Physician and patient

by Worthington Hooker

FOOTNOTES:

[37] Though the plan of charging so much a visit, so universally adopted by the profession, is on the whole the best general plan of regulating the prices of the physician’s services, it is liable to some abuses. Some variations from it must of course be allowed; and in making these a door is opened for manœuvering on the part of dishonorable practitioners. It is a very common ‘trick of the trade’ to make more visits than are necessary, perhaps quite short ones, and then charge less per visit than is usually charged by medical men in the same neighborhood. In this way the credit of being both a very cheap and a very attentive physician is most unjustly obtained.

CHAPTER XIV.
THE MUTUAL INFLUENCE OF MIND AND BODY IN DISEASE.[38]

Many seem to think that when the body is sick, it is simply a sickness of the body alone, and the mind has nothing to do with it. They do indeed allow that when actual mental derangement occurs in connection with any disease the mind is affected with the body; but they are prone to lose sight of the fact in all ordinary cases of disease, and yet it exists in these as really, though not to the same degree. The influence of disease upon the mind is obvious to the most careless and superficial observer, when he sees the delirium produced by inflammation of the brain; but such cases seem to him to stand out as glaring exceptions to what he considers the great general fact—that the mind is independent of the ailments of the body. Physicians themselves too often overlook the influence of mind in their treatment of disease, and the community generally have very inadequate views of its extent and universality. There can not be any sickness of the body, however slight, that does not produce some effect upon the mind, and which is not influenced either for good or for ill through mental impressions.

It is important in the management of the sick, not only that this fact should be kept clearly and steadily in view by the physician; but that it should be understood by the community, so that the efforts of the physician may not be thwarted, as they often are, by the attendants and friends of the sick, when he aims to act upon bodily disease by impressions made on the mind. And I refer not in this remark merely to impressions of this kind where the attempt to produce them is so palpable that the most careless observer would perceive it, but to all those influences which the physician is exerting upon the minds of the sick, in his daily intercourse with them. In truth, everything that he says and does in the sick room, is to be regarded as really a medicine, and producing as real if not as manifest effects upon the state of the patient, as any of the drugs that he administers.

It will be profitable, then, to the general reader, as well as to the medical man, to examine the influences which the mind and the body exert upon each other in sickness, the use which can be made of such influences in the cure of disease, and the abuse to which they are liable from the mismanagement of those who have the care of the sick.

Before doing this, however, it may be both interesting and profitable to look at the connection which exists between the body and the mind. There are various figures used to illustrate this connection. The most common one is that in which the mind is spoken of as dwelling in the body as a habitation. In a certain sense this is true. This tabernacle of flesh, as the Bible aptly terms it, is, in its present state a habitation, which the mind is to leave in a short time, to return to it, however, at length, rebuilt and refitted in a more glorious, an incorruptible form, to dwell in it then forever. But this illustration of the mysterious connection of the mind with the body is but a partial one—it does not express the extent nor the intimacy of that connection. The mind is not a mere dweller put into this habitation. Its union with it is not thus loose and easily severed. It is bound to its every nerve and fibre, so that the least touch of the body at any point affects the mind. Instead of being put into the body, it has, being thus interlaced, as we may say, fibre with fibre, grown with its growth, and strengthened with its strength. In the feebleness of infancy the mind is just as feeble as the body, and they both grow together up to the vigor and firmness of manhood, and both decline together in old age. So close is their union through all the stages of life, and so equally is each affected by the joys and sufferings of the other, that we might justly conclude that at death, when the tabernacle crumbles into dust, the mind falls with it never to rise again, had not a divine revelation told us that, indissoluble as this connection appears during life, almighty power will dissever it and release the soul from the thousand ties that bind it to its habitation at the very moment of its destruction. Were it not for this assurance of our immortality, we could look forward in the uncertain future to nothing but blank, drear annihilation, as awaiting our minds, just as it does the minds of the brutes that perish.

In our carefulness to avoid materialism, we are too apt to look upon the mind and the body as two separate and independent things. At death they do indeed become so, but who of us knows that they would, were it not for the fiat of the Almighty? Who knows that there is not a necessity for the putting forth of his power in each individual case at the time of death, to prevent the mind of man from dying with his body, just as the mind of the brute does with his? The very prevalent notion that the mind is essentially indestructible, and that it is put into the body as a separate thing, having the power of itself to leave the body whenever it dies, rests on no substantial proof. That it is destined thus to leave the body is quite another thing.

Materialists, of whom we are pained to say there are many among believers in phrenology, though they flatly deny it,[39] seem to think that the brain produces thought pretty much as the liver makes bile or the stomach gastric juice. This doctrine would be gratuitous, a mere supposition, even if there were no Christian revelation to contradict it. But while we discard all such anti-Christian and absurd fantasies, we must not run to the other extreme, as some good men have done. It must be admitted, that in this life all the manifestations of mind are not only connected with, but are dependent upon, a material organization. The nature of this connection and dependence is of course a mystery, but of its existence there is no doubt. So far as injury is done to the brain and nervous system, just so far are the manifestations or actions of the mind impaired. And, on the other hand, moral causes, acting directly upon the mind, affect through it the organization. And when insanity results from moral causes thus acting, it is not a direct effect, but an indirect one—the organization affected by the mind is thrown into a diseased state, and reacts upon the mind, influencing its manifestations. If the mind thus acted upon were a spirit, separated from the body, the result would be merely the feelings, which the motives applied would naturally produce, and not the unnatural feelings of insanity. It is not strictly proper then to speak of a ‘mind diseased.’

