Chapter XII: Part II: The Practical Work of Psychotherapy (5)

A physician had acquired the habit of using and misusing cocaine
for the treatment of a disease of his nose. The habit grew to a
craving for cocaine while the cocaine itself poisoned the brain.
Acoustical hallucinations began; he heard voices from every corner
of the room, and on the street the voices took persecutory
character. He connected them with his brother living in Europe,
heard his voice in the denunciations, and developed a pathological
system of ideas around the central thought that his brother had a
telepathic influence on him. His reason succumbed, he lost all
consciousness of delusion, and believed himself really to be under
the control of the absent brother. When he came to me he had been
without sleep and without food for several days, and he was not
seeking my help to get rid of the mental disturbance but to
overcome the power of his older brother. He did not connect the
fear at all with his misuse of cocaine. When I discovered the role
which the cocaine played, I determined to try the suggestive
influence, the more as I found that he was in a half-hypnotic state
as soon as he had entered my room. I suggested to him to sleep and
to take food and to reduce the cocaine dose by a fourth. The next
day he was an entirely different man by the effect of ten hours'
sleep and a large breakfast. Now I concentrated my efforts on the
reduction of the cocaine. After ten days of hypnotic treatment he
gave up cocaine entirely, after three weeks the voices disappeared
and slowly the other symptoms faded away. The pathological idea of
the telepathic influence lasted a while after the voices had gone
until this idea, too, yielded to suggestion. It still took six
weeks before he himself felt that he was entirely normal.

The way in which the average physician nowadays neglects the simple tool of suggestive treatment, when it can be used for the protection of society, is perhaps nowhere so reckless as in the case of the morphinist and cocainist. To give a typical case of this neglect I may mention that of a highly intelligent young man who had been in the habit of using both cocaine and morphine for ten years when at his own request he was sent to a New York hospital. He had been taking alternately morphine for a year or two, then cocaine for a year or two, and had sometimes alternated and sometimes combined both in an irregular way. When he entered the hospital in May, 1908, he was in a cocaine period and was taking the enormous dose of one hundred and eighty grains of cocaine every day. In the hospital they withdrew the drug altogether. During the first weeks, he was entirely sleepless. They energetically refused him any substitutes and after six weeks he began to feel comfortable. He gained steadily in weight and after three months, when he left, he had gained fifty pounds, felt entirely comfortable, and seemed in all respects normal again. Before twelve hours had passed after leaving the hospital, he had again taken thirty grains of cocaine and ten grains of morphine, and this dose rapidly grew until after a few weeks it again reached a hundred grains of cocaine and up to sixty grains of morphine a day. Then came the complete breakdown. If that man in the last two or three weeks of the hospital treatment, when he felt entirely comfortable and normal and had gained his normal weight, had received even a slight suggestive treatment suppressing any desire for cocaine or morphine, he would easily have been saved. To let such a man after a drug career of ten years go out again to the places of his old associations, where the desire had to be stirred up, is inexcusable at a time when psychotherapeutics has won its triumphs in this field. It might have been sufficient to give him preventive treatment at least for the first three days of his freedom. And such a case is typical of hundreds.

The overstrong impulse and overstrong desire finds its counterpart in the abnormal lack of energy and lack of attention. The patient--and it is especially the neurasthenic patient--has lost his usual strength, he shrinks from every undertaking, he cannot decide upon any action, he needs a disproportionate effort for the smallest task, and cannot concentrate his attention in spite of his best will. The varieties of this lack of power and inertia are familiar to every physician. They certainly often need much more than merely psychotherapeutic treatment, although on the physical side no schematic method is admissible. The laziness of the anaemic needs a different treatment from the laziness of the exhausted but in every case psychological factors can be of decisive influence, whatever the physical and chemical treatment besides them may be. A few letters may again illustrate the varieties. Here again there is no sharp demarcation line between the normal and the abnormal. Letters like the two following, for instance, are hardly letters of patients. They show a variation which is still entirely within normal limits and yet a source of suffering; it is a disturbance which usually can be removed by psychotherapeutic means.

"I do almost everything with effort, nothing spontaneously. I have
been writing for five years but am a mood writer of the worst type.
The mood comes at such uncertain times that I seem to be absolutely
at the mercy of caprice. This might not in itself be a misfortune
but writing is my only calling and I suffer the proverbial torments
of lost spirits when I am idle. The necessity of driving myself to
every piece of work, aggravated by the fact that my parents allowed
my constitutional inertness to have full play, has hitherto
prevented me from forming any regular habit of labor. I am now
thirty-eight. Would you suppose that if I kept my nose to the
grindstone for one, two or three years, I might yet hope to work
with some ease and regularity? That is, if I compelled myself to
write a certain number of hours every day as a discipline,
regardless of the quality of matter I produce, is there any
probability that I might ultimately overcome the fearful paralysis
that so often grips my faculties? Can constitutional indolence be
overcome by determination? I put in a little time on a couch every
day. When worried I get neurasthenia and all kinds of phobias. Just
now I am afraid to look at the newspapers on account of the cholera
in St. Petersburg, and I have seen the time when I found it
difficult to drink water after I had boiled it myself."

