Psychic Conditions of Hospitals.—The atmosphere of the hospital must all conduce to peace and quiet of mind. It is surprising the differences that may be noted in this respect. I have been in a hospital where only a dozen of operations were done a week and have scarcely ever been there without hearing complaints of pain and discomfort that were surely disturbing to others. On the other hand, I have been in a hospital where twenty capital operations a day were done, and have heard no complaint, and at nine o'clock at night have found in it the peace of a religious community. I knew that it was all due to the personality of the surgeons and their lack of power in one case to impress their patients' minds and a very marvelous power in the other of impressing patients favorably. The success of many a surgeon in a material way depends on this power to impress his patients. It is they who send others to him, and in general there is a feeling that if he cannot cure them no one can.

Of course, it is extremely important that circumspection should be employed as regards chance remarks that may be seriously misinterpreted and prove unfavorably suggestive. Patients should not, as a rule, be allowed to see their own charts whenever there are disturbing developments in pulse and temperature. During dressings the conversation should be cheerful, distracting to the patient, and should not contain remarks that may be disturbing. The surgeon and his assistants must know how to control their expressions so as not to reveal any solicitude that may be occasioned by the patient's progress or by the state of his wound when these are not satisfactory.

Surgeon's Visits.—Practically every time that a surgeon visits a patient after operation there is something that the patient has to ask or have explained. A good deal depends, as far as regards the comfort and peace of mind during the interval until the coming of the surgeon again, on the satisfaction derived from the surgeon's explanation. He should be prepared, therefore, to answer in such a way as will leave no haunting doubts in the patient's mind. Some patients are very prone to find unfavorable suggestions in even simple expressions of the physician. He must be prepared for {761} this, therefore, and be sure to say nothing that can possibly be misunderstood. In spite of this, at times patients will draw unfavorable inferences and then the nurse should have the confidence of the patient sufficiently to set the matter right or at least to give reassurance that will keep the patient's anxiety from disturbing until the next visit of the surgeon. All of this seems trivial from a certain standpoint, but even surgery is as yet an art and not a science. Art depends on personality and the influence of it and the power to express itself. The personality of the surgeon must be felt in the patient, and the more he can make it felt the better the convalescence and the less discomfort even though there should be more of pain. The amount of pain actually felt depends on how much of it gets above the threshold of consciousness.

Almost any surgical patient, especially if he has gone through a serious convalescence, will tell you how much good the visits of his physician used to do him, though a glum and over-serious surgeon may have exactly the opposite effect. Sometimes busy surgeons neglect to visit their patients daily, and nearly always this has an unfortunate effect. In serious cases, the seeing of the surgeon several times a day, when it is well understood that his visits are not due to over-anxiety with regard to the patient, may hasten convalescence materially.

Comfort, Mental and Physical.—Everything must be done to make the patients as physically comfortable as possible. It must be well understood, however, that comfort lies much more in variety and response to feeling than in any continuous condition. Patients will have little complaints and there must be always something novel to do for them. This does not necessarily imply medicine or even troublesome external applications, but the rearranging of bed clothing, the use of a hot-water bag or of an ice bag, the relief of pressure, sometimes mild applications of pressure, the lifting of the head, slight turning, even small changes of position and the like. Whenever a patient can be relieved by some means so simple as these external trifling remedial measures, confidence is awakened that the discomfort they feel is not due to any serious condition, but is only such achy tiredness as comes from confinement to bed. Without relief afforded in this way, they are likely to let unfavorable suggestion accumulate until their dread of something serious may inhibit convalescence or at least interfere with sleep and greatly enhance their discomfort generally. It is the state of mind that develops as a consequence of continued trifling discomforts and not the physical results of those discomforts that must be carefully looked to in post-operative patients.

Nursing.—In the general management of patients after operations it would be eminently helpful to the surgeon if surgical nurses were supposed to read at least once a year, Florence Nightingale's "Notes on Nursing," [Footnote 61] written half a century ago, and if the surgeon himself should have read it through once at least and dip into it occasionally afterwards. In her chapter on Noise there are many remarks that I should like to quote, but the whole chapter is so valuable that it is hard to know where it stops, and so only a few expressions may be given here. For instance, "Never to allow a patient to be waked intentionally or accidentally, is a sine qua non of all good nursing. If he is aroused out of his first sleep he is almost certain to have no more sleep." "The more sleep patients get the better will they be able to sleep." "I have often {762} been surprised at the thoughtlessness (resulting in cruelty, quite unintentionally) of friends or of doctors who will hold a long conversation just in the room or passage adjoining the room of the patient, who is either every moment expecting them to come in, or who has just seen them, and knows they are talking about him." "Everything you do in a patient's room after he is 'put up' for the night increases tenfold the risk of his having a bad night. Remember, never to lean against, sit upon, or unnecessarily shake or even touch the bed in which a patient lies."

[Footnote 61: American edition, Appleton, N. Y.. 1860.]