Let me not be understood to mean that mental derangement in every case is to be attributed to disease that leaves such palpable traces that the dissecting knife would reveal it if death were to take place. There are diseased operations in the body, that are hidden from our view—so hidden, that they not only leave no traces, but often develop no characteristic bodily symptoms.

Although the principles above stated are often overlooked, and sometimes doubted, or even denied, there are some cases in which they stand out so plainly, that everybody acknowledges for the time their truth. For example, if a man, by a blow on his head, has a piece of his skull pressed inward upon his brain, he becomes senseless, and, if he arouse at all from his stupor, his mind is obviously in an unnatural state. The surgeon raises the depressed bone, and thus taking off the pressure from the brain, restores the mind of the man to activity and sanity. In this case it is plain to every one, that the mental manifestations were suspended by a cause acting directly upon the material organization, and that they were revived again by the removal of this cause.

Take another example. A man of strong and clear mind becomes deranged, and at length arrives at perfect idiocy. He goes down to the grave in this condition. No one supposes that in such a case the mind is affected independently of the body, but the mental state is of course attributed to bodily disease; and affection fondly, and we may say rationally, cherishes the expectation, that when the mind shall be freed from this tabernacle of flesh, it will emerge from its long night of darkness, and possess again its faculties in full, just as the man who lies senseless from pressure upon the brain, is restored to mental activity when that pressure is taken off by the trephine and elevator of the surgeon.

Now what is true of the cases that we have cited is true in every case—all mental aberration, however slight it may be, results from the connection of the mind with the body, and would not occur without this connection. It is the product of some impression made upon the material organization, either directly, or indirectly through the mind. This impression may be momentary and evanescent, or it may produce a real change of structure. It would be interesting to enlarge upon these points, but it is not necessary for our purpose.

We speak of the brain as the seat of the mind, or soul. If we mean by this simply, that this is the great central organ of that system in the body (the nervous system) through which the mind acts upon external things, and is acted upon by them, it is correct so to speak. But if we mean to localize the mind, as sitting there, and especially if we fix upon some one part of the brain, as Descartes did upon the pineal gland (a body smaller than a pea) as the seat, the throne of the mind, the illustration is an erroneous one. The mind acts upon the whole body, through all the parts of the nervous system, and each portion of that system has its own peculiar offices to perform in obedience to the mind. This is as true of the brain as it is of the rest of the nervous system. This organ is a complex one, and the different parts have their different offices. This we know in regard to some of these parts, and we can justly presume it in regard to others. And we do this without adopting the fanciful ideas of phrenologists in locating the different faculties of the mind.

While the brain is the great central organ of the nervous system, by which the mind imparts and receives impressions, there are other parts of that same system which seem to bear some other relation to the mind than that by which they transmit these impressions to and from the mind through the brain, as the nerves ordinarily do. They seem to have a connection with the mind independent of the direct agency of the brain, and for aught we know they have such a connection. When the mind is affected by any passion, either of the cheerful or the depressing kind, its sensible effects upon the body are not observable chiefly in the brain, but in the region of the heart and the other organs adjacent to it. The thrill of joy is felt there, and grief produces there its sensation of oppression, prompting the occasional sigh to relieve it.

Such facts as these led an eminent French physiologist, Bichat, to adopt the theory, that while the intellectual functions have their seat in the brain, the moral sentiments have theirs in the ganglionic system of nerves, (as it is called,) which has certain great nervous centres in the region of the heart, stomach, &c.

I will not stop to expose the fallacy of this plausible theory. It is sufficient for my purpose simply to advert to the fact, that the moral sentiments of the mind or soul are manifested more in that part of the body than in the brain. The very language of the affections, and the gestures which accompany the utterance of that language, or supply its place when feeling is too big for utterance, are in consonance with this fact. We speak of the heart, and we place the hand upon the heart when the moral sentiments are in lively action. And when feeling is so great as to be overpowering, or when the attempt is made to suppress it, there is with the load which is felt at the heart, a sensation of choking, (no word expresses it so well as this homely one,) preventing utterance; and then when it finds vent, it seems as if there was a gushing forth from the heart, not merely figuratively, but from the material heart that is throbbing in our bosoms.

The fact which I have been illustrating shows the force of such expressions in the Bible as ‘bowels of compassion,’ ‘bowels did yearn,’ &c. It throws some light also on the influence of grief upon the stomach, and on the depression of spirits which so sorely afflicts the dyspeptic.

It gives but a faint idea, then, of the all-pervading connection of the mind with the body, to suppose the mind to be locked up in some chamber of the brain, there receiving by the nerves messages from every quarter, and sending forth messages in return by the same media. There is no evidence of the existence of one great central point of attachment for the mind, but the ties of its connection with the body are multiplied and diffused. It is not merely, therefore, positive disease existing in the brain that affects the mind. Disorder of mind is infinitely modified by the different seats and modes of disease in different portions of the nervous system, as well as in different parts of the brain itself. I speak not now of palpable insanity alone, but of all the various states of mind occurring in sickness.

One of the most common and prominent characteristics of the state of mind in sickness, is weakness. The weakness of body caused by disease is generally accompanied by a corresponding debility of mind. When Cassius speaks of Cæsar, as asking, ‘give me some drink, Titinius, as a sick girl,’ you see something more than weakness of muscle—the giant mind of the mighty Cæsar is prostrated to effeminacy.

