A premise "is a proposition laid down, proved, supposed, or assumed, that serves as a ground for argument or for a conclusion; a judgment leading to another judgment as a conclusion" (Standard Dictionary).

Let us illustrate good and bad judgment by following out two lines of reasoning, each quite accurate as such.

I want sweets. Sweets are good for people. They give heat and energy, and I need that, for I am chilly and tired. People say "Don't eat sweets between meals." But why? They contain just what I need and the sooner I get them the better.

So I have sweets when I want them. The judgment to take the sweets as desire indicates is entirely logical if we accept all the premises as correct. And they are, so far as they go; but they are partial; and so cannot altogether correspond with the facts of life. Sweets are good for people who expend much physical energy. They prove injurious in more than limited amounts to the bed-ridden, the inactive, or the sluggish. Hence this premise is partial and so far incorrect. Sweets do give heat and energy, true. I am chilly and tired, also true. But why? Because I am already toxic from the sweets and meats I have had throughout my sedentary years. The question is, Do I need any more energy-producing food when I am not burning up what I have? So again the premise is partial. I do need heat and energy, but I already have the material for it, and my mode of life has disorganized my system's capacity to utilize these foods normally. So now sweets have become a detriment to my well-being. The judgment which determines me to the habit of eating sweets between meals is the result of logic, but of logic spent on tying up premises which do not fit the facts of the case.

One of the most prevalent defects of judgment is illustrated in this common disability to select premises which fit the facts. Ignorance, emotional reasoning, and a defective critical sense probably explain most poor judgments.

The other judgment illustrates the logic of correct, provable premises.

"No, I shall wait until dinner-time. I have no need of so rich a food, for I had an adequate meal at the usual time and have not worked hard enough to justify adding this burden to my digestive apparatus; besides only hard workers with their muscles can afford to eat many sweets. They cause an overacid condition when taken in excess; and any except at mealtimes would be excess for me, with my moderate physical exercise."

This judgment we call good. Its premises correspond to scientific facts.

But much reasoning must always be done with probable premises, ones which seem to correspond to the facts, but which have yet to be proved. And our judgment from such suppositions cannot be final until we see if it works.

Some few centuries ago supposedly wise men called Christopher Columbus a fool. Of course the world was flat. If it were round man would fall off. It was all spread out and the oceans were its limits. If it should be round, like a ball, as that mad man claimed, then the waters must reach from Europe 'round the sphere and touch Asia; or there might be land out there beyond the ocean's curve. But it wasn't round, and the idea of finding a new way to Asia by sailing in the opposite direction was a fool's delusion.

Their logic was perfect. If the earth was flat, and Asia lay east of Europe, it was madness to sail west to reach it. But they argued from a wrong premise, so their judgment was imperfect—for they did not yet know the facts.

The result of all reasoning is judgment. And judgment is good as the materials of the reasoning process correspond to facts, or are in line with the most probable of the yet unknown. It is poor as the reasoning material fails to meet the facts, or is out of harmony with the most probable of the yet unproved.

It is of no avail, then, to attempt to improve our final judgments as such. We must examine the materials we reason with, then learn to group and compare them logically. And in the very separating of true premises from false, we use and train the judgment we would improve. And this the normal mind can do.

REACTION PROPORTIONED TO STIMULI

In the normal mind the emotional or feeling accompaniment of thought and action is proportionate and adequate to the circumstances, i. e., there is a certain feeling, of a certain strength, natural to every thought and act; and when only that strength, not more or less, accompanies the thought or the act, we say, "That man is emotionally stable. His mind is normally balanced."

Joy naturally follows some stimuli; sorrow others. Disappointment or loss, shock, failure, death of loved ones, illness in ourselves or others, do not normally bring joy. A keen sense of suffering, temporarily, perhaps, of numbness; the inability to grasp the calamity; or flowing tears, an aching heart, or the stress of willed endurance, are natural, and normal reactions to such stimuli.

A developed will may refuse indulgence in the outward expression of the normal feeling of shock, grief, and loss; and this may be normal. But normal volition does not force us to laugh and dance and be wildly merry in the face of grief and loss and pain. It only suggests the adequate, reasonable acceptance of the facts that cannot be changed—the acceptance of love, faith, and hope that sees in present suffering a means of consecration to service; it does not convert the emotion of sorrow and loss into a pleasurable one. Normal reason does not suggest that will force the reactions to loss and suffering that belong by nature to attainment and success.

Nor does reason suggest the long face, the bitter tears, a storm of anger, in response to comedy and farce, in the face of a good joke, or to meet success; and normal will puts reason's counsel into effect.

NORMAL EMOTIONAL REACTIONS

Some emotions, that seem exaggerated at first thought, may be normal under the circumstances. For no one can know the whole background for emotional response in the life of another. After being long shut up in a darkened room, with bandaged eyes and aching head and sick body, the first visit to the bit of woods back of the house—when all the pains have gone—may bring almost delirious joy. The green of the foliage, the blue of the sky, the arousing tang of the air, the birds, the sense of freedom—all go to the head like new wine. The abandon of joy is a normal response under the circumstances, now. It would hardly be normal to one whose habit it is to visit this same bit of woods every day, to one who loved it, but for whom it had lost the force of newness.

To the child, who has never in all his little life had a wish not gratified, the denial of a desired stick of candy is as great a calamity as is the loss of a fortune to the grown man. And the child reacts to feeling equally intense. These are normal reactions to stimuli—normal, under the circumstances.

THE NORMAL MIND

The normal mind reasons clearly with the best data at hand to results that will stand the test of conformity to reality; the normal mind uses reason and feeling, guided by reasonable attitude; in the normal mind reason advises action and will brings it about; in the normal mind feeling proportionate to the circumstances accompanies every thought and every action. And in the well-balanced man or woman every function of the mind leads to action as its final end.

But man only approximates the normal. The perfectly balanced man or woman is so rare as to be a marked person. The average intelligent individual only in general approximates this standard. He goes beyond it in spurts of untrammeled genius, to wrench lightning from the heavens, and to send his trains through the air; or he allows his feelings to dictate to his reason, and much of the time so exaggerates or depreciates the simple facts of life that the results of his reasoning no longer conform sufficiently to reality as to be thoroughly dependable.



CHAPTER VII

PSYCHOLOGY AND HEALTH

In the use of its functions the mind manifests certain powers and certain modes of expression which can act as powerful allies or as damaging enemies of health. We speak of man as adaptable, but also as a being of habits. We speak of him as "feeling" when we wish to express the fact that his emotions influence his body. We expect of the average man a certain amount of suggestibility. We say that he is tremendously affected by his environment, which simply means that his attention, naturally centered chiefly on the things at hand, largely determines what he is. But we recognize that a man of trained mind can choose and will to substitute for his present surroundings thoughts upon more constructive things from past experience, or from future possibilities, or from within the mind's own storehouse. His ability to largely modify his life by his will, we recognize as man's greatest power. Adaptability, emotional response, suggestibility, attention, thought-substitution, habit-formation, and will can minister vitally to health, or can prove damaging avenues of disease.

NECESSITY OF ADAPTABILITY

Adaptability is as essential to life of mind as to life of body; and health of mind as well as health of body is determined by the individual ability to adjust himself to environment.

There are dreamers who have lived in their ideal world so long that they cannot meet the stern realities of life when they come. The shock is too great for the mind that has accepted only the fantastic, the real as the dreamer would have it; and he lets go altogether his hold on the actual, accepting the would-be world as present fact. And we call him insane. Other visionaries wakened rudely to life as it is, accept it as unchangeable fate, lose all their true ideals and become cynical, or victims of utter depression for whom life holds nothing that matters. Still others go on through the years self-satisfied and serene because they simply refuse to believe unpleasant truths; they "pretend" that their wishes are realities, and acknowledge as facts only the pleasant things of existence. The first two groups have failed to adapt self to life as it is, and the mind is lost or so damaged as to no longer serve its body properly. The "pretenders" have adjusted themselves, and so long as they can remain happily self-deceived all goes well for them, though they complicate living for others. However, they have made an adaptation, a defective one, it is true, but one through which the mind may survive. Some of this class, however, finally build up a more and more elaborate system of self-deception until they, too, are insane.