Miss Nightingale, as might be expected, insists emphatically on the state of the room, the arrangement of the furniture and the cheerfulness of surroundings as important factors for the cure of patients. One of the most important elements is, of course, the nurse. She must be gentle, patient, quick to understand, often ready to anticipate wishes, and always as noiseless as possible. Slowness may be neither gentle nor noiseless. Patients, particularly men, often grow impatient at the slowness with which things are done for them.

Chattering Hopes.—There is scarcely an element of mind in the patient's environment that Miss Nightingale has not thought of and touched with very practical wisdom. She deprecates, as does anyone who knows anything about the care of patients, the "chattering hopes" of those who try to cheer patients by simply telling them that they ought to be more cheerful, that of course they will get well and that they must not be anxious. She says: "I would appeal most seriously to all friends, visitors, and attendants of the sick to leave off this practice of attempting to 'cheer' the sick by making light of their danger and by exaggerating their probabilities of recovery." Cheerfulness and kindness towards the sick are one thing and foolish attempts at encouragement not founded on good reasons quite another.

Variety of Thoughts.—From the chapter on Variety the following quotations show the very practical character of Miss Nightingale's persuasion as to the value of influencing the patient's mind:

"To any but an old nurse or an old patient the degree would be quite inconceivable to which the nerves of the sick suffer from seeing the same walls, the same ceilings, the same surroundings, during a long confinement to one or two rooms." "The nervous frame really suffers as much from this lack of variety as the digestive organs from long monotony of diet." "The effect in sickness, of beautiful objects, of variety of objects, and especially of brilliancy of color is hardly at all appreciated."

As Miss Nightingale insists, flowers are remedies of great value for the ailing and especially for those who are confined to their room for a long period. She pleads for having the bed placed near a window in order that they may see out into the fields and the scenery around them, to which I would add with emphasis, and so that, if it is possible, they may see the occupations of human beings. Miss Nightingale adds: "Well people vary their own objects, their own employments many times a day; and while nursing (!) some bedridden sufferer then, they let him lie there staring at a dead wall without any change of object to enable him to vary his thoughts." Quite needless to say, variety is more important for the ailing than the well.

Pain Psychic Conditions.—Pain after operation is an extremely common symptom and often causes much disturbance. Every surgeon knows how {763} individual are patients in this respect, and how much depends on the personal reaction to pain. There are men and women who have very serious lesions, from which much pain might be expected, who complain very little. There are, on the other hand, many men as well as women who complain exaggeratedly after even trifling surgical intervention. We have probably had some of the most striking examples of the influence of mind over body in these cases. Many a patient who complained bitterly of torment that made it impossible to rest has, after being given a preliminary dose of morphine hypodermically, subsequently been given less and less of that drug, until finally, after a few days, he was getting injections of only distilled water. Without their injection he was in agony. After it he settled down to a quiet, peaceful night. Very often it is noted that these pains are worse at night and there is a tendency for such patients to attract attention only at such times as may be productive of considerable disturbance of the regular order and as may call special attention to them. We used to call such conditions hysteria, though, of course, they have nothing to do with the uterus and must be looked for in men quite as well as women.

Psychoneuroses.—These neurotic conditions, to use a term that carries no innuendo with it, may affect other functions besides that of sensation. Occasionally a neurologist is asked to see a patient in whom, following an operation, usually not very serious, some paralytic symptoms have developed. There is an inability to use one or more limbs, and the suspicion of thrombosis is raised. It is rather easy, however, to differentiate thrombotic conditions from neurotic palsies. The ordinary symptoms of the psychoneurosis are present. There is likely to be considerable disturbance of sensation, with patches of anesthesia and hyperesthesia, some narrowing of the fields of vision, and anesthesia of the pharynx, sometimes even of the conjunctiva. Often there is something in the history that points to the possible occurrence of a neurotic condition. Sometimes it is extremely difficult to get such patients over the mental persuasion that is the basis of their palsy, but usually it can be accomplished by suggestion in connection with certain physical means. Electricity is often of excellent effect in demonstrating to these patients that their muscles react properly under stimulus and that it is only a question of inability to use them because of mental inhibition. Such conditions as astasia-abasia may develop quite apart from surgery, but there is always some "insult," as the Germans say, that is some physical basis for them, and so they are often considered to be surgical.

Psychic Disturbance of Function.—Besides motion and pain, other functions may be affected through the mind. After operations within the abdomen it is sometimes difficult to move the bowels when it is desired to do so. It must not be forgotten that not infrequently in these cases the patient's mental attitude of extreme solicitude with regard to his intestines is inhibiting peristalsis. Such constipation will sometimes not yield to even rather strong purgatives, and yet will promptly be bettered by something that alters the mental state. It must not be forgotten that it is in cases of neurotic constipation that pittulae micarum panis have proven particularly useful. In the chapter on Constipation there is a discussion of this subject that will often prove suggestive to surgeons.