Also the next man is familiar to all of us.

"Plainly we are told every man is born into the world to fill some
purpose, or at least be of some benefit to himself or his
fellowmen. For some reason I do not make friends among men. I have
not the zeal or ambition to carry or even begin a conversation
that will interest the individual man. I worry a great deal. I have
never been able to concentrate my mind to study and figure out
problems. I can read them zealously but apparently do not get to
the bottom and cannot retain what I do read. If I could just get
hold of the power of thinking and dig out that tangible something
that holds me back, I could go forward and make myself what I know
I should be. But I feel that so far I am a total failure. If I only
had that one great gift, the power of concentration and will power,
I would make what I so much desire, a success of myself."

A similar effect and yet psychologically a different condition exists where the lack of energy results from the suggestive power of the opposite, producing a constant indecision.

"I am thirty years old and nearly all my life since childhood I
have been fearfully troubled with the habit of indecision and
regretting whatever I do. It has grown into a habit so fixed that
at times I am fearful of losing my mind. I feel anxious to do
something and decide to do it, then as soon as it is done, I nearly
go wild with regrets until I have to undo it, if possible, and then
only to regret that. I am this way about the most trifling things
and about the most serious. I can't perform any duty well. In
business and in social affairs, it is always with me. It has me in
its clutches, a horrible monster dragging me down. My friends
misinterpret me and wonder what I mean by doing so when all the
time I want to do what is for the best and cannot for this tyrant
who is ever present with me. I will plod for hours and hours at a
time, and at every turn I am handicapped. I am intelligent
naturally and appear a perfect fool."

From the report of such chronic cases we may turn to the acute ones. Here a characteristic letter of, a typical neurasthenic young modern poet.

"These are my plans but I hardly think that I can carry them
through, although perhaps you can help me by suggestion. I have the
feeling that through the whole of last year my development did not
go forward but backward. It is as if by a mental or physical
overstrain, my whole personality has entered into a transition. I
have no joy in life, no sensation in love, no satisfaction in
labor. My will has become weak where it was strong. I am lazy, up
to an absolute dislike of everything, while I have been energy
itself. Often I have only the one desire, to end my life from mere
fatigue. If there had been any external reason for ending my life,
I should perhaps have done it long ago. I am so apathetic that I no
longer take myself seriously. My successes do not please me; the
idea of writing anything gives me anxiety. I have become less
resisting, more sweet, more soft, I should almost like to say, more
feminine. I became infatuated with a girl, simply because I knew
that she hates all men. The inaccessible is still the only thing
which can stimulate me somewhat. I have even written a poem on her,
but nothing can satisfy me in love. I consider my state a disease
of the will as a result of nervous exhaustion. I must find some one
who, with kindly power, reenforces my will system. I need a strong
mind--it may be a man or a woman. It would even be possible in the
latter case that I might marry her.

"Even the writing of this letter has fatigued me so much that I
should like best to sleep. In moments like the present I should
like best to throw myself down on the street or ... quickly ...
sink ... into the ocean. (I regret having made the little points.
They look as if my expressions are a pose.) Yet there are moods in
which I am entirely normal and no one fancies what I am passing
through. I have even become superstitious lately. Are there perhaps
beings which can absorb our energy? Perhaps another being has drunk
up my energy."

Authors run easily into such states. Here is another.

"I am a neurasthenic, and I am beginning to believe, a professional
one. My object in writing is to ask concerning the advisability of
my visiting you for treatment. I am ready to take the next train if
you say the word, if you believe you can help me. It seems that the
regular practitioner, who is very irregular, cannot. If there is
one good doctor I have not consulted, I would like to know his
name. I was doing editorial work in X and broke down. Still the
doctor said that if I liked my work, I should go back to it and
pitch in. I did. It lasted a few days and then I had to give up
altogether, couldn't grind out another word. Then to another
doctor----also the best in the city. He told me to give up all
work, which I did, and then I went on a farm for six months. That
did not help me either. Later I went west and spent some time in
the mountains. I felt no better there. Then I went to Arizona and
lived in a tent out on the desert; that did not help me. There was
always a sensation of exhaustion and any physical exertion put me
on my back, even when it was light and pleasant exercise. Then I
went to California; it did me little good. It is a perfect paradise
for anyone who has not got neurasthenia. I still have not got
myself in hand. I cannot do or say or write just what I wish, and
cannot concentrate my thoughts. To try to read a book is punishment
because I forget as fast as I read." And so on.