The practically adaptable man can dream dreams, but always recognizes them as dreams, and can stop at will; can vision a beautiful ideal, but comprehends that it is not yet reality, though it may some time become so if he learns and fulfils the laws leading to its realization. The adaptable man or woman recognizes the real as fact, desirable or otherwise, the fantastic as unreal and only to be indulged in as a pastime, and the ideal as the possible, a thing for which to work and sacrifice. So perfect adaptability would mean perfect mental poise.

It is for the nurse to realize that the greater number of her patients do not belong to any of these classes absolutely, but that some of them have tendencies leading in these various directions. And it is her privilege to recognize the trend of her sick patient's mental workings, and to so deftly and unobtrusively encourage the recognition of facts as things which are to be used—not as stumbling-blocks—that her mental nursing, as her physical, shall be directed toward health. She can help her patient to accept illness and suffering as realities to be faced, and treatment as a means, whether pleasant or not, of making it possible for health to replace them. The understanding nurse can actively help her charge one step at a time toward adaptation to the new environment, remembering that many of the sick, particularly the depressed, cannot be encouraged or incited to effort by having future health held out to them. They are capable only of living in the present and doubting all the future.

There Can Be No Neurosis Without a Psychosis.—If the brain is the organ of the mind, then what affects the brain must perforce be at least registered by mind. So every physical shock, accident, toxic condition, infection—even the ordinary cold—rouses the mind at least to awareness, usually to discomfort. For the nerve-cells and fibers—those inseparable parts of the body mechanism—speedily report the fact that they are being tampered with. In the toxicity of the infections these very delicate tissues are nourished by toxic fluids; in accidents they carry all the messages from the injured part. Then the brain—that center of all man's reactions and the organ of all his consciousness—receives the report of the disturbance and translates it into terms of more or less disability. The neurosis has become a psychosis. The physical condition has become a mental discomfort. Normally this ensuing mind state should be in accordance with the extent of the injury to the nerve-cells and fibers. But under long-continued discipline, or influenced by emotion, the conscious mind may not recognize the neurosis; whereas, in the hypersuggestible, consciousness will translate it into entirely disproportionate suffering.

A great problem of nervous education is what the mind will do with discomfort or pain. Will it put all its attention there and respond with nervousness, irritability, demand for sympathy; or will it relegate all the minor pains to their own little places, accepted as facts but to be disregarded except in so far as actual treatment is needed? Will it turn to attend to the host of other more desirable objects? Or in case of acute suffering, will it take it as a challenge to endurance? Will it use it as a means to strengthen volition, as a stepping-stone to self-mastery?

Realizing the force of the law—no neurosis without a psychosis—the nurse will try to eliminate unnecessary irritations to physical comfort, while she helps the patient to adjust himself to the ones which are inevitable. It is the doctor's problem rather than hers, except as she carefully fulfils orders, to eliminate the toxic causes of psychosis. It is hers to help the patient to meet adequately the effects of the infections or toxins, and to prevent as far as possible the surrender to uncontrolled nervousness. Her object is to have him face the psychosis as one of the simple facts of science, then turn the sick mind's attention to more important things; she would encourage will to force endurance; she would stimulate the feeling life to the forward look of confidence and faith, or to acceptance of life's suffering as a challenge. The nurse knows that pains beyond the power of endurance the doctor will lighten. And the patient's reaction to discomfort and suffering, the understanding nurse, without any preaching, can very largely influence.

THE POWER OF SUGGESTION

One almost universal condition found in illness is hypersuggestability. Here is the nurse's despair and her hope. Suggestion may come from without or from within. When from within, we call it autosuggestion.

Many of the sick are temporarily resting their reasoning faculties and their judgment. The sick body is causing a feeling of "jangling nerves," and the mind, too, is strongly tempted to be sick. So every harsh sound, every jolt, almost every sentence spoken in their hearing suggests immediate nervous reactions. The mind does not wait to weigh them. The nervous system reacts to them the second the impression is registered. The whole self is oversensitive, and the very inflection of a voice has enormous significance. Let the nurse remember that her way of giving a treatment, her expression, or her very presence becomes a potent stimulus on the second, one to which the patient's mind responds like a flash-light when the button is pressed.

The nurse must comprehend the principle of the nervous effect on the patient of all that is done and said, and realize her tremendous privilege in making those stimuli wholesome. The nurse who has a sympathetic insight, with unswerving loyalty to orders, can carry them out with the average patient, unpleasant though they may be to him, in such a way that his wholesome emotional response will be called forth, a response of co-operation, or of faith or of good breeding, or of "downing" the impulse to indulgence; or a response directed toward holding the nurse's interest and attention, and so keeping her in the room; such a response as will gain some privilege, etc.

But there are some patients in whose cases ordinary persuasion, suggestion or requests fail. They are too nervously or mentally sick to be moved by logic, or to respond with customary grace to a request which their reason is not awake to answer. All usual suggestions may fail of effect. And for these few, in order that health may be at all assured, even the discipline of force may be necessary. But the nurse must use this only as a last resort, of course, and in accordance with the doctor's orders, and then solely as treatment leading toward the ways of health. Before turning to this final method she should clearly, firmly, and kindly explain the principle of the discipline if the patient's mind is at all capable of grasping it. In any case, force should be used only as the surgeon uses his knife. It hurts, but only to help and to save; and it is not called upon when other methods can secure the needed results. But force, thus limited in its application, may prove the only suggestion which will bring about the action necessary to health on the part of the patient. Force unwisely and unkindly used proves a damaging suggestion, causing reactions of fear or anger; or it may lead to delusions of persecution and to strengthened resistance.

Many suggestions come to the patient from within. Discomfort in the right side may suggest appendicitis. A slight indigestion, often purely nervous, may be interpreted as inability to care for certain diet, etc. The wise nurse will displace as many of these as she can by casual suggestions on her own part. She will demand of herself that her very presence be quieting, calming, happy; that her conversation with her patient shall vibrate with a certain something that gives him courage and strengthens the desire and the will to health; that her care of him shall prove confidence-breeding. The patient's attitude, when he is at all suggestible, is largely in the nurse's hands, and she can make his illness a calamity by dishonest, fear-breeding, or suspicion-forming suggestion. After all, the whole question here is one of the normality of the nurse's own outlook on life and people. The happier, truer, and more wholesome it is, the more really can she help her patient to both bodily and mental health. Of one thing let the overzealous nurse beware. Do not irritate your patient by a patent, blatant, hollow cheerfulness that any one of any sense knows is assumed for his benefit. Personally I know of no more aggravating stimulus.

What We Attend To Determines What We Are.—This is one of the first laws of education. If the child's attention from birth could be controlled, his future would be absolutely assured. But attention is a thing of free will and cannot be forced by others. It can be won through interest or self-directed by will. The child's attention is entirely determined by interest, interest in the morbid and painful as truly as in the bright and happy. Punishment interests him tremendously because it affects him, it interferes with his plan of life, it holds his entire immediate attention to his injured self. But something more impelling quickly makes him forget his hurt feelings and he is happy again. The average sick person is emotionally very much like the child. His will at the time, as we noted before, is tempted to take a rest, and his interest is ready to follow bodily feeling unless something more impelling is offered. The nurse who can direct attention to other people, to analyzing the sounds of the street, to understanding something of the new life of a hospital or sick room, to planning a house, or choosing its furniture or equipping a library, or supplying a store; to intelligent references to books or current events; or to redecorating the room—all in his mind; to an appetizing tray, a dainty flower, a bit of sunshine, a picture, etc., is fixing the patient's attention on something constructive, helping him to get well by forgetting to think of himself.

Thus the nurse, knowing the laws of attention, can keep herself alert to divert and direct her patient's thought to wholesome interests. Knowing the possibility of thought substitution, she can open up new channels of thinking. Knowing the power of the will to assist in health bringing and health keeping, she can sometimes stimulate long-dormant determination. Let her beware, however, of making the convalescent too dependent upon help from without, but prick his pride to gradually increasing doing for himself. Arouse his reasonable ambition, but let him realize that life must be taken up again a step at a time; and that he can do it. If limitations must be accepted, try to inspire the feeling of pride in accomplishing the utmost possible within a limitation, and an acceptance of the inevitable without bitterness.