This same thing is true with regard to post-operative urination. In women, {764} particularly, there may be difficulty of urination after vaginal operations, which may be attributed to some lesion of the urinary tract and yet only be due to failure of the patient properly to control muscles in these cases. As in obstetrical cases, position, the presence of others, and the mental disturbance, may inhibit urination. The subject is discussed more fully in the section on Psychotherapy in Obstetrics. Surgeons are not so inclined now to insist on absolute post-operative immobility, and even a slight change of position may enable patients to gain control over their bladders without the necessity for the use of the catheter, which always carries an element of danger with it.

The influence of the mental attitude with regard to both of these functions—intestinal and vesical evacuation—must not be forgotten. There are many persons who find it extremely difficult to bring about such evacuations in the lying position. Everything is unusual, and their exercise of the coordination of muscles necessary to accomplish these functions is interfered with. It is somewhat like stuttering and the incapacity of an individual who may be able to talk very well to close friends and yet stammers just as soon as strangers are present or he is placed in unusual conditions. It has even been suggested that there should be some exercise of these functions in the lying position before operation, in order to accustom patients to the conditions that will obtain afterwards. They thus become used to their surroundings and the newer methods required, and, above all, if there should be any post-operative difficulty, they realize that it is not due directly to the operation, but rather to the unaccustomed conditions. This proves helpful in saving them from solicitude and consequent unrest and adds to the rapidity of convalescence.

Food Craving.—When food is to be given in small quantities and there is likely to be craving for it, much can be done to save the patient disquietude and disturbance by giving small portions rather frequently, rather than distributing it over three times a day, as the routine of life sometimes suggests. When water has to be denied, small pieces of ice may occasionally be used with excellent advantage. Patients learn to look forward to breaks at the end of comparatively short intervals in their craving, and the accumulative effect is greatly lessened. It is well understood that whenever people are absolutely denied anything, they are likely to let their minds dwell on that fact and crave it much more than would otherwise be the case. If they can look forward to having even the minutest quantities of anything that they want, however, craving is much less likely to be insistent, and the state of mind is much easier to manage. In all of these cases the confidence of the patient and the lessening of neurotic tendencies by suggestion means more than most of the physical remedies that have been recommended. There are some patients who respond almost in a hypnotic way to suggestion from a physician in whom they have great confidence.

Position and Peace of Mind.—The patient's general comfort is very important for the maintenance of a favorable state of mind. It used to be the custom to keep patients rigidly in one position for days, sometimes more than a week, after operation. We know now that this is almost never necessary, and that, of course, it is most fatiguing to the patient. Keep the ordinary well person absolutely in one position, without the opportunity to change from side to side even during a single night, and there will be justifiable {765} complaint of tired and achy feelings as a consequence. To enforce such a state for forty-eight hours in those who are well will produce a highly nervous state, consequent upon the fatigue and soreness of muscles induced. Hence, the importance of taking every possible means to provide even slight changes of position for those who have been operated upon. A number of regular-sized pillows should be provided so that the head may be raised and lowered, and a number of smaller pillows should be at hand which can be so placed as to relieve pressure at various parts and permit the patient to make at least slight changes of position during the first forty-eight hours. After this, usually definite alterations of position may be allowed without danger. The surgeon must think of these elements in the treatment and insist on them with his nurses, or they will not be carried out. It is possible now to permit patients to sit up much sooner than before, and, indeed, in pelvic operations, this is said to be definitely beneficial by preventing the spread of any infectious material that may be present into the general peritoneal cavity, and in older people it prevents the development or, at least, greatly facilitates the dispersion of congestion or such beginning pneumonic areas from hypostatic congestion as may be present.

APPENDIX I

ILLUSIONS

A physician who wishes to use psychotherapy effectively should know something about physiological psychology, or analytical or experimental psychology, as it is variously called, because of the help that he will derive from it in understanding many of his patients' symptoms. Fortunately this branch is now being taught in some of the medical schools, and the greater requirements for preliminary training bring to the medical school men who have already had a course in this subject. The chapter on Illusions is particularly important because it affords many illustrations of how easy it is to be deceived by the senses and, therefore, how many precautions have to be taken in order to be sure that impressions produced on patients' minds that seriously disturb them may not merely be due to exaggeration of the significance of information brought them by their senses.

These illusions are of special interest because they represent not only failures of the senses to convey truth, but because they illustrate how easy it is for the mind to be led astray by the senses. People often declare that they have seen things with their own eyes or in some other way have definite sensory knowledge of them, yet these illusions make it clear that it is perfectly possible for such sensory phenomena to convey quite mistaken information. People who are suffering from many symptoms are persuaded that they must pay attention to their sensations. The main purpose of the psychotherapeutist often is to have them neglect their sensations and correct them by means of information gathered from other sources. We do this with regard to our sensory illusions, why not also with regard to many sensations which are probably quite as mistaken, in certain individuals at least, as these universal illusions of mankind. The argument from analogy holds very well and can be used to decided advantage in many cases.