And as weakness of muscle is attended with unsteady, irregular, and sometimes even spasmodic action of its fibres, so it is with weakness of mind. Its efforts are fitful, and it is easily thrown off from its balance. A feeble man tottering along, occasionally resting upon his staff, or taking hold of a post or a fence, is thrown down by the gentlest touch, or by stumbling over even a slight obstacle, that he chances not to see so as to avoid or guard against it. And in the tedious journey of sickness, mind and body totter along in their feebleness together, and either is exceedingly liable to fall. And if the one fall, the other is pulled down with it. The guide, therefore, of these two travellers in this journey, must see to it, that all obstacles in the way of either be removed or avoided, that no rude hand be permitted to touch them, and that all those supports be supplied on the way which either can best use.

The mental weakness which disease occasions, is often exhibited to the physician under affecting circumstances. Minds that have been able to grasp the most difficult and abstruse subjects return, in the debility of sickness, to the simplest ideas—those which are both common and precious to the child, the man, the angel, and to God himself. The ‘strong meat’ is turned from, for the ‘milk of babes.’ I remember one of lofty intellect, fading away with consumption, who well exemplified this remark. Her aged father was reading to her a chapter in one of the epistles of Paul. ‘It is good,’ said she, ‘but I cannot understand it now. It bewilders me. Something more simple—something from the Apostle John is better for my poor feeble mind.’

The mind, weakened by disease, is easily disturbed and agitated, except in those cases in which disease blunts the sensibilities. Derangement of mind is often the product of mere weakness, under increase of excitement, without any fresh accession of local disease. A familiar illustration of this you may see in fever. Very often there is mental derangement only during the paroxysm of fever, the mind being quite clear in the remissions. Especially is this the case with children, whose sensibilities and sympathies are in so much more lively a state than those of the adult.

Slight causes, therefore, which would produce little or no effect upon the mind of one in firm health, may affect strongly the mind of a sick man. A single example will suffice. The patient was sick with typhus fever. He had been very much deranged, and great care had been taken to guard against any excitement, which might act injuriously upon him. He was now getting better, and his mind had become calm and clear, though still, like his body, it was very weak. A friend came in one morning as usual to inquire about him. He knew that all visitors had been prohibited from going into the sick room, but he wished very much to see his friend, and, as he had an opportunity, he looked in through the door, as it chanced to be a little open. The dull eye of the sick man saw him dimly, and he at once became as much affected as if he had seen a dreadful vision. His distempered fancy conjured up ideas of a painful character, which remained upon his mind for a week, and endangered as well as delayed his convalescence.

This incident leads me to remark that physicians find great difficulty in securing a due degree of quietness in the sick room. I use the word quietness in its widest sense. I do not mean the avoidance of noise merely, but of all improper excitement. Visiting is generally a nuisance in the chamber of sickness. Multitudes of lives are continually sacrificed to curiosity and mistaken kindness. The tattling circles that gather round the fireside of the sick room, and retail their mixtures of medical lore, and slander, and hair-breadth escapes, and wonderful cures, often inflict torture upon the shattered nerves of the poor patient, and that torture sometimes, I have not a doubt, ends in death, when a recovery might otherwise have taken place.

No one should enter the sick room from curiosity or from a mere vague desire to do good. Nothing but the actual prospect of doing good should prompt him to go there. Indeed, everything which interferes with the proper quiet of the sick should be most scrupulously avoided. It should always be remembered, that in many cases of disease, mental excitement may do as much harm as the excitement produced by stimulating medicines. And it is as much the business of the physician to direct in the management of this matter, as in the administration of remedies; for it has as real, if not as great a bearing on the recovery of the patient. Indeed, sometimes it is vastly more important than all the medicine that is given in the case. I call to mind a case which illustrates this last remark so strikingly, that I will state it as briefly as possible. A patient was taken sick, with some important business pressing upon his attention at the time of the attack. He was persuaded to dismiss it entirely from his thoughts for the time. He was soon relieved by the remedies that were used, and he was in a fair way for a recovery. He was, however, in such a state, that it was very important that he should be kept from all excitement, and as I saw that he was disposed to do the business now with some friend, whom he wished to have called in for the purpose, I told him and his family in plain terms the risk which he would run if he should pursue this course. He however disregarded my injunctions, and the consequence was that in the evening of the same day he was very sick, and in a few days died from disease in the brain, which was clearly induced by the mental excitement. If he had followed my directions as scrupulously in regard to this point as he did in regard to the medicines which were given, recovery instead of death would probably have been the result.

Some in their anxiety to secure the quiet of the sick, go to an extreme, and give almost the silence of the grave to every sick room. They institute a sort of prison discipline, and shut out both the light of heaven and all cheerfulness of intercourse. The very means which they take to produce quietness, the stealthy step and the whisper, are apt to disturb the patient more than noise or excitement would do. Discretion should be exercised by the physician, and the friends of the patient should rely on him to direct this part of the management of the case, as well as that which is strictly medical. He must judge as to the degree and kind of excitement appropriate to the case, and direct in its application, for the same reason that he should, in a case of disease of the eye, direct as to the amount of light which should be admitted to it.

It is often very difficult to carry out these principles, especially in families that have but a small number of apartments. The fear of giving offense, too, very often opens the door wide for visitors, against the most positive injunctions of the physician. To obviate this difficulty, I have in some few cases put upon the door a card, forbidding this kind of intrusion—an expedient which I have found to be very successful. One case was that of a clergyman’s family. So many were sick, that the house was a perfect hospital. A large portion of the parish poured in of course, to offer their sympathy and their services. Most of these persons did more harm than good. I attempted to remedy the evil by directions to the nurses, and by conversation with individuals, but in vain. At length I put up a card on the door of the house, to this effect: ‘Visitors are requested to go directly into the parlor. No one is to enter the sick rooms but those who have the care of the sick. No talking in the entry.’ This effected the desired change at once. I introduce this case simply to show the difficulties which exist on this point, especially in country towns, and the very plain remedy which can be applied. There is no reason why a universal rule should not be adopted in every case in which it is deemed necessary by the physician.