Attending to the unhappy, the painful, the boring without looking beyond makes life unhappy, painful, and a bore. Not that the nurse should ignore these realities, but she can accept them whole-souledly herself as not the final things, as merely the rocks that can be used to stand upon and get a view of the something better for everybody. When they are thus used by the wholesome mind, facts, the very barest and meanest of them, can be made useful as stepping-stones to the happier facts beyond them.

If the nurse can direct or tactfully lead the patient's attention away from himself and his illness, she has found a big reinforcement to his treatment. This question is so vital in the care of patients that it will be discussed at greater length later on.

ONE THOUGHT CAN BE REPLACED BY ANOTHER

If we control attention we control thought, and with the suggestible patient this principle depends upon the one just now considered. Hope and courage-breeding thoughts can replace despairing and fearful ones, but it will be only when attention is directed through interest or by will to new material. There is no blank in waking consciousness. The last thought or feeling or perception, through association of ideas, brings up a related one, and so on indefinitely. We may start with a pebble on the road and go on logically, smoothly, until in five minutes we are thinking of the coronation of King George, with no sense of anything at all unusual in the succession. It may be a very roundabout process, from "pebble" through "rough way," "ways that hurt," "dangerous ways," "brigands," "uncertainties of life." "Uncertain lies the head that wears a crown," "King George and his crown," "coronation." But this constant stream of thought can be broken into at any point by a spoken word, a passing vehicle, which diverts the mind's trend. So the nurse can take advantage of the mind's very suggestibility, and substitute for the unhappy and sickness breeding by turning attention to anything else of a happier color, and may divert the entire stream of thought in that direction. She who knows these simple laws of the mind, and who at all knows people, is a therapeutic agent of unlimited value.

HABIT IS A CONSERVER OF EFFORT

It is always easier to follow a beaten path than to break one's way through untrodden forests. It is easier to walk after we "learn how," and learning how is simply doing it over and over until the legs and feet have acquired habits of motion and accommodation to distances and to what is underfoot. It is easy to do anything after we have done it again and again, so that it has become second-nature, and "second-nature" is habit. The wise man early forms certain habits of personal care, of eating, sleeping, exercising; of study, of meeting the usual occurrences of life. The first day he spent at anything new was a hard one. Nothing was done naturally. Active attention had to be keenly held to each detail. He had to learn where things belonged, how to do this and that for the first time, how to work with his associates.

Do you remember the first hospital bed you ever made, the first bed-bath you gave, the first massage? You had to be taught bit by bit, detail by detail. You did not look upon the finished whole, but gave almost painful attention to each step that led to the made bed, the completed bath, or the given massage. Your fingers were probably all thumbs unless you had experience in such things before you came to the hospital. Your mind was tired from the strain of trying to remember each suggestion of your instructor. The second time, or certainly the third or fourth time, it went better. After a week of daily experience you gave the bath or massage or made the bed with much less effort. A month later the work was practically automatic and accomplished in a fraction of the time you spent on it that first day. Now you can do it quickly and well with little conscious thought; and at the same time carry on a brisk conversation with your patient or think out your work for the day. Your mind is free for other thoughts while you perform the task easily and perfectly. Your method of doing the work has finally become a habit which saves the effort of conscious attention. The details of your routine work are directed by the subconscious. The habit will be energy and time saving in proportion to the accuracy of your first conscious efforts spent on the new undertaking. Thus, useful habit is the result of active effort.

We can acquire habits of thinking and habits of feeling as well as habits of doing.

But the other habits, the bad ones, are not acquired with effort. We fall into them. Hazy thinking is easier than clear thinking. Suppose you are by nature rather oversanguine or overdespondent, and you make no genuine attempt to evolve that nature into poise. Directing will to do what desire opposes is too difficult, and you go the way of least resistance. So easily are the bad habits formed; but only with tremendous effort of will and persistence in refusing their insistent demands can they be broken or replaced by helpful ones.

But habits can be learned; and bad habits can be broken when an overpowering emotion is aroused against them, possesses the mind, and controls the will; or when reason weighs them in the balance and judgment finds them wanting, and volition directs the mind to displace them by others.

The nurse meets in her patients numberless habits which retard recovery of body and make for an unwholesome mental attitude. Some patients have the complaint habit, some the irritation habit, some the self-protection habit, some the habit of impatience, some of reckless expression of despair, some of loss of control, some of incessant self-attention. The nurse who can arouse an incentive to habits of cheer expression when the least cause of cheer appears, who can by reason, or if that is not possible, by suggestion; by holding out incentives, or by making some privilege depend upon control—this nurse can help her patient to displace habits of an illness-accepting mind by habits of a health-accepting one. Above all, let her beware of opening the way to habits of invalidism. Some people acquire the "hospital habit" because it is easier to give way to ill-feeling, however slight, and to be cared for with comfort, than to encourage themselves to build up endurance by giving little attention to minor ailments.

THE SAVING POWER OF WILL

It is not uncommon to hear a doctor say, "Nothing but his will pulled him through that time." It does not mean quite what it says, for the patient's will would have been helpless to cure him without the medicine and the treatment. But it does mean that in some cases when life is hovering on the brink, even the most skilful treatment cannot hold it back if the will to live is gone. The chances may be half and half. Lack of desire to live may drop the balance on the death side. Determination and hope and confidence may overweigh the life side. For the influence of will in refusing to surrender to depression may throw the needed hair's weight in favor of more normal circulation. Depression and emotion may so effect the sympathetic nervous system as to cause a lowered circulatory activity. Determination, based on volition, may stimulate a response from the sympathetic system which will increase heart activity. And certainly, when it is not a matter of life and death, but a prolonged recovery, will is a saving grace. The patient who sets all his sick energies to the task of winning health reaches his goal quicker than the hopeless and depressed. Perhaps his will merely brings utter relaxation for the time, forces acceptance of present helplessness only for the sake of giving the body a better chance to recuperate; but the very fact that it is acting to hopefully carry out orders lightens by half the nurse's task of getting him well; and she can encourage this will to co-operate with the doctor's efforts by suggestion, by her directness and honesty, by the quiet assurance that at least a reasonable degree of health is won by effort.

We have touched upon only a few of the laws of the mind. The nurse can help develop saving mental habits and wholesome attitudes while she helps to strengthen sick bodies; she can make a cure a little more certainly lasting who will remember that:

1. Adaptability is essential to life and health. 2. There is no neurosis without a psychosis. 3. Suggestion may be a powerful factor for health. 4. What we attend to determines what we are. 5. Thought substitution is possible. 6. Habit is a conserver of effort. 7. Will is a saving power.



CHAPTER VIII

VARIATIONS FROM NORMAL MENTAL PROCESSES

DISORDERS AND PERVERSIONS

Life would be a very simple proposition if the mental machinery always worked right. But this is peculiarly subject to damage both from without and from within. From without it may be damaged by the toxins of food, as in the acute toxic psychoses; by the poison of drink, as in the alcohol-produced psychoses, such as acute alcoholic hallucinosis; by lack of muscular exercise, resulting in a deficient supply of oxygen to burn up the accumulated toxins from energy-producing foods; by the infections, which may result in the infection-exhaustion psychoses; by wrong methods of education, and by surroundings which demand too severe a mental strain in the struggle toward adjustment. These damages from without we class roughly as environmental.

From within the mental workings may be injured by emotional dominance; by bad habits of thinking and feeling and doing—often the result of wrong methods of education; by defective heredity; by undeveloped will; by the insanities. These danger sources from within we might classify as self-produced and hereditary.

There may be disorders of any or every function of the intellect, disorders of feeling, and perversions of will. Some of the most commonly met we list below.

Disorders of the Functions of Intellect.

/ Hyperesthesia (exaggeration of sensation) { as found in neurasthenia, or in mania. { Anesthesia (absence of sensation) { as in the numbness of hysteria; in sensory { paralysis. Disorders / Retardation of < as in dementia and melancholia. Sensation "Clouding" or dulness { as in simple depression. { Perversion { as in dementia and melancholia. Sweet may taste sour; fresh food may smell decayed.