A startling illusion which makes it clear that care is needed in interpreting our sensations, is the so-called tube illusion or experiment. If a sheet of note paper be rolled into a tube of something less than an inch in diameter and then held close to one eye, both eyes being kept open, while the hand opposite to the eye before which the tube is held is placed palm faceward against the side of the tube about its middle, a hole will be seen, as it were, through the palm of the hand. This false vision is as clear as can be and persists after any number of repetitions of the experiment. It merely illustrates two-eyed vision. We have a picture in each eye and we combine them. When the pictures cannot be combined for any reason, optical illusions result. There are many more optical illusions than we think and there are many reasons besides two-eyed vision for them.

Other illusions of two-eyed vision may be illustrated rather easily. If {767} two dots are made on a sheet of paper about two inches apart and the eyes look at them in a dreamy way, looking far beyond the paper, with vision more or less fixed between them, after a few moments a number of things happen. Usually the two dots exhibit a tendency to float together.

Fig. 26

After an interval four dots will be seen—each of the dots having a picture in each eye. Then only one dot may be seen because the pictures combine. Sometimes three dots will be seen. When the dots swim toward one another, a curious feeling of insecurity comes over the experimenter, showing how much our sense of stability is dependent on vision and illustrating why vision from a height is so disturbing because objects cannot be properly fixed on the distant background.

Fig. 27

Just as the two dots may be made to come together, so, after a little practice, a bird may be made to go into a cage (Fig, 27) or an apple made to go onto a plate (Fig. 28),

Fig. 28

These illusions show how many things that people {768} "see with their own eyes" are not so. All depends on the attention and the state of mind at the time when the seeing is done. In day-dreams these illusions often occur and may be the basis of delusions.

Fig. 29

There are, however, a number of optical illusions which illustrate certain defects of our vision that cannot be corrected, no matter how much we may desire to see correctly. We continue to see them not as they are but as they seem, and we must correct our vision by information from other sources. The Müller-Lyer lines are familiar and are given here (Fig. 29) because {769} they show how easily the senses may deceive us, even that most acute of our senses, vision, as to the sizes of things.

Fig. 30

Figure 30 illustrates how easy it is to be deceived by the juxtaposition of different portions of objects. I have had a woman who had cut out high collars for children and who happened to put them in the juxtaposition of the sketch here given think that she was either losing her sight or her judgment was being affected by the nervous condition in which she was. Nothing would persuade her that some serious development was not taking place until I showed her this illustration. In this illusion the juxtaposition of the short curved line to the long curved line of the other figure produces all the disturbance of judgment of size.

The illusions of filled and unfilled space are interesting and are quite inevitable. They are due to physiological visual effects and are very strikingly illustrated by what is known as the sun and moon illusion. Both these luminaries seem larger at the horizon than they are at the zenith. This is entirely an optical illusion. The horizon seems farther away than the zenith because vision to it is interrupted. The heavens appear not to be a half sphere, but more like an old-fashioned watch glass.

Fig. 31

Since the sun and moon occupying the same space on the retina are, because of this apparent difference of distance, judged to be farther away at the horizon than they are at the zenith, we are inevitably forced to the conclusion that they are larger in size than when in the other position. The over-estimation of filled space as compared with {770} the unfilled is mainly due to the interrupted muscular action of the eyes in traveling over the space requiring more effort. This makes it seem longer. Probably physiological processes on the retina also contribute to the illusion. A series of objects, even dots, will cause a greater physiological excitation of the retina than an equal amount of space, the boundaries of which alone are brought to our attention.

Illusions of size are even more startling than illusions of distance. It is perfectly possible to take three spaces, each exactly a square inch, and by drawing lines in two of them in different directions to make the figures appear of {771} very different size. This is a rather disturbing illusion, particularly for women who are apt to think that perpendicular lines make them appear tall and thin, while horizontal lines have the opposite effect. This is true if the lines are not placed quite close together. The reason why women wear many ribbons, however, whether they themselves recognize it or not, is that the attraction of attention to these makes the space in which they are seem longer. Hussars are dressed in uniforms with many rows of gilt cord or braid running across their chests in order to increase their apparent height. As a rule, a cavalry man must not weigh over 140 pounds or his horse will break down in long, forced marches. Such men are often of small stature and their apparent height must be increased by their uniform, so as to make them look formidable. Advantage is taken of this optical illusion of filled space to produce this effect.

Fig. 32

Other illusions of size are quite frequent. It is rather hard for the ordinary observer to think that the half circles, a and a' (Fig. 32), are the same size, or that b and b' in the same chart are the same curve. The interruption in the circles c and c' produce very curious erroneous impressions which require a knowledge of this illusion to correct.

Optical illusions with regard to directions of lines are extremely common. Quite unconsciously we translate directions into special meanings. This is what enables perspective to be effective in drawings. It has many disturbing features, however. Some of these are striking illustrations of the defects of our vision.