The attendants on the sick often make a great mistake in supposing the patient to be so fast asleep, or so stupid, as to receive no impressions from their conversation. Often, from this cause, he is obliged to hear what may do him great harm. Amid the confused thoughts of his dreary bewildered state of mind, the idea of his own death is conjured up by some remark, to trouble and affright him. Instead of getting the rest which his wearied body and mind so much need, his nerves are disturbed by the hum of conversation, and his mind is harrassed by a succession of dread thoughts and visions, suggested by remarks, of which it is supposed that he takes no cognizance.

Some, who are very cautious on these points in regard to adults, never think of their application to children. Often, for example, does the physician find, on entering the sick room, those whom kindness and curiosity have assembled there, talking loudly, while the mother is trying in vain to soothe the troubled child by rocking the cradle as if for a wager. Much, too, is often said in presence of sick children that ought not to be, on the false supposition that they do not understand what is said. Many a child is frightened by horrid stories, and by gloomy comments upon his own case. Visitors stand over him, and besides fretting him by their staring, they say something, perhaps, of this sort. ‘Poor thing! how sick he looks! I don’t believe he can get well.’ And then they go on to tell about some little child, perhaps his playmate, that had died recently, and whom, perhaps, he saw laid in his grave, and utter in his hearing, with all due solemnity and sorrowfulness, the opinion that he is affected much like him, and will probably die in the same way; adding, by way of consolation to the poor mother, that then they will be in heaven together. Children have sensibilities and hopes and fears, like adults, and they understand, even at a very tender age, enough about death to be affected, and often very strongly, by this holding up of its grim visage directly before them. The mind, and the nervous system, by which the mind is connected with the body, are as excitable in the child as in the adult, and the avoidance of unnecessary alarm and excitement is as important in the sickness of the one as in that of the other.

I cannot forbear here to notice one thing, which often exerts a bad influence upon the mind of the child in sickness. It is the habit which many people have of threatening their children, when in health, with sending for the doctor to bleed them, or to give them some bitter medicine, as a punishment for their misdeeds. The inevitable tendency of this is to increase the mental depression and agitation which disease produces, by the gloomy associations which are thus necessarily attached to sickness in the mind of the child. The physician should never be held up as a bugbear to children, but should uniformly be spoken of in their presence in such terms, that when he visits them in sickness they may rejoice to see him, both as a friend and as one who is to bring them relief. There is no doubt that many a child is seized with an ill-defined terror, when the physician is called in, and thinks of him only as some dreadful monster that cuts off children’s ears, and gashes their flesh almost for sport. The effect of such a feeling on the weakened and agitated nerves is always injurious and undoubtedly is sometimes fatally so. One may get some adequate idea of the feelings of children under such circumstances, by imagining himself, in a state of weakness and disease, to be visited by an incarnate demon, who has both the power and the disposition to torment him.

I am anxious to impress most faithfully the mind of the reader with the importance of giving rest to the mind in sickness. I have already remarked on the extent and the intimacy of the union between the mind and the body. It is never to be forgotten in the chamber of sickness, that the mind not only is not by itself, alone and independent, but that it is not connected with sound nerves, but acts upon a deranged body, and is acted upon by it, through the multitude of nervous filaments, which, scattered everywhere, are receiving impressions at every point, and transmitting them to the mind. If, therefore, the mind, thus disturbed by disease, be at the same time troubled by causes applied directly to it, the result must be a reaction from the mind through the nerves upon the disease itself. The mental and the bodily irritations must increase each other. It is then just as important to withhold all irritating causes from the mind, as from the diseased organ. For example, if the brain be inflamed, that inflammation may be aggravated as certainly by exciting the mind, as it would be by the administration of any stimulant to the body. In either case the same result occurs—the brain is stimulated—the only difference is in the channel through which it comes. And it is the duty of the physician to shut out the irritation from one channel, as much as from the other. When the eye is inflamed, one part of the curative means is to exclude the light, because the light, by exciting the nerve of sight, would increase the inflammation. But the action of the mind is as really connected with the brain and nervous system, as the act of vision is with the eye; and therefore it must be guarded against, in inflammation of the brain, as vision is in inflammation of the eye. The same may be said, to some extent, at least, of every other part as well as the brain, for every organ is supplied with nerves connecting it with the mind.

As an illustration of these remarks, I will introduce a case, showing the influence of the irritation of passion upon a diseased body. I refer to the death of John Hunter, who has been often called the greatest anatomist and physiologist of his age. “On October 16, 1793,” says his biographer, “when in his usual state of health, he went to St. George’s hospital, and, unexpectedly meeting with some things that ruffled his temper, he allowed himself to give way to passion; the heart became overloaded with blood, the ossified aorta, not yielding to the effort of the heart, the countenance became dark, angina pectoris immediately ensued, and turning round to Dr. Robertson, one of the physicians of the hospital, he was incapable of utterance, and died.”