/ Hyperesthesia (exaggeration) { as in neurasthenia or mania. { Anesthesia Disorders { as in hysteria or paralysis. of { Retardation Perception { as in dementia and melancholia. / "Clouding" or dulness (being < as in simple depression. dependent Illusion on sensation { found in normal mind—easily corrected; is always { found in many insanities. disturbed { Hallucinations with it). { frequently met in the infection-exhaustion psychoses, { in dementia, in paranoia, in acute hallucinosis of alcoholism.

/ Hypochondriasis { found in many of the hypersuggestible, frequent { in the mild depressions and in all victims of { self-attention. { Retardation { found in most depressions. { Deficiency { as in idiocy—the inability to form new concepts. { Acceleration { as in hypo-mania. { Poverty { as in the abnormally self-centered; { as in melancholia. { Rambling ideas { as in chronic insanity. { Flight of ideas { as in manias, hysterias, and acute deliriums. Disorders / Fixed ideas of < as in paranoia. Ideation Perversions (concepts change their meaning altogether) { as in dementia. { Ideogenous pains { as in hysteria. { Compulsive ideas { common in borderland states; { in psychasthenia, or hysteria. { Disorientation { { thing, { (wrong idea of { place, or { { person); { found in confused conditions; { in delirium from infections; { in insanities. { Confusion { as in the infection-exhaustion psychoses; in insanities.

/ Absent-mindedness. { Amnesia (morbid forgetfulness). { { temporary, Disorders / Aphasia { prolonged, of < {permanent (see later explanation). Memory Perversion { as fabrications, due to memory-confusion or { inaccuracy; also due to excessive ideation and defective judgment.

/ / Somatic { { as in hypochondriasis. { { Persecutory { { as in paranoia. { { Unworthiness { { as in simple depression or { { melancholia. { Delusions { Grandeur { Systematized / as in mania or paranoia. Disorders / Transient < Nihilistic of < Fixed often found in melancholia. Reason { Reference { { as in paranoia. { { Altered personality { { as in hysteria. { { Perverted personality { { (patient may believe he is a dog); { as in dementia. { Emotional thinking. { Shut-in personality { as seen in the deficient social capacity of potential dementia praecox.

/ Defective judgment { in all insanities; { in hysteria. { Ex.: Patient who accepts mental suggestion { of disability as reality. { Perverted judgment Disorders / in severe dementias—as influenced by unreasonable of < fear, hatred, etc.; Judgment in all acute insanities—as manifested in inability { of patient to rid himself of his delusions. { Absence of judgment { in all acute insanities; { in later dementias. { Limitations in many so-called normal and in all the abnormal.

/ Suggestibility { in hysteria. { Excitement { in mania. { Depression { in melancholia. Disorders / Phobias of < as found in psychasthenia. Emotion Deficiency { as in the apathy of depression. { Perversion { in mania, in depression, in catatonia. { Deterioration { in dementia. { Sense of unreality found in all borderland cases.

/ Wilfulness { in many "normal." Very common in hypomania. { Willessness (aboulia or paralysis of will) { often found in psychasthenia; and in depressive { states. { Morbid inhibition { as in depressive states. { Indecision { as in psychasthenia; { as in simple depression. { Obsessions { found pre-eminently in psychasthenia. { Tics Disorders / in many borderland cases; of < in the hypersensitive as often the only expression Will of any neuropathic tendency. { Distractibility { as in hypomania and frequently in hysteria. { Negativism { as in catatonia. { Mutism { as in catatonia. { Compulsive acts { as in psychasthenia, hysteria, etc. { Psychomotor overactivity (volition unable to check) { as in mania. { Psychomotor retardation (volition unable to energize) as in depression.

From this limited survey of the mind's disorders we realize that every departure from the normal mental attitude tends to associate itself with one of the following five states of mental disability.

Depression, Exaltation, Perversion, Enfeeblement, Deficiency.



CHAPTER IX

VARIATIONS FROM NORMAL MENTAL PROCESSES (Continued)

Hyperesthesia is abnormal sensitiveness to stimulation.

Anesthesia is loss, either temporary or permanent, of any of the senses.

Perversion is morbid alteration of function which may occur in emotional, intellectual, or volitional fields.

Example: The odor of a rose causing an acute sense of physical pain.

An illusion is a false interpretation of a perception.

The normal mind is quite subject to illusions, either due to a faulty sense organ, or to a preconceived state of mind which so strongly expects or presages something else than reality as to misinterpret what the senses bring.

Examples: The crooked stick as a snake. A ghost created from shadow. An ordinary ringing in the ears as sleigh-bells. Milk tasting like blood.

An hallucination is a perception without an object.

The hallucinated individual projects, as it were, the things of his mind's creation into the outer world, and accepts them as reality. He sees snakes where there is nothing to suggest them; sees a ghost where there is no shadow; believes that the taste of blood is constantly in his mouth.

There are possible hallucinations of every sense. Nonexistent objects are seen, touched, tasted, heard, or smelled.

Hypochondriasis is a state characterized by persistent ideas of non-existent physical disabilities.

The hypochondriac has every known symptom of indigestion, or of heart disease, or is threatened with tuberculosis—all in his mind; and whatever the disorder he seizes upon, his attention hovers there, while the ideas of that particular disability persist and strengthen.

A flight of ideas is an abnormal rapidity of the stream of thought.

Every perception so immediately is linked with some association of experience that expression is swift and often incoherent. One word will follow another with amazing rapidity, words suggested by sound association, usually, rather than by that of meaning.

Example: "Made a rhyme, had a dime, did a crime, got the time, bring some lime." This association by rhyme is quite common. But the associations of meaning are not uncommon.

Example: "Made a rhyme. Mary was a poet. Mary had a little lamb. Where's Mary?—Mary!—No Jim—Jim, all my children—calling, calling, calling," etc.

A fixed idea is one which morbidly stays in the mind and cannot be changed by reason.

Example: In hypochondriasis, as given above.

Ideogenous pains are either pains born of an erroneous idea, or mental reproductions of pains now having no physical cause.

A suggestible person, learning that his grandfather died of an organic heart, conceives the idea that he has inherited the trouble, and begins to suffer cardiac pains; and as long as the idea persists the pain is felt.

Compulsive ideas are ideas which intrude, recur, and persist despite reason and will.

Example: The compulsive idea of contamination may lead its victim to wash and rewash his hands at every contact with matter, until finally, though they are raw and sore, he is incapable of resisting the act.

Disorientation is a state of mental confusion as to time, place, or identity.

Amnesia is pathologic forgetfulness.

Example: As sometimes found in the infection-exhaustion psychoses, when the entire past of the patient may be wiped out for the time. Cases of permanent amnesia are known.

Aphasia is a defect in the interpretation or production of language.

There may be motor aphasia, auditory aphasia, vocal aphasia, sight aphasia; and with disability to produce words, they may yet be recognized when seen; or when they can be spoken they may not be recognized when heard; or with inability to speak them, they are accurately sensed by hearing; or though understood when heard, they are incomprehensible when read.

A delusion is a false belief which cannot be corrected by reason.

A somatic delusion is one centering upon alterations in the organs or their functions.

Example: Absence of a stomach, inability to swallow.

A nihilistic delusion is one which denies existence in whole or part.

Example: Mother denies the existence of her child.

A delusion of reference is one in which the deluded individual believes himself an object of written, spoken, or implied comment.

Example: The actors on the stage are directing their remarks directly against the victim in the box.

A shut-in personality is one that habitually responds inadequately to normal social appeal.

Sense of unreality is one of the commonest psychic alterations through which customary sensation states are displaced by unnatural and usually distressing ones.

Examples: The breakfast table appears undefinably altered. Laughter is accompanied by strange, rather than by normal, sensations.

Morbid inhibition is an abnormal, negative activity of the will.

Sometimes a patient will try pitifully to express some thought or feeling; the desire to explain is there, but will is blocked in action. Or the patient attempts to dress, makes repeated new beginnings, but cannot succeed. We say, "He is inhibited."