Fig. 33

Fig. 34

Poggendorf's illustration of the displacement of oblique lines (Figure 33) {772} and Zöllner's distortion of parallel lines as illustrated by Figure 34, make it very clear that our judgment of direction must depend on many factors besides our vision, if we are not to make serious mistakes.

These optical illusions might seem to be of little significance, but the Greeks thought them of so much importance and recognized so thoroughly that they could not be corrected, and that the distortions and displacements would inevitably take place, that they deliberately put certain optical corrections into their great architectural monuments in order to avoid these false appearances. These have been traced very accurately in the Parthenon, for instance. In a word, the Greeks, knowing of these optical illusions, in order to make the lines of their buildings appear correct, deliberately made them wrong to a sufficient degree to correct the optical illusion; This frank mode of yielding to a limitation of human nature is a fine lesson for patients to learn if they can only be made to learn it from these illustrations.

It is with regard to colors, however, that we have the best examples of optical illusions depending on the individual and his special anatomy and physiology. Color-blind people are quite sure that they see color, just as other people do, until their defect is demonstrated to them. A man who is color blind for red thinks that he sees that color as other people do, while all that he sees is a particular shade of brightness which, because other people call it red, he has come to call red. When asked to pick out red from a series of other colors he may often succeed. When asked, however, to take a skein of red wool selected for him to a basket containing a number of different colored wools, and to bring back all those that are of the same color, he will select grays and browns and sometimes greens as well as reds, and present them as all matched colors. A man who is color blind for all colors will still think that he sees colors as other people do. The ingenious illustration of the American flag as it appears to people suffering from different forms of color blindness, though they are all persuaded that they see the same kind of flag, is an interesting example of how different may be people's sensations, though their conclusions are the same. It may be seen in many of the text books of analytical or experimental psychology.

Dalton, to whom we owe the atomic theory, was himself color blind for red and made the first investigations in that subject. He was of Quaker origin and found that a great many of his brethren were deficient in color vision. It becomes much easier from this to understand why they resolved to wear nothing but gray. They did not see colors as other people do and therefore could not understand nor sympathize with the joy of other people in color. Dalton tells the story of a Quaker prominent in his sect who once went to town to buy a gray waistcoat and purchased instead one of bright red. When he appeared at meeting in this he was promptly tried for heresy and violation of church regulations.

There is an interesting tendency on the part of people who are themselves defective in certain faculties of sensation, to conclude that when other people are wrapt in admiration of something that they cannot perceive, it is because these other people have some mental defect that leads them to enthuse too easily over their sensations. A story is told of a newspaper man who used to insist that all that was said about the beauty of the song of birds was due to the vivid imagination of the writers, for he could find nothing to admire about the songs of birds. He was placed in a room with a number of fine song birds all round him and it proved that he could not hear any of the higher notes at all. It was easy, then, to understand his condemnation of the enthusiasm of others as hysterical and imaginative. Nearly this same thing is true of many quite intelligent people with regard to music. They hear ordinary sounds, as did the newspaper man, very well. They are tone-deaf however, that is, they are quite unable to hear and appreciate combinations of sounds or even to catch melodious successions of single notes. They cannot recognize one tune from another and often do not know "Yankee Doodle" from the "Doxology," or, at most, know only the most familiar tunes, but they set themselves up very calmly as judges of the intellects of others and conclude that music lovers are really a hysterical set of people who go into ecstasies over certain quite insignificant sensations.

These interesting tendencies are helpful in enabling the physician to understand his patients better. They often serve as texts from which the physician can explain curious things to patients who are prone to draw wrong conclusions from them and often suggestions unfavorable to their health.

These illustrations and their discussion serve to make very clear the distinction between illusions, delusions and hallucinations, which are often confounded. Illusions are deceptions of the senses. If a man walking along a country road where he fears the presence of snakes sees in the gathering twilight a piece of rope coiled, he will almost surely mistake it for a snake. This is an illusion produced by the conditions in which the object is seen. If walking along the same road the next day, more timorous than ever as to snakes, he should see in broad daylight the same coil of rope, he might in his fright not stay long enough to decide whether it was a snake or not, and his illusion would continue, though it would partake somewhat of the nature of a delusion due to fright disturbing his judgment. If, in spite of careful examination, however, of it, such as would satisfy any ordinary mind that it was a coil of rope and not a snake, he should still insist in believing that it was a snake, this would be a delusion. There is always a mental element in delusions. If, having seen nothing, he should insist, owing to fright and {774} nervousness or to some other cause, that he sees a snake where there is nothing at all resembling a snake and where evidently whatever is the basis of his idea of the presence of the snake, is within his own mind, then he is suffering from an hallucination.