I answered him certainly not to come but tried to induce some
autosuggestions. A few weeks later, he wrote me: "Ever since you
wrote me, I am now feeling somewhat improved." Yet I cannot judge
how far the improvement belonged to the psychical factor only,
inasmuch as I had advised him also to take some bromides. The
really effective treatment would have been heterosuggestion and I
had no time to enter into the case.

Where direct suggestion is used, the effect is often surprising.

A young lawyer after a period of overwork had come to a state of
complete lack of energy. He could not find strength to write a
letter and he came to me at a day when he did not see any way but
suicide open for himself. He complained that, as soon as he began
to grasp a thought, it was evaporating. He stared absently about
the room and felt sure that he would never again achieve anything.
He had not even the energy to read the newspaper. I hypnotized him
three times, each time waking in him the pleasure in a definite
piece of work, at first simply in a novel which he was to read,
then in some letters which he was to write, and then in his
professional work. There was always an interval of three days. The
fourth time he declared himself that the hypnotic influence was
unnecessary, as he felt that he was again in the midst of his work.

As a rule the effect is a much slower one, but if all personal factors are well considered and especially physical disturbances are excluded, the result is usually satisfactory.

Very different from such neurasthenics, of course, is the lack of attention in the feeble-minded, and suggestion of the ordinary type is hardly advisable, but it is surprising how much can be reached by a systematic psychical regime. I give one typical instance, representative of many.

A boy of twelve years when he was brought to me showed the mental
powers of a stupid child of four. In a silly way he repeated every
question which he heard without answering it; he talked steadily to
himself in a nonsensical manner, mostly repeating nursery rhymes
without end, never holding his attention to anything in the room,
giving the impression that there was no attention whatever. The boy
was a child of rich parents; he had his own teachers, but was for a
large part of the year under the influence of the parents only, who
very naturally yielded to every desire of the unfortunate child. I
insisted on a complete change of the education. It was my effort to
build up the mind by a rigorous training and by development of the
power of inhibition. I absolutely forbade any meaningless material
like the nursery rhymes, insisted that the child should never be
allowed to talk to himself, and whenever he began to speak to
himself he was to be addressed sharply, and if he yet went on, to
be slapped on his hands. In the same way he was not allowed to
repeat a question, but the question was repeated until he answered
it, the question always formulated in simple words. He was forced
to go through simple reading and writing without being allowed to
make his silly diversions. His whole life was brought under strict
discipline and no parental indulgence was permitted. Six months
later the child was completely changed. It seemed as if he had gone
through an improvement of three years. I regulated the whole of
his elementary studies in accordance with the successful principle.
The training of inhibition stood in the foreground and every
haphazard reaction was severely rebuked. The summer vacations spent
with the parents in the fashionable surroundings, to be sure, had
always a retarding influence, but the main part of the year in
which it was possible to carry through the strict discipline showed
such steady and inspiring progress that the boy, while of course
feeble-minded for life, can yet live externally a harmonious life.

A systematic training of the power of inhibition is indeed the fundamental factor in all psychotherapeutic treatment when the disturbance is in the volitional sphere, but the inhibition is secured most safely by reenforcement of the antagonistic attitude. From these volitional variations on the one side, from the ideational disturbances on the other, only a few steps lead to those dissociations of the personality which are characteristic of many graver cases of hysteria. But to give to them any adequate analysis, it would be insufficient to refer in this brief way to particular cases. Psychopathological literature possesses some excellent analyses of such complex disturbances. As I said before, I abstain entirely here from such complex phenomena, as they enter too seldom into the sphere of the practitioner and as the bewildering manifoldness of their symptoms does not allow us so easily to recognize the fundamental principles which alone were to be illustrated by our short survey of practical cases.

XI

THE BODILY SYMPTOMS

The discussion of the bodily symptoms which may yield to psychotherapeutic treatment, naturally forms only a short appendix to our discussion of the mental symptoms. Our interest was from the beginning essentially a psychological one. I shall have to be the more brief as my personal experience in the treatment of bodily diseases through mental therapy is entirely secondary and accidental. The psychological laboratory would, of course, be an entirely unfit place to struggle with diseases of which the chief symptoms are not psychophysical. Yet in spite of frequent testimonies of well-known physicians to the contrary, I am still inclined to think that this is also the situation at large. I think that in medicine in general the psychophysical effect of mental treatment is by far more important and by far more extended than the healing effect on diseased peripheral organs. Of course these peripheral parts of the body may be favorably influenced in an indirect way by the mental treatment; we shall have to take notice of this important result but that is strictly not a therapeutic effect on the bodily symptoms. Moreover, purely psychical effects may give an impression as if the bodily symptom itself has been removed.