An obsession is an idea which morbidly dominates the mind, constantly suggesting irrational action.

Obsessed patients may consistently step in such a way as to avoid the juncture of the flagstones on the pavement; may insist on removing their shoes in church; may hail each person met on the street and tap him on the arm; may refuse to ever leave the house without an open umbrella; or may try to attack every man they see, not because they want to hurt or kill, but because they are obsessed to the performance of the action.

A tic is a useless, habitual spasm of a muscle imitating a once purposeful action.

Motor tics, such as habitual jerking of the arms, shrugging the shoulder, contorting the face, shaking or nodding the head, snapping the fingers, etc., are very common among nervous children, and even in many otherwise normal grown-ups.

Distractibility is an abnormal variation of attention.

The common inability of the hypomanic patient to hold his attention to any subject when another is open, is very like the distractibility of the child who turns to every new interest as it is presented.

Negativism is a state of persistent compulsion to contrary response to suggestion.

It is with these patients as though not only initiative were lost but also the power to follow another's lead. But their independence asserts itself in opposing every suggestion and in acting so far as possible contrary to it.

Mutism, as used in psychiatry, is an abnormal inhibition to speech.

Patients sometimes speak no word in many months. To all appearance they are true mutes. Then suddenly something may remove the mental blockade and they talk.

Compulsive acts are acts contrary to reason, which the will cannot prevent.

A seemingly quite normal patient will sometimes grab a vase from a stand in passing, and dash it to the floor. Something "urged" him to do it, and he could not resist. Others will tear their clothes to shreds, not in anger, but because they "could not help it."

Psychomotor overactivity is abnormal activity of both mind and body, contrary to reason and uncontrolled by will.

Psychomotor retardation is an underactivity of both mind and body in which consciousness is dulled and the body sluggish.

A neurosis is a disorder of the nerves, which may be functional or organic.

Nervousness is properly termed a psychoneurosis—for we have learned that there can be no neurosis without an accompanying psychosis.

Psychosis is the technical synonym for insanity.

Borderland disorders constitute a group in which mental perversions do not yet so dominate reactions as to make them irrational.

Twilight is neither night nor day; the feelings of the hysteric are not insane, but the actions may be.

Insanity is a prolonged departure from the individual's normal standard of thinking, feeling, and acting.

Mania is insane excitement.

Melancholia is the inability of the mind to react to any stimulus with other than gloom and depression.

Melancholia may be of the intellectual type or of the emotional type. The patient who tells you constantly that he has murdered all his children, that he is a criminal beyond the power of God to redeem, who seems chained to his delusions, yet shows no adequate feeling reaction, no genuine sorrow, we call a case of the intellectual type of melancholia. Another patient misinterprets every normal reason for happiness until it becomes a cause of settled foreboding. The mother, whose son fought safely through the war and is now returning to her, feels that his coming forecasts calamity for him. He had better have died in France. She is of the emotional type of melancholia.

Hysteria is a nervous disorder based upon suggestibility, and capable of imitating most known diseases.

Insane impulses are morbid demands for reckless action beyond the control of the will.

Example: The impulse to kill, quite regardless of who may be the victim.

Psychopathic personality is a term much used today to designate an hereditary tendency on the part of the individual to mental disorder.

The neuropath is the individual with an inborn tendency to the neurosis.

Neurotic is a term broadly employed for the nervous in whom emotions predominate over reason.

Neurasthenia is a nervous disorder characterized by undue fatiguability.

Psychasthenia is a nervous disorder characterized by a sense of unreality, weakness of will, self-accusation, and usually by phobias and obsessions, all subject to temporary correction by reason or influence from without.

Hypochondriasis is a disorder characterized by morbid attention to bodily sensations, and insistent ideas of bodily disorder.

Phobia is a morbid fear or dread.

FACTORS CAUSING VARIATIONS FROM NORMAL MENTAL PROCESSES

HEREDITY

When we consider the accumulated possibilities for disorder which the family tree of almost any one of us can show, the wonder is not that there are so many nervous or insane, but rather that any come within hailing distance of the normal. For multitudes are born of parents whose bodies were food poisoned or alcohol or drug poisoned, and whose nervous systems were tense and irritable, oversensitive, and suffering from the effect of these same toxins on the brain. Others are of manic-depressive parentage; some are possibly even of paranoic or dementia praecox lineage; while many of our finest and best had psychopathic or neuropathic heredity. Syphilis, itself, and the underpower bodies of tuberculosis are heritages of many.

When we realize, too, that we are born with certain inherent tendencies of temperament, which are too often of the melancholic or overcholeric type, our wonder grows that we are not doomed to defeat at birth. Were it not for the possibilities in the germ-plasm of choosing the much of good also in our heredity, often enough to overbalance the bad, and for the proved power of environment and training to modify or even altogether overcome the harmful parts of our birthright, there would be little hope for many.

ENVIRONMENT

While environment may prove the saving grace from poor heredity, it may itself add heavily to the debit side. With the very best of health backgrounds, environment may damage body and mind beyond repair. Under environment we include everything that touches life from without—people, things, work, play, home, school, social life, business life, college-life, etc. Among factors of environment damaging to mental health are overemotional family life, overstrict home discipline or the lack of needed discipline; overfeeding, underfeeding, wrong diet, lack of proper exercise, stimulants, drugs, overstimulation, overprotection, too much hardship and privation, loneliness, poor educational methods, immorality, etc.

PERSONAL REACTIONS

What will decide whether a human being can resist, successfully, bad tendencies in heredity, or in environment, or in both, and keep a reasonably balanced mind? It demands insight, ambition, will; and if these remain the body can be forced to saving ways of health, and body and mind can largely make their own environment. But with heavy handicaps of heredity or environment, or both, and poor insight, or lack of desire, or weak will, nothing can save the mind from neurotic taint or worse—nothing but obedience to some one strong enough to control the habits of that life, until self-control is born. And there is a hope that it can be born in the most neurotic or neurasthenic, so long as the mind is sane.

But after all, a large number of people whose mental processes are not normal, have only themselves, their poor emotions, their lazy wills, their hazy thinking to blame. We except what are called the heredity insanities—dementia praecox and the other dementias and the manic-depressive groups and paranoia and psychasthenia—for in these cases, possibly with the exception of the manic depressives, even the most perfect environment could probably not prevent the disorder from asserting itself. Many neurotics, neurasthenics, and hysterics are curable if they will seriously undertake to fulfil the laws of physical and mental health—simple laws, but ones which demand a strengthened will to carry out.



CHAPTER X

ATTENTION THE ROOT OF DISEASE OR HEALTH ATTITUDE

THE ATTENTION OF INTEREST

Attention naturally follows interest. It can, however, be held by will to the unappealing, with the usual result of transforming it into a thing of interest.

One of the laws of the mind we have already stressed is that what we attend to largely determines what we are, or shall be. The interests which secure our consideration may be the passive result of emotional life, the things which naturally appeal, which give us sensations that the mind normally heeds; or they may be the active result of our will which has forced application upon the things which reason advised as worth acquiring.

We found that the beginning of health of mind consists in the directing of thought toward the health-bringing attitude. We have seen how quickly the normal mind can be diverted from the undesirable by a new or stronger emotional stimulus. We found that the sole appeal to attention in the baby-life is through the emotions, and that it is natural throughout life for the mind to heed and follow the interesting; which is only another way of saying that thinking follows where emotion leads, unless volition steps in to prevent. The supreme test of the will's power is its ability to hold the train of thought in the line that reason directs, when feeling would draw it elsewhere. This ability marks the man who does big things; while the inability to ever turn attention away from the interests proposed by feeling assures weakness.

Some of the most charming people we shall ever know are those temperamental children of happiness whose interests are naturally wholesome and externalized, whose natures are spontaneous and joyous, and who live as they feel, seemingly never knowing the stress of forced concentration. With them attention follows feeling, feeling is sweet and true, and volition simply carries out what feeling dictates. And life may not be complicated.