Illusions may be quite inevitable. Most of the optical illusions continue to appeal to us as truths even when we know that they represent errors of vision. In spite of the fact that we know that the sun and moon are not larger at the horizon than they are at the zenith, by optical illusion we continue to see them of larger size. It is our duty to correct such illusions by information gathered from other sources. To follow an illusion, that is, to give it credit, when we should correct it, is a delusion. To think that because we cannot see red that therefore there is no red, or because we do not hear the sounds of notes of birds that they do not utter any notes, in spite of the fact that we have the testimony of nearly the whole human race to the contrary, is a delusion. When, using the verb in its broadest sense, as "perceive," we seem to see things very differently from the generality of people around us, there is every reason to suspect that there is some specific or individual limitation of our senses which makes us fail to perceive these things as others do. We have to suspect our sources of information then and to correct them by what we can learn from the experience of others. These are important considerations for many of the ideas that patients cherish with regard to themselves and their ills.

Hallucinations are entirely mental. But the phenomena that sometimes appear to be hallucinations may be due to illusions of the senses within the organism. For instance, those who indulge in cocaine often have the feeling of having a veil over the face, or of having run into a cobweb or something of that kind. The presence of the veil or the cobweb on the face is probably not an hallucination, but is due to certain disturbances in the circulation, or perhaps in the nerves themselves, which affect the nerve endings of the face, causing them to tingle in a particular way, and this sensation is translated as coming from without in terms of something that has been felt before. Some of the appearances of muscae volitantes, or of specks before the eyes, or occasionally of wavy lines, are due to disturbances of the circulation within the eyeball which cause corresponding disturbances of the optic nerve, with consequent apparent visions. When the eyeball is pressed upon, the sensation first produced is that of light and not of pain, because whenever a nerve of special sense is irritated, it produces its own specific sensation in the brain.

The chilly stage in malaria is a typical example of a physical condition having an effect upon sensory nerves that more or less necessarily produces a delusion. The patient is actually at the height of his fever when the chilliness and shivering come on and when he demands a larger amount of covers in order to protect himself from the cold he will often have a temperature of 104 degrees Fahrenheit, or even higher. What has happened is that the little blood vessels at the surface of the body are shut up by the effect of the plasmodium upon the system. Whenever we are cold these little blood vessels shut up in order to protect the blood from being chilled by the external atmosphere. The shutting up of the little blood vessels deprives, for the time being, the terminal nerves in the neighborhood of some of their nourishment. Their response is to set up a tremor or shivering, which will mechanically tend {775} to open the blood vessels so that they may have their nourishment once more. Whenever we have a set of sensations that correspond to this connected set of events, we translate them as feeling cold. The outer air does feel cold to the body because the blood is not flowing through to the surface as it would normally in order to warm it. Hence the chilliness. This is not an hallucination; but an illusion with something of a delusion in it; until we know how things are. Nervousness may set our teeth chattering just as it may cause tremor through our sympathetic nervous system, disturbing the flow of blood through muscles and so disturbing control of them. Vehement emotion, anger, fright, and even those of less violence may cause similar effects. All these phenomena illustrate the close relation between mind and body.

APPENDIX II

RELIGION AND PSYCHOTHERAPY

Religion and psychotherapy have, of late, come to have many relations to each other and many interests in common, at least in the minds of a number of clergymen, and in popular estimation. There is no doubt but that religion can do much to soothe troubled men and women, even when their troubles are entirely physical in nature and origin. It at least lessens the unfavorable effect of worry in exaggerating such pathological processes as are at work. All diseases, functional and organic, are rendered worse by solicitude, while many troublesome symptoms become quite bearable if only the patient does not dwell on them too much but takes them as they come, carefully refraining from emphasizing them by over-attention. That is the very essence of psychotherapy. Religion, in the sense of trust in divine wisdom, can do much to originate and maintain this imperturbed frame of mind. People who are without religion, that is, without the feeling that somehow all their ills are a part of the great plan of the universe, the mystery of which is insoluble, but the recognition of which is demanded by reason, and who lack the assurance that somehow, in Browning's phrase:

—are more prone to give way to over-anxiety and consequently to make themselves suffer more in all their ills, than is necessary or even likely in the more favorable state of mind of those whose trust in Providence is thorough and efficient.

In recent years there has been in the general population a distinct loss of faith in the great religious truths that are so helpful in engendering a peaceful state of mind in suffering. Many have come, if not to doubt of the Providence of the Creator, at least to feel that we do not know enough about it to place any such supreme dependence on it in the trials of life as would make it a source of relief, or at least consolation, in suffering. This same spirit of doubt has paralyzed faith in the hereafter and in all that trust in it brings, to sufferers, of consolation to come for their ills if these are borne as becomes rational creatures whose suffering has a purpose, though we may not comprehend it. Some people are destined by their physical make-up or by accidental conditions to considerable suffering. There are many ailments that are incurable and are definitely known to be incurable. Some of these entail great suffering of body and even more suffering of mind. Such suffering becomes quite unbearable unless the patient is of a very stoic disposition, or unless the thought of a hereafter in which the sufferings of this life will have a meaning is present to console.

