Psychotherapy

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

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

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

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

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

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

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

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

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

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

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

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

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

SECTION XX

PSYCHOTHERAPY IN SURGERY

CHAPTER I

PSYCHOTHERAPY IN OLD-TIME SURGERY

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

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

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

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

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

Medieval Surgeons and Mental Influence.—Some of the insistence on this favorable state of mind for operations during the Middle Ages is extremely interesting. One of the great surgeons of the fourteenth century was Mondeville, whose text-book has recently been published in both France and Germany. I have translated in "Old-time Makers of Medicine"59 some of his emphatic expressions, which show how important he deemed it to keep the patient in as favorable a state of mind as possible before and after operations. He went so far as to suggest that someone should be deliberately called in to tell him jokes. He said, "Let the surgeon take care to regulate the whole regimen of the patient's life for joy and happiness by promising that he will soon be well, by allowing his relatives and special friends to cheer him, and by having someone to tell him jokes, and let him be solaced also by music on the viol or psaltery. The surgeon must forbid anger, hatred, and sadness in the patient, and remind him that the body grows fat from joy and thin from sadness. He must insist on the patient obeying him faithfully in all things." He repeats with approval the expression of Avicenna that "often the confidence of the patient in his physician does more for the cure of his disease than the physician with all his remedies."

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

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