To begin with the latter case, it is especially the inhibition of pain which easily makes one believe that a bodily disturbance is successfully treated. I have repeatedly seen cases in which I tried by suggestion to soften the pain resulting from a peripheral disturbance like inflammations, rheumatism, decayed teeth and so on. The effect was often such a total disappearance of the pain that the patient himself was inclined to believe that the objective disease had been ended, while in reality the state of the diseased organ was not changed at all. It has often happened that I tried to cure a person of certain mental symptoms by suggestion, ignoring entirely the existence of some pain resulting from a bodily disease with which I had nothing to do. Yet the suggestion of improvement seemed almost to irradiate and the pain disappeared in spite of having been ignored by the hypnotizer. For instance, I treated a woman who suffered from psychasthenic obsessions, fearing all the time that something would happen to her child. I did not give any direct attention to the fact that she had had for years a painful disease of the bladder for which she was constantly treated by a specialist. But while I did not mention the bladder in my hypnotic suggestion, yet the abdominal pain disappeared together with the obsession and the situation might easily have suggested that the bladder trouble was a nervous one which had been cured by the hypnotic sleep. The fact was that the bladder disease was not influenced by the mental treatment at all, and needed a continuation of the same local treatment. It was only the psychophysical pain in the brain which had been inhibited.

Quite parallel to the disappearance of the organic pain sensation is the arising of a general feeling of improvement. This organic sensation of general betterment may again be a strictly mental occurrence without any objective reference to a real improvement in the bodily conditions. Yet again that easily gives the impression of an important change in the bodily conditions themselves. The miraculous cures of various diseases through mystic agencies generally belong to this category. There is no doubt that often the migrating charlatans who advertise themselves by a free treatment of the sick and invalids on the theater stage of small towns, produce momentary effects which are sufficient to deceive. The quack handles the diseased organ, perhaps a goiter or a leg crippled by rheumatism, with a cruel rudeness and overwhelms the suggestible mind so completely that the first autosuggestion is that of a complete change, and that means cure. The disastrous results follow later. But from such barbarisms we come by gradual steps to the suggestion of improvement where the feeling of betterment can be in itself an important factor for the cure. Yet even there we must not mistake the possible secondary effect of a mental change from a psychotherapeutic cure of the bodily disease.

Not seldom the removal of physical disability seems secured as soon as certain mental disturbances are removed. There is no reason to believe for instance that suggestion can have an important influence on a diseased sense organ, and yet hypnotic influence and even autosuggestive influence can under certain circumstances greatly improve seeing and hearing. Especially in the field of hearing the central factor is of enormous importance. Hyperaemic and anaemic conditions in the brain centers of hearing control the vividness of the received sound. The patient who cannot hear a certain watch more than one foot distant may be able to hear it after some glasses of wine at a distance of three or four feet. Thus it is only natural that a hypnotic influence can produce similar changes on the psychophysical centers in such cases in which the source of the trouble is a psychophysical laziness in the acoustical center. Sometimes even this laziness itself is the result of psychical autosuggestion which can be fought by counter-suggestion. I saw, for instance, a distinct improvement in hearing in the case of a young woman who had increasing deafness while the aurists declared that the ears were in proper condition. I found that she lived with a father who suffered from a severe middle-ear catarrh and that she was simply controlled by a hidden fear that she might have inherited the ear disease of her father. I removed this fear, partly by reasoning, partly by suggestion, and partly by tricks which surprised her, for instance, making her hear her watch with unaccustomed strength when she took it between her teeth and closed both ears. The autosuggestive fear was uprooted by these and the central ear organs slowly came to normal functioning.

The purely psychical character is still more evident in the frequent hysterical anaesthesias. No one doubts that here the sensations are inhibited only and that the mental influence removes this inhibition without any influence on the sense organs proper. Frequently also organic troubles like stomach diseases appear cured when in reality hysterical disturbances are at the bottom. The stomach may be sensitive to any pressure and may produce severe pains and vomiting on taking any food and everything may indicate a serious local disturbance. Yet hypnotic treatment may quickly remove the symptoms because the whole reaction may have resulted from the shock which perhaps a too hot piece of potato caused. The removal of this mental starting point results in a cure of the apparent stomach disease. Again in other cases, the appearance of a physical cure is given by the creation of psychophysical substitutes. I do not believe that hypnotism or suggestive treatment can influence the brain parts which have suffered from a hemorrhage. Yet the paralysis of the arm, for instance, which resulted from such a breaking of a blood-vessel in the brain may be to a high degree repaired by building up new motor images in the psychophysical system, which become starting points for a new learning of movements. The patient did not understand how to make the most out of those motor paths which had been left. The destruction of the chief channels of discharge had inhibited in his mind the idea of possible movement. He no longer believes that he can move and it needs new suggestions to overcome this inhibition. The curative effect on bodily disabilities is thus often an illusory one.