But there is another class whose attention also follows in the ways of least resistance; and life for them is a wallowing in the morbid and unwholesome. In them feeling is perverted, they seem to see life habitually through dark glasses; they passively attend to the sad, the distressing, sometimes the gruesome and the horrible with a sort of pallid joy in their own discolored images. The first group puts joy in all they see, because they are brimming full of joy themselves. These others find only the unwholesome in life because their minds are storehouses of it. We say that each type has projected himself, that is, has thrust himself out into the external world, and is standing back, looking at his own nature and calling that the universe.

But neither of these two groups can long withstand the stress of a world they only feel and have never attempted to comprehend. The irresponsibly happy ones are too often crushed and broken when life proves to bring loss and failure and disappointment; the morbid probably will cease some day to enjoy their melancholic moods, and be unable to find their way out of them. If both had learned to control attention, they might have been saved. The happy, care-free child of the light is at desperate loss when the sun he loves is obscured, if he has not learned to look upon the far side of the clouds to find that there they glow golden with the rays temporarily shut from him. Because clouds were not interesting to him he never attended to them—and now he cannot. If the pessimistic, morbid one had looked away from the shadow to the sun it hid he, too, in the end might have seen with sane eyes and lived so wholesomely as to find all the good there was in life. Willed attention, rather than spineless feeling distractibility, might have saved him.

When thinking can be forced to follow where trained reason directs, and can be kept in that direction, the greatest problem of physical and nervous well being is solved. To the nurse there is no other principle of psychology so important. But no child ever had his attention diverted by reasoning alone. The object at which you wish him to look must be made more impelling than the one he already sees, or he must want much to please you, else he only with his eyes will follow your command while his mind returns to his real interest; and the second you cease to command that eye service, he looks back to the thing that was holding him before. The beginning of all education is in arousing a want to know; in turning desire in the direction of knowledge.

I am an undisciplined child and I want only candy for my lunch. It is not good for me. Milk is what I should have. I don't want it. You may deprive me of the candy and force me to drink the milk, and I can do nothing but submit. But I rebel within, and I am only more convinced that I "hate" it and want candy, and that you are my natural enemy because you force the one upon me and deprive me of the other. If I were insane and so, of course, could not be reasoned with, this might be inevitable. But it would be unfortunate. In that case, if possible, do not let me see the candy; let only the food it is best for me to have be put before me, and perhaps eventually I shall come to want the more wholesome thing—for it is better than the hunger.

But as it happens I am a perfectly normal person, only I am sick. I am tired of bed, and want to sit up—and it does seem that I should have my desire. The nurse, wise in her knowledge of sick "grown-ups," who are, after all, very like children, will find a way to divert my mind from the immediate "I want" to something which I also can be led to want. I may agree that I want more the better feeling an hour from now. Perhaps her humorous picture of the effects of too early freedom on my condition, or of my body's urgent demand for rest, regardless of my mind's wish; perhaps only a joke which diverts me; perchance the "take-for-granted you want to help us out" air; mayhap the story to be read or told; or simply the poise and quiet assurance of the nurse who never questions my reasonableness and acquiescence; perhaps her confidence that this will serve as a means to the end I covet—will result in my gladly taking her advice, and my perfect willingness to wait for new orders, while I indulge in beautiful plans I shall carry out when they finally arrive.

In other words, with the sick as with children, attention naturally follows interest. And the good nurse realizes that it is not wise to force co-operation when she can secure it by diverting her patient's thoughts to another interest than the one now holding him. Very often, merely by chatting quietly about something she has learned has an appeal, she can make the patient forget his weariness and boredom, or his resistance to details of treatment. The very milk he is refusing to drink may be down before he realizes it. But right here lies a hidden reef which may cause wreckage in the future. It is good therapy to divert attention by appealing to another interest when the patient is too sick or too stubborn or not clear enough mentally to be reasoned with. But if this becomes a principle, and his reason and active co-operation are never secured to make him choose the way of health for himself, the hour he is out of the nurse's hands he reverts to the things that now happen to appeal to him. Then unless some wise friend is near to continue her method of making the reasonable interesting, the advice of reason can "go to smash."

There has been a very constant illustration throughout the past of the unwisdom of relying upon diverted attention alone as an effective therapeutic agent. We hope this will not illustrate our point so clearly in the future. The drunkard, who is just recovering from a big spree, and feels sick and disgusted with himself, and sore and ashamed, is appealed to in glowing terms of the wellness and strength and buoyancy of the man who never drinks. He has no "mornings after." The Lord is just waiting to save this dejected victim of alcohol from his hateful enemy who has made him what he is at this hour, and will forgive all his sottishness, his sins. He will be respected; he can command the love of his family again. He will no longer be a slave, but a free man. Right now, respect of the world and love of family and friends, and cleanness, and the forgiveness of a good God are infinitely more interesting than this splitting headache, this horrible sick feeling. And attention may be very readily diverted. This promised new life is more attractive than the present. It is easy to keep attention there. And he reforms. He swears off "for keeps." He is a happy man, a free man. For a few days or weeks, perhaps even longer, he glories in his new self-respect. It is a strange and enticing sensation. Then one day something goes wrong. He loses some money, or he is awfully tired, or the wife and children bore him, and all of a sudden the one greatest interest in the world is a drink. And because his thinking can always be led by his feeling; because he has never learned to force it to go elsewhere, he has his drink. Appealing to his emotions did not and cannot save him unless that appeal is followed at the right moment by awakened reason, which will look at the whole proposition when the mind is at its normal best, and choose to follow where rational feeling directs. Nor will reason save unless volition comes to its support and strongly backs it up and enforces what it advises.

THE ATTENTION OF REASON AND WILL

So the good nurse will not consider her work done when she has diverted mental processes into channels of co-operation. When the patient, who is capable of reasoning, knows the why of his treatment, and realizes that he can only keep well as he himself takes over the job and puts his mind on things outside of his feelings, and carries out the doctor's instructions for the sake of securing a certain end—then he has been under a good nurse. This wise helper never "preaches," but makes the healthy goal very desirable, stirs up an ambition to attain it, and prods the will to keep on after it despite anything feeling may say.

This attitude on the part of the nurse presupposes that her own attention, while with her patient, is upon him and upon securing his health, and not upon her tiredness, or boredom, or headache, or the party tonight, or the man who has asked her to go to the theater with him tomorrow. She, surely, must learn to direct her thoughts where reason suggests, and to gain new interests through willed attention, or as a nurse she is less than second rate. Nor can she get the best results until she can turn with a single mind to the patient at hand as the immediate problem to be solved. And probably neither nurse nor doctor does any better service, except in saving life itself, than in keeping the patient from thinking constantly of himself and his ills. For it seems of little use to have made some people physically well, if they are to carry through prolonged years the curse of constant self-attention, self-centeredness, an ingrowing ego.

There are a few simple laws of the mind hinging upon attention which are today being impressed upon teachers in every department, in kindergarten, public school, college, and university. And they are as necessary to the nurse as to the teacher. Three of them we have already discussed:

1. Attention naturally follows interest.

2. Attention may be held by will where reason directs.

3. New interests grow out of willed attention.

A fourth we shall stress before considering the use the nurse can make of them:

4. The thing to which our chief attention is given becomes the most important thing.

Do not contradict this too quickly. Don't say that nursing gets your chief consideration because it is, of necessity, your profession; but that you love your music infinitely more, and look forward to that through all your hours on duty. If this merely proves that music is distracting your attention, you are doing your nursing as a means, and not as an end; you give it probably all the attention necessary for good work, but your real desire is music. Your chief attention is directed toward that goal. Hence music is to you the most important thing. If your will is sufficiently trained to keep you from consciously thinking of it, still you are dreaming of it and working for it. You may make a very good nurse, but you will never be as excellent a one as the woman from whom nursing demands first and chief attention.

We sometimes speak of one woman as a born nurse, and say of another, "She's a good nurse, thoroughly conscientious, but not a natural one like Miss X." It only means that Miss X's main purpose in life has always been caring for the sick, while Miss Y's secondary concern is that. There is a third, however, who may be sidetracked into nursing, but whose chiefest interest and attention in life has not been so much a certain profession or accomplishment, but a passion for people, with an ability to enter into their lives understandingly. She may not care for nursing in itself. It is only accidental that her thoughts were turned to it. But her liking for people makes it easier for her to concentrate attention on the details of nursing, as thereby she is fulfilling her life's ambition in studying and serving human beings. She may be a real success if she can only convince herself that this is her forte. If not, and she dreams of other fields of service, her concentration on the thing at hand is not perfect enough for her to compete successfully with the "born nurse."