Great scientists in the midst of all our advance in science—one need but mention here such men as Lord Kelvin, Clerk Maxwell, Johann Müller, Laennec, Pasteur, Claude Bernard, though the number might easily be multiplied—have insisted that the existence of a Creator is absolutely demanded by what we know of the physical universe. "Science demonstrates the existence of a Creator," is Lord Kelvin's expression. The existence of a Creator implies, also, the existence of laws made by Him, by which His universe is regulated in every detail, nothing being left to chance. Chance is indeed only a term which indicates that we do not know the causes at work. If somehow the Creator's power has been sufficient to bring the manifold things of the universe into existence according to a plan in which there is no such interference with one another as would cause serious disturbance of the universal order around us, then He can be trusted also to care for even the minutest details of creation and of human life.

In the gradual disintegration of the religious sense which has come as a consequence of certain materialistic tendencies in nineteenth century education and science, these religious sources of consolation have been shut off from a great many people. They have come to the feeling of being portions of a machine that moves hopelessly on, somehow, on the old principle, "The mills of the gods grind slow, but they grind exceeding fine." The sufferings of humanity then, are, for these people, only a portion of a great universe of suffering that is constantly going on but for which they can see no reason and no purpose. Lucretius's lines which make human sufferings the butt of the jokes of the gods who look gleefully on from their Elysian happiness, would represent the feelings of these doubters better than any religious expression. We have come back in this age, when evolution has so much influenced the thought of the time, after the curious cyclic fashion in which human thought repeats itself from era to era, to the attitude of mind of the old Roman poet who almost singly among his contemporaries, had been deeply affected by the same doctrine of evolution. The pessimism he was prone to as to the significance of human life has become once more the fashion.

Such pessimistic thoughts do not come, as a rule, while people are in good health, but they assert themselves with double emphasis in moments of trial and suffering. Lucretius himself is said to have committed suicide. The result of the diffusion of this materialistic pessimism in our time has been a gradual preparation for a revulsion of feeling in many minds. One manifestation of this reaction has been seen in a form of religion which denies entirely the existence of evil. God the Creator is good and therefore there can be no evil in His world. Whatever of evil there is, is only due to man's failure to see the entirety of things. Evil is an error of mortal mind—only that and nothing more. In spite of the manifest absurdity of the underlying principle, if people can only be brought to persuade themselves that there is no such thing as evil or suffering, then many of their discomforts disappear, all of their symptoms grow less and a sense of well-being results. It is, indeed, surprising how many even physical ills will be relieved by this state of mind if sincerely accepted. It is the highest possible tribute to psychotherapy and the curative influence of mind over body.

Another phase of this revulsion of feeling has been the institution of a church movement that would make sufferers realize once more all the {778} consolations there are in religion. The sufferer is brought to a renewed lively sense of the presence of the Creator in the universe and of His care for His creatures. The great purpose of suffering in making people better and stripping them of their meanness and selfishness is brought out. Anyone who has ever had called to his attention the difference between two brothers, one of whom has been chastened by suffering above which he has risen by character development, and another who has enjoyed good health and prosperity all his life, will realize how much of good suffering means in the world. Pain is not in itself an evil, but a warning, and most of the trials of life can rather readily be shown to partake of this character. A man who can be made to submit himself, then, to the will of the Creator and be persuaded to acknowledge that somehow we must try to work out our part in the great scheme of things behind which the Creator stands, is somewhat like the soldier ready even when tired and worn out, to go in on a forlorn hope, because he has confidence that he is executing a part of the plan of his general for his country's welfare, though he does not know how, and he is quite well aware that it is going to cost him much in pain and suffering, and perhaps his life.

There is no doubt that an abiding sense of religion does much for people in the midst of their ailments and, above all, keeps them from developing those symptoms due to nervous worry and solicitude which so often are more annoying to the patient than the actual sufferings he or she may have to bear. While religion is often said to predispose to certain mental troubles, it is now well appreciated by psychiatrists that it is not religion that has the tendency to disturb the mind, but a disequilibrated mind has a tendency to exaggerate out of all reason its interests in anything that it takes up seriously. Whether the object of the attention be business, or pleasure, or sexuality, or religion, the unbalanced mind pays too much attention to it, becomes too exclusively occupied with it, and this over-indulgence helps to form a vicious circle of unfavorable influence. While many people in their insanity, then, show exaggerated interest in religion, this is only like other exaggerated interests of the disequilibrated, and religion itself is not the cause but only a coincidence in the matter.

Clouston, in his book on "Unsoundness of Mind" (Methuen, London, 1911), put this very well when he said, "It is true that religion, touching as it does, in the most intense way the emotional nature, and the spiritual instincts of mankind, sometimes appears to cause and is often mixed up with insanity. But in nearly all such cases the brain of the individual was originally unstable, specially emotional, over-sensitive, hyperconscientious, and often somewhat weak in the intellectual and inhibitory faculties and, if looked for, other causes will usually be found." He had said just before, "To talk of 'religious insanity' as if it were a definite and definable form is in my judgment a mistake."