That does not mean that the field in which psychotherapeutics may work directly on the body is not after all a large and interesting one. Theoretically it is still little open to real understanding. The explanation has essentially to rest on the acceptance of a given physiological apparatus. A certain psychophysical excitement produces by existing nerve connections a certain effect, for instance, on the blood-vessels or on the glands of a certain region, or on a certain lower nervous center. That such apparatus exists, the physiological experiment with persons who are hypnotized to a high degree can easily demonstrate. Their nose bleeds at a command; a blister may arise on a part of the skin which is simply covered with a penny, when the suggestion is given that the penny is glowing hot. With some subjects, the pulse can become slower and quicker in accordance with the suggestion; with some even the bodily temperature can change on order. Our understanding of these indubitable facts indeed does not go further than the acknowledgment that the paths for such central connections exist. That means we simply describe the facts once more in the terms of anatomy. But after all in the same way we rely on the nervous connections, if a thought makes us blush and ultimately if our will moves our arm or if our ideas move our speech apparatus. We do not choose the muscles of our arm, we hardly know them; we know still less in speaking, of the movements of our vocal cords, and in blushing of the dilated blood-vessels. That ideas work on the lower centers of our central nervous system, centers which regulate the actions of our muscles and blood-vessels and glands, must simply be accepted as the machinery of our physiological theory. The connection of such theories with purely physical facts is given by the experience that an electrical stimulation of the nerve may have the same influence as ideas. The electric current, too, can regulate the beat of the heart, or contract and dilate the vessels, or reenforce and relax the contraction of the muscles, or strengthen and weaken the functions of the glands.

Nearest to the psychophysical processes stands the bodily symptom of insomnia. There is no doubt possible that the work of the psychotherapist can be very beneficial in producing sleep by suggestion. That autosuggestions for sleep play an important role is popularly accepted. Next to the most immediate means such as lying down, or cutting off sense stimuli, or trying not to think, or avoiding movements, certainly the most well known factor is the expectation of sleep with the belief that sleep will come. This belief may be reenforced to strong autosuggestion which may then overcome other factors that hinder sleep. For instance, I have repeatedly received letters from strangers containing expressions of gratitude with news which under other circumstances would at least not flatter an author. They wrote to me that immediately after reading one or another essay of mine on hypnotism, they fell into deep sleep. Yet as they were always patients who had suffered from insomnia, I was pleased with this unintended effect of my writings. But in most cases a real cure demands heterosuggestion.

There is room for any variety of effects; often they enter immediately. The other day I gave sleep suggestion to a young woman who had overworked herself in literary production. For months she had not slept more than three or four hours a night and even that only after taking narcotics. I intentionally did not allow her to come into a hypnotic sleep but kept her fully awake, increasing her suggestibility while her eyes were wide open. I suggested to her to take a walk, then to eat her dinner, and after that to go to bed at once. She went to bed at seven o'clock and slept without waking until ten o'clock the next morning, and after fifteen hours' sleep she was like a different being. A regular eight hour sleep is sometimes secured, even where no immediate direction has been given for it. On the other hand, I cannot deny that I have sometimes been entirely unsuccessful in securing better sleep by the first three hypnotic treatments. When the first three treatments were unsuccessful, I always gave it up on account of lack of time. Yet the experience of others shows that in such cases, often after a long continued hypnotic treatment insomnia yields to suggestion. One of the great factors which work against the mental treatment is the habit of so many sufferers of relying on their sleeping powders which, to be sure, remain effective only by increasing the dose and thus finally by making them dangerous. Every chemical narcotic has in itself suggestive power and strengthens the belief of the sleep-seeker that he cannot find rest without his dose. To overcome the monopoly of the opiates is one of the most important functions of psychotherapy.

It is not surprising that the relations of psychotherapy to sleep show such a great variety. The factors which cooeperate in normal sleep are many and the disturbance can have very different character. We had to speak of the psychophysics of sleep when we discussed the theoretical relation of sleep to hypnotism and insisted that it is misleading to consider hypnosis simply as partial sleep. We claimed a fundamental difference between the selective inhibition in hypnotism and the general reduction of functions in sleep. To understand sleep, we have to recognize it as one of the fundamental instincts, comparable with the instinct for food or for sexual satisfaction. Every one of such instincts has a circular character. Mental processes, subcortical processes, and physical effects are involved in such a way that each reenforces the others. The physical effect of the sleep instinct, comparable with the pepsin secretion in the food instinct, or with the hyperaemia of the sexual organs in the sexual instinct, is a change in the cortex by which the sensory and motor brain centers are put out of action. What kind of a change that is, is quite indifferent. It may be a chemical one but more probably it is a circulatory one. Let us say it is a contraction of blood-vessels which by the resulting anaemia makes the sensory centers unfit for perception and the motor centers unfit for action. In this way the brain becomes protected by sleep against the demands of the surroundings. The mental reactions are eliminated and the central nervous substance has an opportunity to build itself up. This protective physical activity is now evidently itself controlled by a subcortical center, just as secretion and sexual hyperaemia are controlled. This center probably lies in the medulla oblongata.