Whatever it is, the thing that gets our chief attention is the most important to us. It may be lack of appetite, or pain in the side, indigestion, general disability, discomfort, the mistreatment we once received, the mistake we once made, or the sin we committed—whatever it is that holds our attention, it is the most absorbing and interesting thing in the universe, though it may be an utterly morbid interest, an unhappy attention. But it blots out for the time the rest of the world. A big hint for the nurse exists therein. Let her try in every lawful way to divert her patient's attention from the disease-breeding stimuli toward the happy and wholesome ones.

For the nurse herself in the care of patients let us draw some conclusions from these laws of the mind's working:

1. Have a goal in view for the patient's health of both body and mind.

2. Work toward instilling in your patient a health ambition—a pride in health.

3. Remember that overcrowding the mind defeats your purpose of making one clear impression.

4. Win interest by any legitimate means to the next step toward the goal, and only the next.

5. Work for attention to hopeful, courageous, and happy things.

Let us as nurses remember always that it is for the patient's sake and not for our own that certain results must be obtained. Our work is usually in helping the doctor to get the best possibilities out of the material at hand, and we cannot hope to change the fabric. But we can help to repair it; we can sometimes influence the color and suggest some details of the pattern, or assist in the "making over" process; and when the fabric is substantial and beautiful we may assist in preventing its marring. So we may help to evolve a body-health and mind-health attitude from what seemed the wreckage of a disease-accepting mind; or we may have the great privilege of warding off the disease-accepting attitude. But always, in all our care of patients, let us not neglect or fail to use wisely this central fact of psychology; that anything that gains attention, even for a moment, leaves its impress on the mind; that the direction of attention determines our general reaction to life.



CHAPTER XI

GETTING THE PATIENT'S POINT OF VIEW

WHAT DETERMINES THE POINT OF VIEW

The point of view of any individual depends upon temperament, present conditions—mental and physical—and the aim of the life. That is, it depends upon his inherited tendencies plus a unique personal something, plus all the facts of his environment and experience, plus what he lives for.

Richard and Jim both live in Philadelphia, Richard on Walnut Street and Jim on Sansom Street. Richard's father is of the best Quaker stock, with hundreds of years of gentle and aristocratic ancestry behind him. He followed his father and his grandfather into the profession of medicine, and is a well-known specialist, alert, keen, expert, and deservedly honored. He is at home in Greek and Latin, French, and the sciences. He selects at a glance only the conservative best in art and music and literature. His world is a gentleman's world, a scholar's world, and the world of a scientist and a humanitarian. And Richard, his son, is true to type.

Jim's father is the ash man. His world is in the alleys and basements. His pastime, cheap movies, and the park on Sundays. When he is not working he is too "dead tired" for anything heavier than the Sunday Supplement or perhaps the socialist club-rooms, where he talks about the down-trodden working man and learns to hate the "idle" rich. He spends his money on food and cheap shows and showy clothes. He talks loudly, eats ravenously, works hard, is honest, and wants something better for his children than he and the "old woman" have had. His music is the street-organ, the movie piano, and the band—some of it excellent too—but none of your dreamy stuff—good and lively. And his son, Jim, is true to type.

After the Armistice Jim and Richard, who have fought for months side by side, go to Paris together. Richard may "have a fling" at Jim's amusements for the sake of playing the game and "seeing how the other half lives" and all that—but before long we shall find him in the high-class theaters and restaurants, visiting the wonderful art collections and libraries, riding in luxurious automobiles, and staying in the best hotels he can find. And even though Jim may have saved Richard's life and Richard is eternally grateful, and loves Jim as a "dandy good scout," their ways will inevitably drift apart when the one big common interest of fighting together for a free world is over. They will always remember each other. Jim will decide that a "highbrow" can be a real man, and Richard will ever after have a fellow-feeling for the "other half" and think of them now as "folks." But Jim is not at home in Richard's neighborhood and circle; and Richard is a fish out of water in Jim's. The point of view of each has been largely determined by his heredity and his environment.

But suppose Jim isn't true to type. From the time he was a mere youngster the ash-man life did not appeal to him. In school he liked the highbrow crowd; he "took to" Latin and literature. He has a feeling of vague disgust when he sees a vulgar picture, a shudder when the street-organ grinds. There is something in Jim different. He isn't in tune with either his immediate heredity or his environment. The contribution from some remote ancestor has overbalanced the rest, and Jim becomes a professional man.

Or perhaps Richard breaks his father's heart. Instead of following the trail already made, he cuts loose, frequents vulgar resorts, hates his school work, becomes a loafer and a bum—and, finally, a second-rate day laborer. Again, what he is himself, his "vital spark" has been stronger than immediate heredity and environment, and has broken through.

GETTING THE OTHER MAN'S POINT OF VIEW

Our points of view are very frequently merely hereditary or acquired prejudices, hence altogether emotional rather than rational. We only with great difficulty see things through another man's eyes. It necessitates comprehending his background fully, and standing exactly where he stands, so mind and eyes can both look out from the same conditions that confront him. And this is only possible for the man or woman possessed of a vicarious imagination. Such an imagination, however, can be cultivated.

You hate my father. He injured yours—unjustly, to your mind, of course, for yours can do no wrong. From my point of view this father of mine is a great, good man. From your point of view he is wicked and cruel. We are both honest in our emotion-directed opinions. Until you can know my father as I know him, and I can know yours as you know him, we shall never agree about them. But I can learn to understand why you feel as you do, and you can learn to understand why I feel as I do. I can put myself, in imagination, in your place, and see that other man as my father, and pretty well grasp your point of view, and you can likewise get mine.

After all, the law is very simple. Each man is the result of the things he puts his attention chiefly upon; and he puts it naturally upon the things which his forebears and his surroundings have held before him. The rare person and the trained person can assert the "vital spark" of his own personality and tear attention away from the easy direction and force, and hold it somewhere else. So he can change his points of view by learning that there are other vantage grounds which direct to better results. With some one else to lead the way and give a bit of help, or with the urge of desire to understand the new viewpoint, or by the drive of his will, he can change his own.

Let us not forget that what we see depends on whether or not our eyes are normal, on where we look, or on what kind of spectacles we wear. Two things we can change—where we look, and the spectacles. If our eyes were made wrong we probably cannot change that, but we can often correct poor vision by right artificial lenses. There are people doomed to live in most unattractive, crowded surroundings who make a flower-garden of charm and sweetness there, or, without grounds, keep a window-box of fragrance. The normal person can pretty largely either make the most impossible environment serve his ends or get into a better one. So we can usually look to something constructive, helpful, attractive, or beautiful; and we can refuse to wear blue spectacles.

We nurses soon realize that there are just about as many points of view as there are people, and that if we would help cure attitudes as well as bodies, and so lessen the tendency to sickness, it behooves us to learn to see what the other man sees through his eyes or by the use of his glasses, from where he stands.

Let us try just a few experiments. Hold your pain and suffering from your appendix operation, and disappointment because you can't be bridesmaid at your chum's wedding, up close to your eyes, and you cannot see anything else. They crowd the whole field of vision. Look at the world from the eyes of a spoiled woman of wealth who for twenty years has had husband, friends, and servants obedient to her every whim. She has grown selfish and demanding. What she has asked for, hitherto, has been immediately forthcoming. Now she is ill, and she naturally considers the doctors and nurses mere agents to secure her relief from discomfort. She is willing to pay any price for that—and still she is allowed to suffer. From her point of view it is utterly unreasonable, inexcusable. What are hospitals and nurses for, anyway? And she is carping, critical, and disagreeable. Her attitude is as sick as her body. How could it be otherwise?

Look about you from an aching mind and body, after days of suffering and sleeplessness, and unless you are a rare person and have a soul that sees the sunshine back of everything—you will find the world a place of torture. Look out from despair and loss of the ones you love best, or from failure of will to meet disaster, and everybody may be involved in bringing about your suffering, or in effecting your disgrace.