This, it is true, is an extraordinary case; but the result of mental irritation in common cases of disease, though not as great and as palpable as in this case, is nevertheless as real. While it caused in the case of John Hunter a sudden and final suspension of the heart’s action, it would, in a man suffering from some inflammation, aggravate that disease, by driving the blood too forcibly into the inflamed part, and by making its irritable nerves partake of the general excitement of the system. The effect might not be at any moment very powerful, but if the irritation be repeated or continued, although it may be vastly less in amount than it was in the case of Hunter, the accumulative effect of the excitement upon the disease would at length become very great, perhaps destructive. And in certain low states of disease, when, in the midst of great weakness, the nervous system is in an extremely agitated condition—a condition, in which little causes may produce powerful effects—a comparatively slight irritation induced in the mind, connected as it is with every trembling filament of that nervous system, may overwhelm the very powers of life as certainly, if not as suddenly, as did the strong passion of Hunter, in overloading his diseased heart, and thus stopping its action.

But withholding irritation, and securing rest and quiet, do not comprise all the physician’s duty in relation to the mind, any more than they do in relation to the body of the patient. He is sometimes to excite the mind to positive action, for the same reasons that exciting medicines are sometimes administered to the body; and he may thus often exert, through the mind, a very happy influence upon disease. This remedy, as I have already hinted, is to be applied with discretion, according to the nature of each case, and so as not to interfere with that rest, which I have shown to be so necessary to the mind in the treatment of disease. The excitement must, with some few exceptions, be agreeable in character, in order that it may produce a genial influence upon the nervous system. The mode, the time and the degree of its application require the exercise of discrimination, as much as the dose, and form, and time of any stimulant or other medicine that is given to the patient. The judgment and tact of the physician are never more needed than upon such points as these. Tissot, a French physician, relates an amusing case, showing the utility of discrimination in regard to the kind of mental stimulation to be applied. A lady was affected with a lethargy, and many applications were used to rouse her, but to no purpose. At length a person, who knew that the love of money was the ruling passion of her soul, put some French crowns into her hand. After a few minutes she opened her eyes, and was soon entirely aroused from her stupor.

The influence of the imagination upon the body is familiar to every one. I will mention a few cases to show its power.

Beddoes, an English physician of great enthusiasm, had imbibed, among other new ideas, the notion that palsy could be cured by inhaling nitrous oxide gas. He requested that eminent chemist, Sir Humphrey Davy, to administer the gas to one of his patients, and sent him to him for that purpose. Sir Humphrey put the bulb of a thermometer under the tongue of the paralytic, to ascertain the temperature of the body, so that he might see whether it would be at all affected by the inhalation of the gas. The sick man, filled with faith from the assurances of the ardent Dr. Beddoes, and supposing that the thermometer was the remedy, declared at once that he felt better. Davy, desirous of seeing how much imagination would do in such a case, then told him that enough had been done for that time, and directed him to come the next day. The application of the thermometer was made from day to day in the same way, and in a fortnight the man was cured.

When Perkins’ tractors were in vogue, Dr. Haygarth of Bath, as I have stated in another chapter, had a pair of wooden ones made of precisely the same shape with the orthodox metallic ones, and contrived to color them so that the deception should not be discovered. He then applied them to quite a number of patients, with the same results that followed the use of the genuine tractors, which cost five guineas a pair. Pain was relieved as if by magic, and the lame were made to walk. Their operation in these cases is of course to be accounted for in the same way with the operation of the thermometer in the case just related.

Some medical students determined to try the influence of imagination upon a countryman who was going into town to market. They met him one after the other, each telling him how pale and sick he looked. At first, as he felt perfectly well, he paid no regard to it, but after two or three had thus accosted him, he began to think there must be something the matter with him. By the influence of imagination he soon began to feel badly, and to look really pale. And as he still continued to meet persons, who declared themselves struck with his peculiarly sickly and ghastly appearance, he grew worse, and the result was that he sickened and died.

I could cite numerous cases illustrative of the influence of the imagination upon the condition of the body, but these will suffice.

The physician has constant opportunities for making use of the influence of mental association to much advantage in the management of the sick. He does this almost insensibly in his daily intercourse with his patients, exciting trains of agreeable associations in their minds, varied to suit the mental and moral character of each, thus aiding materially the operation of his remedies.

Dr. Rush gives a striking instance of the influence of association, which I will relate in his own words: “During the time,” says he, “that I passed in a country school in Cecil county, in Maryland, I often went on a holiday with my schoolmates to see an eagle’s nest, upon the summit of a dead tree in the neighborhood of the school, during the time of the incubation of that bird. The daughter of the farmer in whose field this tree stood, and with whom I became acquainted, married and settled in this city about forty years ago. In our occasional interviews, we now and then spoke of the innocent haunts and rural pleasures of our youth, and, among other things, of the eagle’s nest in her father’s field. A few years ago I was called to visit this woman, in consultation with a young physician, in the lowest stage of a typhus fever. Upon entering the room I caught her eye, and with a cheerful tone of voice said only, the eagle’s nest. She seized my hand without being able to speak, and discovered strong emotions of pleasure in her countenance, probably from a sudden association of all her early domestic connections and enjoyments with the words I had uttered. From that time she began to recover. She is now living, and seldom fails, when we meet, to salute me with the echo of the eagle’s nest.”

It is important in the treatment of disease, to remove all causes which awaken disagreeable associations in the minds of the sick, for they often retard, and sometimes prevent the recovery of the patient. It is as clearly the duty of the physician to detect the causes of such associations, and to remove them if possible, as it is to detect and remove the material causes of any irritation or inflammation.