Some theorists, to be sure, are inclined to think that the fatigued brain cells enter directly through their exhaustion into the protective sleep state. But that simplifies the situation too much. It is quite true, as these theorists claim, that monotonous stimulation of the senses produces sleep. But it is evident that the sleep occurs even then not only in the particular overtired brain cells. A monotonous stimulation of the acoustical center raises the threshold of perception for all the senses and brings sleep to the whole brain. This control of the whole apparatus is thus surely regulated by one definite center. But this lower center, which controls the anaemia of the cortex, is itself directly dependent again upon a mental condition, the mental experience of fatigue. The fatigue sensation, which is possibly the result of toxic processes, works on that lower sleep center, just as the appetizing impression or the sensual images work on the centers of the other two instincts. On the other hand this protective blood-vessel contraction creates again as in the other cases a characteristic organic sensation, the sensation of rest which arises when the threshold of perception and activity is raised. The world begins to appear dim and far away, no impulse for action excites us. This organic feeling of rest associates itself with the fatigue feeling. The fatigue sensation, the subcortical sleep center, the contraction of the vessels in the cortex, and finally the rest sensation form together the complete circle. The difficulty which arises in this case lies only in the fact that the cortex gone to sleep annihilates also, of course, the fatigue sensation and the rest sensation. For that reason the real circle can appear only in the preparatory stages of sleep. As soon as sleep itself sets in, the circle is broken. The circle character of every instinct must lead the physical effect upward to a higher and higher degree. Not to become excessive, the physical effect must be checked somehow. In all other spheres, it finds its end in satisfaction, for instance, by eating or by the sexual act. In sleep the circular process ends automatically by its own effect as soon as complete sleep is reached. Its causes, the fatigue and the rest feeling, are stopped, as soon as the effect, the anaemia, is secured.

We see now how widely different starting points can lead to sleep and can understand from it how widely different disturbances can prevent sleep. Sleep must result when fatigue is coming, but sleep must also result when the elements of the rest feeling are produced, and as we saw that the components of the rest feeling were the sensations of decreased sensitiveness and decreased activity, sleep must result when either the sensations and associations are absent and actions are suppressed, or when monotonous sensations and automatic actions raise the threshold. Sleep must arise further if our will associates the mere idea of such rest, and finally physical or chemical means may produce a sleep bringing effect either on the lower center or on the blood-vessels and cells of the cortex. Correspondingly sleep may be prevented by disturbances in any one of these spheres. There may be no normal fatigue, there may be no fatigue sensation, there may be no rest feeling on account of perceptions, or on account of associations, or on account of impulses to action; there may be no normal response in the subcortical center, there may be no physical effect in the cortex on account of an existing hyperaemia or on account of an abnormal condition of the cells. The psychotherapeutic treatment must carefully analyze which element would be fit to supply the last link in the circular chain. Sometimes we need the suggestion of fatigue, sometimes the inhibition of ideas, sometimes the suppression of impulses, sometimes the suggestion of rest, and so on. A mere general suggestion of sleep is on the whole effective only in the cases of those persons in whom this idea in itself awakens those various components. Very often it is entirely ineffective in this general form. Sometimes it is possible to carry the hypnotic state itself directly over into sleep, but it seems more in the interest of the patient to separate those two states distinctly.

We are still confined to processes in the brain itself if we turn to headache. If it were only a question of inhibiting the pain by mental suggestion, the case would not be different from inhibiting the pain of a peripheral organ without attempting to cure the diseased organ itself. But in the case of headaches, it seems justified to claim that in certain varieties of this multifold symptom, not only the pain is suppressed but the disturbance itself is removed. Especially where the headache seems to result from hyperaemia, the trouble seems to be accessible to psychotherapeutics. On the other hand I have never seen any lasting effect on the so-called sick headache or migraine. While continuous headaches or headaches which occur daily yielded to my influence, sometimes completely, I was unable to prevent even by preparatory hypnotization any migraine which appears periodically, for instance, simultaneously with menstruation.