On the contrary, there is now a growing conviction that a deep religious feeling, a sense of dependence on and trust in the Almighty, will do more than anything else to keep people from those neurotic manifestations which so often are seen in our day and are growing more and more frequent as life becomes more strenuous and more attention is paid to the material side of things, to the exclusion of the spiritual. How true this is may be judged from expressions that have been used in recent years by well-known specialists in {779} nervous diseases and in psychology. These have included men who were often not believers in religion themselves but who recognized its influence for good for others. Such expressions are to be found in the writings of men of every nationality. Not infrequently, in spite of their own religious affiliation, they acknowledge what a profound influence certain forms of religion have over people. These testimonies have been multiplying in our medical literature in recent years, because apparently physicians have come to appreciate much better by contrast the influence for good of religion over some of their patients, since so many of the sufferers from nervous diseases they see have not this source of consolation to recur to.

In America we have a number of such testimonies. In his "Self Help for Nervous Women" Dr. John K. Mitchell of Philadelphia, who may be taken to represent in this matter the Philadelphia School of Neurologists, to which his father has lent such distinction, said:

It is certainly true that considering as examples two such widely separated forms of religious belief as the Orthodox Jews and the strict Roman Catholics, one does not see as many patients from them as from their numbers might be expected, especially when it is remembered that Jews as a whole are very nervous people and that the Roman Church includes in this country among its members numbers of the most emotional race in the world.

Of only one sect can I recall no example. It is not in my memory that a professing Quaker ever came into my hands to be treated for nervousness. If the opinion I have already stated so often is correct, namely that want of control of the emotions and the over-expression of the feelings are prime causes of nervousness, then the fact that discipline of the emotions is a lesson early and constantly taught by the Friends, would help to account for the infrequency of this disorder among them and adds emphasis to the belief in such a causation.

Prof. Münsterberg, who may be fairly taken to represent the German school, but whose long years of residence in America have made him a cosmopolitan, is quite as positive in his declaration of the place that religion may hold in making human suffering less. In his "Psychotherapy" he devotes considerable attention to the subject. The religious discipline, that is, the training of human beings from their earliest years to recognize that there is a higher law than their own feelings and that they must suppress many of their desires and take evil as it comes as a portion of human life, is of itself, he insists, an excellent preparation to enable the individual to bear up under the physical and mental trials of life and to make many symptoms that would otherwise be almost intolerable, quite bearable. It is from earliest years that this training must make itself felt, and Prof. Münsterberg insists that from early childhood the self-control has to be strong and the child has to learn from the beginning to know the limits to the gratification of his desires and to abstain from reckless self-indulgence. A good conscience, he says, a congenial home and a serious purpose, are, after all, the safest conditions for a healthy man, and the community does effective work in preventive psychotherapy whenever it facilitates the securing of these factors.

Self-denial has always been one of the main elements of religious training, and indeed was declared a chief source of merit for the hereafter. The modern psychotherapeutist, however, preaches self-denial almost as strenuously as the religious minister of the olden time, only now not for any religious {780} merit or reward, but because it makes life more pleasant and by that much happier. When men and women have learned to deny themselves in their younger years, it is not hard to stand even pain when they grow older, and pain is inevitable in every human life and the training to stand it is therefore worth while. Pain borne with equanimity is lessened by one-half if not in its intensity then at least in its power to disturb, and since religion will do this it possesses an important remedial value. Here is where religion is particularly valuable and the passing of it from many minds has thrown them back on themselves and left them without profound interests, so that they occupy themselves overmuch with the trivial incidents of life within them and disturb the course of many of their functions by giving exaggerated thought to them. Religion adds a great purpose to life and such a purpose keeps men and women to a great extent from being disturbed about trifles.

Of course, it would be too bad if religion should do no more than this. This, however, is the only phase of it with which we are concerned here. We may think very strongly with Prof. Münsterberg, that it would be quite wrong to assign to it only this place in life. He says: "The meaning of religion in life is entirely too deep that it should be employed merely for the purpose of lessening the pains and aches of humanity and the dreads that are so often more imaginary than real." He insists that "It cheapens religion by putting the accent of its meaning in life on personal comfort and absence of pain." He adds, "If there is one power in life which ought to develop in us a conviction that pleasure is not the highest goal and that pain is not the worst evil, then it ought to be philosophy and religion." Present-day movements, however, tend to subordinate religion to this-worldliness rather than to other-worldliness, and by just that much they take out of religion its real significance. We are here on trial for another world is the thought that in the past strengthened men to bear all manner of ills, if not with equanimity, at least without exaggerated reaction. It has still the power to do so for all those who accept it simply and sincerely.