Dr. Rush mentions a case that came under his observation, in which the influence of disagreeable associations hindered the recovery of the patient. “A gentleman in this city,” he says, “contracted a violent and dangerous fever by gunning. After being cured of it, he did not get well. His gun stood in the corner of his room, and being constantly in sight, kept up in his mind the distressing remembrance of his sickness and danger. Upon removing it out of his room he soon recovered.”

Some are much more readily affected by mental associations than others. A gentleman in a stage coach was observed to keep his cloak lying by his side, while he was shivering with the cold. He was asked by one of his fellow travellers why he did not put it on. He replied, ‘I have just returned from a voyage, in which I was very sea-sick, and while so I lay with that cloak wrapped around me. Foolish as it may seem, I cannot put it on without renewing the nausea.’

The various degrees and modes in which mental associations appear in the sick room, require of course the exercise of discretion and tact, in managing them to good purpose. There is often much injury done by failure in this respect. If, for example, the patient have great irritability of stomach, and if some medicine which has been doing him good, at length become exceedingly offensive to him, the continuance of that medicine might do him essential harm, by the mere influence of mental association; though, aside from this, it may be still an exceedingly appropriate remedy for his disease. Under such circumstances a change must be made, or the patient will be injured, it may be fatally. It will not do to call the patient whimsical, and to go right on with the course. The mental association connected with the medicine is practically one of the ingredients in it, and as such has so modified its nature as to render it inappropriate to the case.

The physician can often do much in curing disease by diverting the mind of his patient. Disease is frequently broken up by producing a new action in the system. This is a principle in medical practice which is familiar to others, as well as to the physician. And this change may sometimes be brought about in the system, by a corresponding change effected in the mind, especially in those cases where the state of the mind is particularly influenced by the disease. The husband of a poor woman, who in a feeble state of health had fallen into a settled melancholy, broke his thigh. The whole current of her thoughts and feelings was now diverted into another channel, from her own sorrows to the care of him and the relief of his pains, and she recovered her sanity, and with it, for the most part, her health, long before the fracture was united. The misfortune of her husband was a severe remedy, but an effectual one.

A physician of my acquaintance some years since became thoroughly impressed with the idea, that some symptoms which he had, indicated the existence of an organic disease which was certain to end fatally. At his request I made a full examination of his case, and found the symptoms to be purely of a nervous character. The expression of my opinion relieved him for the time of his anxiety. But as he brooded over his feelings when alone, the same idea returned again. I examined him repeatedly with the same result, but the comfort which he received from me was only temporary. Knowing that he was paying his addresses to a lady who was not only cheerful herself, but who had the power of making every body else cheerful about her, I recommended to him to be married at once, and told him that if he would be, we never should hear any more about his aneurism. My prescription was followed, and was entirely successful. The idea, which had so long haunted him like an evil spirit, was cast out never to return.

Every one is familiar with the fact, to which I have already alluded, that dyspepsia has a depressing influence upon the mind. And as the mental depression reacting upon the disease aggravates it, anything which tends to remove this depression assists materially in curing the disease. Diversion of the mind from its habitual gloomy ideas to cheerful thoughts and efforts, often exerts a great influence in such cases. I will mention a single case illustrative of this remark. A gentleman of high intellectual character, who was sadly afflicted with the dyspepsia, visited his friend Dr. Ives of New Haven, and placed himself under his care. The Doctor saw at once that medicines would do but little good in his case, so long as his mind remained in the same condition, and occupied with the same thoughts; and that a change there would go far to effect a corresponding one in his bodily condition. He determined to produce this change without the patient’s being aware of his intention, as it in this way would be more effectually accomplished. In one of his rides with him they alighted to pick some wild flowers. He adroitly excited his friend’s curiosity in regard to the structure and growth of the flowers, and leading his mind on step by step, he did not stop till he had fairly made him a student of botany without his knowing it. The result was that he engaged in the study with great enthusiasm, and followed it up for some time. He was changed at once from a gloomy self-tormentor into an ardent and cheerful seeker after knowledge in one of its richest and fairest fields, and this change made his recovery a rapid and easy one.

But it is not only in those cases in which the mind is obviously affected, that the physician is to apply the principle of which we have just been speaking. He can make use of it with much profit in ordinary cases of disease, in his intercourse with his patients from day to day. The sick are prone to brood over their own complaints, and to watch their sensations, and they need to have the mind diverted to other subjects.

In this connection I will notice very briefly the influence of change of scene upon the invalid. When the same objects are seen by him from day to day, and he has the same subjects of thought and conversation, these all act as so many fastenings, or points of attachment, tending to hold the disease in the same unvarying condition. But take him away from them all, and set him free from this discouraging and burdensome sameness, and let his thoughts and feelings flow into other channels, and the change of course favors the introduction of a new state of things, bodily as well as mentally. The new objects that he sees not only take off his attention from his diseased sensations, but the new excitement that he feels, as he sees them one after another, diffuses a refreshing and invigorating influence throughout his system. And imagination lends her aid in producing this effect. It seems to him that everything is better than it was where he was so lately shut up with the feeling almost of a prisoner—that the air is more pure, the grass more green, the foliage of the trees more dense and rich, and even the sun more cheerfully bright. Something, it is true, is to be attributed to change of air under such circumstances, but much less commonly than to the influence of change of scene upon the mind.