A few words only as to the general diseases and disturbances for which a very strong therapeutic effect has been claimed by masters of the craft like Wetterstrand, Moll, Dubois, and others. From my own experience I can affirm the often lasting effect in the disturbances of the functions of the digestive apparatus. The stomach and the intestines seem to a high degree under nervous influences which can be changed through hypnotic suggestion. If we consider what intimate connection exists between the functions of these organs and the normal emotions, it seems hardly surprising that mental factors can regulate their disturbances. Vomiting, diarrhea, and especially constipation, often yield to slight suggestions, even in a superficial hypnotic state. Here, too, I have seen repeatedly a complete regulation of a long-standing disturbance as an unintended by-product of hypnotic suggestion directed towards the cure of psychical troubles. Much value is claimed for hypnotic method in the treatment of anaemic conditions. It is said that anaemia improves after a few hypnotic treatments, the appetite becomes better, the cold hands and feet grow warmer, the headaches disappear, the capacity for work increases rapidly, and most surprising of all the leucorrhea ceases. As to heart disease, we ought to think in the first place of the disturbances of nervous innervation. I have seen repeatedly a remarkable decrease of nervous palpitation of the heart through direct mental influence, abstracting here from the secondary effect of suppressing mental excitement and fear. Where organic heart diseases are surely present, it seems that hypnotism can sometimes act beneficially if the heart trouble is accompanied by anaemia and general debility; of course a developed valvular disease cannot be removed. In the same way it seems that in Bright's disease, certain painful symptoms may be suppressed, but the kidneys certainly cannot be influenced. At least open to serious suspicion are the insistent claims that diabetes can be cured by suggestion. Dr. Quackenbos of New York, for instance, gives to some of his diabetes patients a hypnotic suggestion by the following words: "If your pancreas be crippled in its production of the natural ferment which is given off to blood and lymph and which conditions the normal condition of sugar in the body or restrains the output of sugar from the liver tissues, you will see that it forthwith pours into your blood or lymph the sufficient quantity of sugar oxidizing ferments." It certainly transcends our present understanding if we are to believe that a suggestion of this type will change the action of the pancreas. It is hardly worth while to enter into the still more extravagant claims from other sides like those for curing cancer and phthisis. On the other hand, in the light of all that we have discussed, there is no difficulty in understanding the easily observable influence in the regulation of menstruation, in the cure of contractions, local congestions, and incontinency of urine. I may mention finally the use of hypnotism for helping in a safe and quick confinement.

But in addition to all this, we have the great help which psychotherapy may bring indirectly in the treatment of physical diseases. I said, for instance, that I do not believe in a real help by mere suggestion in cases of diabetes. But no one ought to underestimate the value which may result for the treatment from a suggestion of a well-adapted diet. The patient who feels a craving for bread and potatoes and perhaps sweets, and is too weak to resist it, is indeed brought into safety if suggestion liberates him from such desires. The same holds true for every other diet and for any medical regime of life which does not harmonize with the natural instincts of the patient. For not a few sufferers, reenforcement of the interdict against coffee and tea or alcohol and tobacco is more important than any medicine. Hypnotic suggestion can easily create dislike of the prohibited material and can build up new desires and inclinations. In the same way it is indirectly most important to stir up, for instance, the sensations and feelings of appetite and thus to make normal nutrition possible. Also in cases of anaemia or tuberculosis, such indirect assistance can produce some beneficial consequences.

The same holds true of the power of the psychotherapist to secure sleep. The fight against insomnia which we discussed referred only to that sleeplessness which is itself an expression of the disease. But as a matter of course, the loss of sleep can accompany most different diseases, as an almost accidental result. To secure sleep means then not to treat the symptoms of the disease but a by-product; and yet every physician knows how much is gained if the lost energies are restituted by a sound sleep. And finally we have the indirect help towards the cure by the suggestive removal of pain. We have no right to say that it is a pure advantage for the treatment of the disease if the pain is centrally inhibited. Pain surely has its great biological significance and is in itself to a certain degree helpful towards the cure, inasmuch as it indicates clearly the seat and character of the trouble and warns against the misuse of the damaged organ which needs rest and protection. To annihilate pain may mean to remove the warning signal and thus to increase the chance for an injury. If we had no pain, our body would be much more rapidly destroyed in the struggle for existence. But that does not contradict the other fact that pain is exhausting and that the fight against the pain decreases the resistance of the organism. As soon as the disease is well recognized through the medium of pain and the correct treatment is inaugurated, not only the subjective comfort of the patient but the objective interest of his cure makes a removal of pain most desirable. While it would be absurd to say that hypnotism can cure tuberculosis or cancer, it is fully justifiable to say that hypnotic treatment in tuberculosis or cancer is to a high degree beneficial, inasmuch as it can secure sleep, appetite, and freedom from pain, three factors which indirectly help to fight the disease. The elimination of pain may sometimes also play its role in slight operations where other methods of narcosis seem for any reason undesirable, and very frequently hypnotic suggestion has been used for this purpose at childbirth.