Look out on the world from the eyes of the immigrant who has lost all his illusions of the land where dollars grow on the street and where everyone has an equal chance to be president, and if you do not cringe in abject humility, you are not unlikely to be insufferably self-asserting, considering that the world has robbed you and that now it is your turn to get all that is coming to you. So you make loud demands in a rude, ordering voice. The nurse is there to wait upon you—and finally you will have your innings.

Look out from the resentful eyes and smarting mind of the negro who is just beginning in a northern city to realize that his boasted "equality" is a farce, and you will try to prove to the white nurse that you are as good as anybody. You are impossible; but back of all your bravado and swagger and rudeness and complaint of neglect because of your color, you realize that you cannot measure up. You know you belong to a different race, most of whose members are daily giving evidences of inferiority; and you are sure that the nurse is thinking that.

Look from the eyes of the "new rich," or the very economical, and you are going to get your money's worth out of your nurses.

The nurse who can get back of her patient's forehead and put her mind there and let it work from the patient's point of view, will learn a saving sense of humor, will be strict without antagonizing, will clear away a lot of mental clouds and help to make permanent the cure the treatment brings.

One can often judge very truly a patient's real character by his reaction to his sickness. On the other hand, frequently it only indicates that he has not yet properly adapted himself to a new experience and a trying one. We hear so often, "Why, she's a different person these days, since she's feeling better. It's a joy to do things for her." She was the same person a while back, but had not learned to accept discomfort. Any of the following list of adjectives we hear applied to our patient again and again by the nurses:

unreasonable stubborn lazy deluded cranky resistive unco-operative will-less hipped obsessed hypocritical of mean disposition excitable fearful exacting dissatisfied undecided wilful self-centered morbid doubtful demanding retarded abusive depressed spineless self-satisfied

Unpleasant terms they are, and condemning ones if accepted as final. When the nurse realizes that under the same conditions she would probably merit them herself, she becomes more anxious to remove the conditions, and less bent upon blame.

We must admit that the highest type person, when sick of any physical illness, does not deserve such descriptive terms as these. But they are the rare folks, few and far between; while the great mass of us have not acquired more than enough self-control and thoughtfulness for the ordinary routine of life. We are weakly upset by the unexpected. If it is a pleasant unexpected, we are plus in our enthusiasm, and people applaud; if the unpleasant unexpected, we fall short, and people deplore our weakness. If we learn our lesson of self-control and adaptability, and gain in beauty of character through experience, it has served a purpose. But the nurse deals with the average of human nature, and she finds their reaction faulty. Very often, if she is observant, she will discover that a patient responds in a very different way to some other nurse, who somehow finds that "trying" sick woman charming or thoughtful, likable or sweet. Of course, it may be because the other nurse weakens discipline and caters to the patient's whims; but it is just as likely to be because she has tempered her care and her strictness with understanding. She has grasped the patient's point of view; and with that start, the chances are 50 per cent. more in favor of the patient grasping and acceding to the wise nurse's point of view.

Shall we not remember that our trying, cranky, stubborn patient is a sick person, and learn to treat that stubbornness or crankiness as a symptom indicating her need, just as we would a rising temperature?

When we can meet her attitude with comprehension, and, if necessary, with quietly firm disregard, then we are beginning to be good nurses.

Some of the most common of these sick reactions with which the nurse must deal are enhanced suggestibility, repression, oversensitiveness, stubbornness, fear, depression, and irritability. And each one demands a different method of approach if real help is to be given.

Old Isaac Walton wrote a book many, many years ago called "The Complete Angler." He was a famous amateur fisherman, and he says there are only three rules to be observed and they will bring sure success:

1. Study your fish. 2. Study your fish. 3. Study your fish.

If the angler follows these directions, he is not apt to offer the wrong bait. When he knows all their little peculiarities, he will know how to catch his fish. The "complete angler" has an unlimited patience and an infinite sense of repose and calm. He never hurries the fish, lest they become suspicious of his bait. And he proves that these three rules work.

The nurse who accepts every patient as like every other, and treats him accordingly, will never be a great success. The nurse who "studies her fish" and learns their psychology, will be a therapeutic force. She will know the why of the way that patient acts.

THE DELUDED PATIENT

If the patient's mind is temporarily clouded through infection or suffering, he may be reacting to a delusion, an obsession, a fixed idea of disability, a terrifying fear. Sometimes he persistently refuses food, and gives no reason for it. The unthinking nurse is tried, puzzled, and irritated. In other ways, perhaps, the patient seems quite normal. But, after all, the explanation is very simple. He probably is as confident that the food is poisoned as you are that it is as it should be. No arguing would convince him, for, to his mind, the nurse is either a complete dupe or an agent of the people whom he knows are plotting his death. And urging him only strengthens his conviction.

The writer recalls one such case of a patient who had to be tube fed through many months, though a tray was set before her three times a day—and as regularly refused. Then one day she was seen slipping food from off another patient's tray and eating it greedily, not knowing she was observed. When questioned, though she had never before given a reason for refusing food served to her, she said that "they" had nothing against Mrs. B., so wouldn't try to poison her. Her reasoning was excellent when one accepted her premises. She had bitter enemies. They were not enemies of Mrs. B. and would not harm Mrs. B. Therefore she dare not touch her own food, but could eat Mrs. B.'s if no one knew.

These deluded patients live in a world we often do not sense, a world whose reality we do not appreciate. The nurse, after much experience, finds that there is a key to every resistance, to every lack of co-operation, to abnormal attitudes and actions. She realizes that a powerful emotion of desire or fear, of love or hate, of ambition or self-depreciation, of hope or despair, of faith or distrust, unchecked by reason or judgment through the years, has provided a soil upon which emotional thinking alone can grow. The patient is a mere puppet of the suggestions of emotions which may not be at all pertinent to the facts.

NURSING THE DELUDED PATIENT

The nurse soon realizes the uselessness of attempting to argue a patient out of his delusions, of trying to convince him that the things he sees and hears and perhaps tastes and feels, are but hallucinations. Her very insistence only fastens his attention more firmly upon the false conclusion or makes him more convinced that his mind is giving him a true report from the senses of sight and hearing and taste and feeling. But often a quiet disregard of the delusions while the nurse goes on her way and holds her patient to his routine, consistently and confidently, as she would in case they were not true, will eventually cause him to question their reality just because no calamity results. The nurse acts as if these delusions and hallucinations were non-existent in reality, and when the occasion arises, through the patient's questioning, she urges him to exert his will to act also as if they were not true; to try it and see what happens. Arguing, also, she finds, usually antagonizes or makes the patient stubborn. He cannot prove by her logic his point, but he "knows" from inner experience that he sees what he sees, hears what he hears, and knows what he knows. The fact that the nurse does not is merely annoying evidence that she is blind, deaf, or stupid to these things of his reality. He knows he is lost and damned, or tainted; that he is King George, Caesar, or the Lord, as the case may be; or that his internal organs are all wrong. He "feels" it and the nurse can't—therefore, he alone has true knowledge of it. In the end, the wise nurse who never disputes with him, but leads him on to action which utterly disregards these things, may bring about a gradual conviction in the patient's mind that a man couldn't do what he does if all these things were true; and the delusion slowly may lose its force or the hallucination fade away. Many patients drop them from their lives entirely. Many others in whom dementia is not indicated, or in whose cases it is indefinitely delayed, can come to an intellectual realization that all these things are fantasies, and do not represent reality; that despite their continued, frequent, or occasional demands upon feeling life, they can be consistently ignored. These psychopathic individuals may act as they would if the delusions never came henceforth to their consciousness, and so be enabled to live a comparatively normal life.

THE OBSESSED PATIENT

A patient who is suffering from obsessions must carry out certain abnormal actions, or be wretched. She cannot do otherwise. It is as though she were forced by some outside agent, though the forcing is actually from within. When the nurse realizes this, and the more essential fact—that many patients, who have not true obsessions, yet have a tendency toward obsessed ways of thinking and doing—when she comprehends it almost as she would if she were the victim, then she is ready to help the patient by gently making the action impossible, and at the same time diverting attention.