The sick room, as every physician has frequent occasion to witness, acquires after a time a monotony that is dreary and painful to the confined invalid. Day after day he sees the same furniture and same walls, every irregularity of whose surface he becomes acquainted with, and he is forced to seek for some variety even in the most trivial circumstances. “There, Doctor,” said an invalid playfully, “I have made a little change, to-day. I have had the rocking-chair put the other side of the fire-place, and the bureau moved to that corner, and those phials on the shelf, you see, have changed their places. My friends, Cologne and Camphor, have gone to the other side of that vase, and those drops (which, by the way, Doctor, I think that I have taken so long that some change would be well) have their station now quite at the other end of the shelf. And my good grandmother, you see, looks down upon me from the other side of the room. Variety is pleasing, Doctor, even within a few yards square, when one can not get any farther.”

Even when the invalid is not confined to the sick chamber, but has his rides and his walks, the monotony of every day’s routine becomes a weariness. And no wonder that an escape from this is so often so manifestly beneficial to him.

But it is not merely the diversion of mind, attendant upon change of scene, that benefits the invalid, but his release from those mental associations, that have so tenaciously connected themselves with his sickness, has an important influence. The place where he has spent wearisome days and nights of pain and restlessness and languor, must necessarily have unpleasant associations connected with it. These hinder, and in some cases even prevent convalescence; and when he casts them off, he feels that he has rid himself of a great burden, and as he goes on his course with a light heart, a fresh impulse is given to the vital powers of his body, making him to feel, as he says that he does, like a new man.

The mind of the sick man sometimes gets into a fixed, unvaried state, with one settled cast to its ideas. The tendency of this is to make the diseased condition of body to remain fixed also. It is important, therefore, to alter this mental state—to break up this unvarying train of thought and feeling. There are different ways of doing this in the different cases that present, and the physician must judge as to the most proper mode of effecting the object in each case. I will give a few cases as illustrations.

A patient who had been very sick, but who had recovered from the severity of her attack, and who was in a fair way for getting well, remained precisely in the same condition for some time. Her mind was in a fixed state of gloom, marked by a perfectly unvaried expression of countenance. Her friends had tried in every way to make her cheerful, but it was in vain, for the simple reason that all their attempts to do so were obvious. I knew that she had naturally a lively sense of the ludicrous, and therefore, after getting her somewhat off her guard by some incidental conversation, I then, with an air of perfect carelessness, uttered something which I thought would be very apt to hit her mirthfulness, as the phrenologists term it. It did so, and a smile kindled up at once upon her sad countenance. The spell was now fairly broken. She speedily regained her wonted cheerfulness, and the load being cast off, she went straight on in the bright road of convalescence. In this case it was but a small thing, after all, that turned the current of thought and feeling, and the means which had already been used, most persons would suppose, were much better calculated to do it. All direct and palpable efforts to make the gloomy invalid cheerful, are almost always unsuccessful; and yet it is such efforts that are most commonly made use of by the friends of the sick.

The course which was pursued in another case, was quite a different one. The patient was a clergyman, who had the impression strongly fastened upon his mind that he should certainly die, and could not be made to admit by the force of any reasoning, the possibility even of his recovery. It was not an opinion founded upon evidence, but it was a fixed state of mind, which was the product of the disease. It was important to remove, if possible, this all-absorbing thought, for it was reacting unfavorably upon the disease itself. It could not be done by argument, nor by speaking to him the words of hope; for it was not a conviction of truth arrived at by any reasoning, but an impression unaccountable, but strong and vivid. He did not think that he should die, but he felt that he knew it. Some remedy, then, different from either of these, was necessary. As he was a man of stern, decided religious principle, I determined to make a bold onset in that quarter. I told him that God alone knew whether he would die or recover, and that he was doing wrong—absolutely committing high-handed sin, in setting himself up as knowing what God only knows. This was the substance of what I said to him, and it produced the desired effect. The impression was dislodged from his mind, and though he occasionally talked discouragingly of the result of his sickness, he never said after that, that he knew that he should die.

One other case I will relate, in which the course taken to destroy the diseased mental impression was of still a different character. A patient, a gentleman of superior mental and moral qualities, sent for me to inform me that he had received a revelation, in which God had forbidden him to eat or drink or sleep. The confidence which he manifested in me by sending for me determined in my mind at once the course to be pursued. I told him that I had also had a revelation, which was quite as good as his, perhaps better. ‘And,’ said I, assuming the air of calm authority that expects submission as a matter of course, ‘you must obey it.’ ‘What is your revelation,’ he inquired. ‘My revelation,’ said I, ‘embraces all that is necessary in your case. And in obedience to it you must continue to follow my directions, and you must eat and drink and sleep as you have done.’ I left him with my revelation fastened in his mind, it having supplanted his altogether, and he immediately ate and drank, and that night slept as well as he usually did.

In chronic cases especially, the sick are often prevented from recovering by the influence of unpleasant circumstances in their situation, or in their relation to others around them. The friends of the sick often get out of patience with them in the tediousness of a long confinement. Sometimes there is unkindness, and this to the weakened mind and depressed spirits of the invalid, is often a burden that cannot be borne. Some secret grief often neutralizes the influence of medicine.