The same importance which belongs to the removal of bodily pain in the treatment of a peripheral disease may be given to its mental counterpart, to the worry, excitement, and emotional shock. They all stand in the way of a real success in any cure. Even the chances of a dangerous operation are entirely different for the patient who goes to it with free mind and a happy mood, with full confidence in its success, from those of a patient who has worked himself into a state of fear and anxiety. Here again the depression and the excitement are not in question as symptoms of a disease, as they were when we discussed the phobias and despondencies of the neurasthenic and of the hysteric. They are merely normal side-effects of the bodily disease, accentuated perhaps by a suggestible temperament. To eliminate all these emotions means to change most helpfully the whole atmosphere of the sick-room and to deprive invalidism of its saddest feature. This negative factor corresponds of course most directly to the positive feature of building up new hope and joyful expectation. He who creates confidence makes convalescence rapid and strengthens the power to overcome disease.

It would be medical narrowness if the physician were strictly to deny that the effect of such emotional change may sometimes lead far beyond the ordinary suggestive influences and that in this sense the miraculous really happens. When out of a despondent mood in a suggestible brain an absorbing emotion of confidence breaks through, a completely new equilibrium of the psychophysical system may indeed result. In such cases, improvements may set in which no sober physician can determine beforehand. Central inhibitions which may have interfered a life long with the normal functioning of the organism may suddenly be broken down and in an entirely unexpected way the mental influence gives to the forces of the body a new chance to help themselves. The reasoning of the scientific physician may easily stand in the way there. He may be afraid of such overstrong emotion because he knows too well that such unregulated powers may just as well destroy the good as in another case the bad; in short, that ruin may result just as well as health. But that does not exclude the fact that indeed almost mysterious cures can be made without really contradicting the scientific theories. Such are the means by which the mystical cults earn their laurels. A chance letter of the type which often swells the mail of the psychologist may illustrate this effect. I choose it because it is evidently written by a skeptic. A short quotation from the lengthy epistle is sufficient.

"My condition was horrible in the extreme. I had consumption of the lungs and other supposedly fatal troubles, complicated by wrecked nerves. At the present writing, I am robust and splendidly healthy, looking twenty years younger than I did at the period previously described. The Christian Scientist saw my condition but appeared unconcerned and unafraid, I being absolutely hopeless, skeptical, and deeply contemptuous meanwhile. On the third day of her treatment I was desperate for sleep, she having forbidden drugs, and I deliberately took an overdose of chloral, thinking to die at once and end it. My condition justified the act. She brought me out of the coma of the chloral after three hours of mental work, and the next day I felt decidedly calmer and less afraid of the coming of night, should I live to meet it, which seemed doubtful. At noon she left me to go to her home to lunch. I was pondering seriously on her reiterated 'God is love and fills the universe and there is nothing beside Him,' when I suddenly had a sensation of being lifted up or rising slowly and becoming lighter in body. A rush of power that I have no way of describing to you filled me. I seemed to be a tremendous dynamo in the air several inches above the ground and still ascending. When I noticed everything around me becoming prismatic and more or less translucent, I could have walked on water without sinking, and I had distinct understanding that matters seemed to be disintegrating and dissolving around me. I was frightened but self-conscious and quiet. I remained in this state for about three hours, my consciousness seeming to have reached almost cosmic greatness. I could have cured, I felt, any human ill, was filled with an absorbing altruistic desire to help suffering. It was tremendous and totally foreign to my everyday attitude. At the end of the day, towards twilight, I became wearied of the tremendous throbbing and exalted state in which I still remained and gave utterance to the thought aloud. Almost before I had formulated it the condition left me, and like the sudden dropping of a weight, I struck the ground, the same dull, ordinary person of everyday experience, but with the vast difference of perfect health, radiant and lasting to the present writing. My father like myself is baffled and wondering. We are both pretty hard skeptics. I want the truth, whether it be terrible or otherwise. I am profoundly grateful to the Christian Scientist, if I regained my health through her ministrations, but I have not so far been able to label myself and rise in their church services to tell what has been done on me. The performance repels me as crude and rather bad taste. I swear to you on my honor as an American woman and a mother that what I have written you is true, absolutely. If you can give me any light or if my experience may perchance give you a helping ray, my renewed lease on life may have had some purpose after all, which I have often questioned in my cynical moods."

The unprejudiced psychotherapist will be perfectly able to find room for such cures and, if it is the duty of the scientific physician to make use of every natural energy in the interest of the patient's health, he has no right to neglect the overwhelming powers of the apparently mysterious states. Some of this power ought to irradiate from his eye and his voice whenever he crosses the threshold of a sick-room. Some of that power ought to emanate from him with every pill and drug which he prescribes. The psychotherapeutic energies which work for real health outside of the medical profession form a stream of vast power, but without solid bed and without dam. That stream when it overfloods will devastate its borders and destroy its bridges. The physicians are the engineers whose duty it is to direct that stream into safe channels, to distribute it so that it may work under control wherever it is needed, and to take care that its powerful energy is not lost for suffering mankind.