient. It is not unusual to find that a young woman who is under weight and who needs three meals a day, is taking so little for the first meal that even she hesitates to regard it as a meal. Very often her last previous meal has been taken before seven o'clock the night before, so that she goes out ill prepared for her day's work. Much more than men, women are annoyed in the morning by our transportation systems, and by worry as to whether they will get to the office on time. Suggestions as to the modification of this unfortunate routine, the taking of an earlier train, the using of a quiet local instead of a crowded express, a short walk at least before taking the train, will often help in producing a marked change in the general health.
Home Keeping Women.—For those who really have homes, the morning duties are usually sufficient to rouse their activities and make them begin the day well. For those who live in apartment-hotels, however, and for those who have the luxury of many servants, the morning hours are often a serious problem. Madame does not get up, or if she does, it is only to lie around in dressing gown for most of the morning. Breakfast is easily neglected or may be eaten hurriedly because the head of the house is rushing to business. The lack of an incentive requiring them to rise, and get outside for a time every morning, is probably at the root of more feminine symptoms among leisure class patients than anything else. As we grow older all of us are likely to note the lowered physiological cycle of the morning hours, so that unless there is some sharp reason to compel action, we are rather prone to persuade ourselves that it is better to lie abed, or at least to loll around. This leads to a concentration of attention on self and on one's feelings that easily gives rise to neurotic conditions.
Interest in life.—In my special clientéle I have often found that going to church in the early morning hours was an excellent remedy for many of these patients. It gives them a definite reason for rising promptly, the service provides motives to rouse them to activity, they are likely to think during it of how they shall make their life a little bit more livable for others as the result of their trying to be better, and so the apathy that is so fruitful of ill feeling is shaken off. This can only serve for those who have faith in the service. For others, the old-fashioned going out to market, or the making of appointments at morning hours that will tempt them to regular activity early in the day, is of special significance. It is always ominous for health when a woman can look forward to a whole long day without any particular duties {170} in it until the late afternoon or evening hours. This has become so frequently the case for the women of our large cities, particularly those who live in apartment hotels, it is no wonder that neuroses and psychoneuroses of various kinds have grown in frequency. The best prophylaxis for them is occupation of mind. The cure for them is the securing of many interests and such diversion of mind as will prevent concentration of attention on self.
Mail Before Breakfast.—Many people receive their most important mail in the early morning, and personal mail, in cities especially, is likely to be placed beside the breakfast plate. Not infrequently, letters contain serious matters that are likely to disturb people, and occasionally even important business finds its way to the side of the plate at breakfast time. Authors often find their rejected manuscripts sent back in the morning's mail. Occasionally bad news of other kinds comes in this way, and, as a rule, it is the very worst time for its reception. The human system—it cannot be too often repeated—is at its lowest physiological term in the morning, the temperature is lower than during the rest of the day, all the nervous vitality is below the normal. Half an hour after breakfast the reception of bad news, or the coming of important matters requiring decision, would not make so much difference. Hence, the necessity for knowing whether the mail is ordinarily read in the early morning, in order to know something about people, and about the consumption and digestion of their breakfast.
Company at Breakfast.—Pleasant company during meals is an important factor that makes for good digestion. At the other meals there is much more likelihood of having such pleasant company, while the morning meal is often a solitary, and quite as often as not, a rather glum quarter of an hour, preoccupied with the business cares of the day. As may be readily understood from our discussion of this problem of mental preoccupation during digestion, this may seriously hamper digestive processes. Often men take refuge in their paper. The thoughts aroused by reading the modern newspaper are not the pleasantest in the world and consist, very often, of the following out of details of hideous crimes and scandals. When, as is sometimes the case, these scandals concern relatives, friends or acquaintances in whom we are interested, and with regard to whom we feel poignantly because of the publicity involved, nearly the same effect is produced as when bad news is received in letters, or when business worries are thus brought to the breakfast table.
The best conditions for the eating of breakfast are those in which it becomes like the other meals, a family matter. When father, mother and children eat their breakfast together, nearly always family interests and especially the enlivening effect of the joyousness with which children face a new day is the best possible tonic for a business man in whom a solitary breakfast starts a day of digestive disturbance. Sociability and sufficient time must be insisted on, whether at home or in a boarding house, at breakfast as well as the other meals, and it will often be surprising to find how much difference this makes both as regards the quantity eaten and the digestion of the food.
Morbid Habits.—In matters of diet, it is important to ask for details, for it is surprising what unexpected things may be discovered after weeks of treatment. That was illustrated for me once by a case of persistent acne in a young girl, which all the ordinary remedies failed to cure. I felt sure that {171} I had given her such explicit directions with regard to diet that I knew exactly what she was taking and that nothing could be hoped for from any change. As a last resort, I asked once more with regard to all that she ate and only then discovered that before breakfast every day she ate a baked banana. It had been recommended to her by a friend as a sure cure for constipation, she had formed the habit of taking it as a medicine, and so had not spoken of it. Baked bananas agree with many people well, but just as soon as this was eliminated from her diet her acne began to improve and before long had disappeared almost entirely. The taking of large amounts of warm water, already spoken of, is another of these morbid habits. Then many people take a glass of salt water, or laxative water, and some have curious habits with regard to the eating to excess of salt on cereal or on fruit, or sometimes they eat too great a variety of fruit. All this should be known, but often will not be ascertained unless particularly inquired about.
Probably even more important than details with regard to the early hours of the day, is detailed information as to the day's work, the kind and character of the occupation and the length of time spent at it, the interruptions that may occur, the habits with regard to luncheon, and, above all, the state of mind in which the occupation is pursued. The physician will only learn these details when he sets before himself a definite schedule of what he wants to know, and then proceeds to secure information with regard to it. With this sufficient can be learned in a short time to ascertain the source of the affection or the symptoms complained of. In some cases it is, however, only when the whole day's occupation is reviewed that proper suggestions can be made.