There is often great want of tact in managing the whims and caprices of the sick. Many expect them to be as reasonable in their notions and desires and feelings as if they were well. It is unwarrantable and unjust to demand this of a weakened and beclouded mind, and agitated nerves. Trifles light as air affect the sick strongly. The very grasshopper is a burden to them. It is with the mind of a sick man as it is with his senses. Noise troubles him—even the motion of a rocking-chair, perhaps, or the swinging of a foot, disturbs his sight, and through that sense disturbs his mind. The darling child, whom he delights, when he is well, to see running about playing his little pranks, must be taken out of the room, because he makes his father’s head to whirl and to ache. Thus easily is he disturbed through the senses. Just so is it with his mind—it is as easily disturbed, and circumstances, which would scarcely excite a passing thought in health, now agitate and depress him. Disappointments, that ordinarily would be felt but for a moment and slightly, he can hardly brook now. Every mother has often seen how easily her child is grieved by little things, when mind as well as body is prostrated by sickness. And she does not commonly get out of patience with it for its seemingly unreasonable griefs, but soothes and quiets them. It would be well if the attendants and friends of the sick had more of that patience and forbearance, which are prompted by a mother’s tenderness.

The sick often contract a strong feeling of dislike towards some things, and sometimes towards individuals. They may regret it, and see that it is unfounded and foolish, and yet not be able to get rid of it. Some make the sick dislike them by their very kindness, because it is so officious and pains-taking. There is a tact in the good and judicious nurse which dictates just what to do and how much, and many of the attendants on the sick are sadly deficient in this.

The fretfulness and impatience of contradiction, which are so often the product of the nervousness of disease, are generally not to be combatted, but to be borne with. The considerations which I have already presented clearly show the propriety of this maxim; and yet it is a maxim which is very commonly neglected. Many a dispute about the most trivial things is held between the patient and the attendant or friend, when a little tact might have diverted the weakened mind from the subject, without yielding in the least anything, which pride of opinion or firmness would prompt to hold fast to. I once heard a mother, a woman of intelligence too, dispute with her sick daughter about the number of crackers she had eaten during the day, each maintaining her side of the question with as much zeal and pertinacity, as if it were a matter of vital importance. The result was that the patient was injuriously agitated by this rencontre about nothing, and ended it by bursting into tears, and the mother triumphed, as was her wont to do, by having the last word. And this was a fair specimen of the moral management of that patient during a long sickness. It added vastly to her nervousness, and clouded a mind filled with lofty, and refined, and tender sentiment, and made that chamber a scene of painful exhibition of thought and feeling, when a different management might have soothed her agitated nerves, and left the sensitive chords of her soul to respond clearly and harmoniously to the gentle touch of friendship and love.

The patient often feels, and takes comfort in feeling, that his temporary outbursts of fretfulness and impatience are understood by his friends, as having no consonance with the real feelings of his heart. A much respected patient, of whose sickness I have many pleasant recollections, was one day speaking to me of his sister in the highest terms of eulogy. “Yet,” said he, “I scold at her, but I have no business to do it. However, she understands it. She knows that I am nervous, and that I am sometimes hardly myself and she forgives it all.”

Let me not be understood to mean that all the notions and caprices of the sick are to be yielded to as a matter of course. I only object to an useless and injudicious warfare with them. There should always be firmness exercised in the management of the sick, but there should be no struggle with them from mere pride of opinion, or a desire for authority, or from want of a proper charity for their mental weakness. They should never be directly opposed, except it be distinctly and manifestly for their good.

One very common mistake in the mental management of some chronic cases remains to be noticed. I refer to those cases in which the nervous system is so deranged, as to produce a variety of sensations of a deceptive character. Such patients are generally laughed at as hypochondriacs, and they are told by their friends, and sometimes even by physicians, that these sensations are wholly imaginary. This is not so. Some of their notions about them are mere imaginations, it is true; but the sensations themselves are, to some extent at least, real. Imagination may magnify them, but it does not ordinarily create them. The wrong ground which is so often taken in regard to such patients, sometimes essentially retards their recovery. They feel that they are trifled with, and they have but little confidence in the judgment of those who deny that their sensations are real, and therefore have but little if any in the remedies which they administer to them. Besides, the mind of the patient is disturbed continually by the disputes and consequent ill feeling which such differences of opinion necessarily engender, and this of course has a tendency to aggravate the diseased condition.

As an illustration of these remarks, I will mention a single case. The patient, who had long been an invalid, had, among a great variety of sensations, a burning, twinging, sometimes a pulling sensation, in the region of the stomach. Her notion about it was that there was a cancer there, that really pulled, and burned, and twinged. She had been assured again and again that there was no cancer there, but so little credit had been given to her account of her sensations by those who had told her so, that she had on her part given little credit to their knowledge of her case. I immediately told her that I had no doubt that the nerves in that part of the body were the seat of the sensations she described, but that she was wrong in the disease which she fancied to be the cause of those sensations. By taking this plain and obviously proper ground with her as to the nature of her case, making the true distinction between what was real and what was imagined, she was induced to give up the imaginary notion that was weighing down her spirits. This view of her case, so consonant with the faithful report of her own sensations from day to day, commended itself to her common sense, and by inspiring confidence and hope, did quite as much for her recovery as any other remedial means that were used.

Among the great variety of topics which have suggested themselves in connection with the subject of this chapter I have selected those, the discussion and illustration of which would most interest and profit the general reader. There are two topics, however, of this character which require so extended a notice, that I shall devote to each of them a separate chapter. I refer to insanity, and the influence of hope in the treatment of disease.

In concluding this chapter I remark, that the subject of it demands of medical men a more distinct and thorough attention than it commonly receives. The physician should be something more than a mere doser of the body. Mental influences are among the most important of our appliances in the cure of disease. The physician, therefore, in fulfilling his high vocation, should not only have a full knowledge of mental philosophy, but he should aim to acquire a practical skill in applying its principles to all the ever varying phases, which the mind presents in its connection with disease. The possession of this skill is one of the most valuable endowments of the medical art.