UC-NRLF 
 
 B M 330 033 
 
in 
 
Psychotherapeutics 
 
 BY 
 
 FREDERIC H. GERRISH 
 
 JAMES J. PUTNAM, 
 
 E. W. TAYLOR 
 
 BORIS SIDIS 
 
 GEORGE A. WATERMAN 
 
 JOHN E. DONLEY 
 
 ERNEST JONES 
 TOM A. WILLIAMS 
 
 AND 
 
 MORTON PRINCE 
 
 RICHARD G. BADGER 
 
 ^de (Soriiam Ij^xtiii 
 
 BOSTON 
 
/XZ4 
 
 CopyHght, 1909 and 1912 by Richard O. Badg$r ^ ^ 
 
 AU Biyhtt Regervtd ?}S^^^^ 
 
 Th$ Gorham Preu, Boston, U. 8. A, 
 
CONTENTS 
 
 Chapter Page 
 
 Introduction 7 
 
 I. The Psychological Principles and Field of 
 
 Psychotherapy 9. 
 
 Complex Formation 18 
 
 Conservation 18 
 
 » Dissociation 9.% 
 
 Automatism 26 
 
 Emotional Energy 27 
 
 The Relative Advantages of Education in 
 
 Hypnosis and in the Waking State . 32 
 
 Hysteria S7 
 
 Psychasthenia and Obsessions . . . . 40 
 
 II. The Therapeutic Value of Hypnotic Sugges- 
 
 gestion 42 
 
 Methods of Inducing Hypnosis ... 45 
 Conditions vh which Hypnotic Suggestion 
 
 is Valuable 60 
 
 Correction of Misconceptions concerning 
 
 Hypnotism 67 
 
 III. Simple Explanation and Re-education as a 
 
 Therapeutic Method 68 
 
 IV. The Treatment of Fatigue States ... 78 
 
 Physiological Fatigue ...... 78 
 
 Psychological Fatigue 80 
 
 Psychopathological Fatigue .... 81 
 
 V. Psycho-Analysis in Psychotherapy ... 98 
 
 VI. The Psychotherapeutic Value of the Hyp- 
 
 noidal State 106 
 
 C i^fkfroo 
 
CONTENTS 
 
 Chapter Page 
 
 VII. Obsessions and Associated Conditions in So- 
 
 Called Psychasthenia 131 
 
 VIII. Psychoprophylaxis in Childhood . . . , 141 
 
 IX. The Relation of Character Formation to 
 
 Psychotherapy . . . . . . . 166 
 
INTRODUCTION 
 
 THE purpose of this volume is to present a brief, in- 
 telligible statement of the methods of treatment 
 by psychic means, which are approved by scientific 
 physicians, and, also, a description of the classes of cases, to 
 which such methods are appropriately applicable. 
 
 The book owes its composite character to circumstances, 
 a knowledge of which will give added interest to its perusal; 
 and it will be readily perceived that the value of the work is 
 enhanced by the fact that it is prepared by a group of 
 specialists, whose combined product must be of greater 
 worth than that of any one writer, however able. 
 
 In 1909, one of the authors. Dr. Gerrish, was president of 
 the American Therapeutic Society, and, as such, had the 
 privilege of arranging the program for its annual meeting. 
 A careful examination of the programs of the previous years 
 disclosed the fact that, although this national association is 
 specifically devoted, as its name implies, to the treatment of 
 disease, no paper on psychic remedies had ever been read 
 before it. This neglect of a whole class of curative measures is 
 explicable only on the ground of the lack of appreciation of 
 their value by the medical profession generally — a lack 
 attributable, in large measure, to the failure of medical 
 schools to attempt to interest their students in these agencies, 
 and, in some degree, to the disrepute into which psychic 
 remedies have been brought by their dishonest and other- 
 wise objectionable exploitation by charlatans. Certain it is 
 that the profession has looked askance at psychotherapy, 
 and has been unwilling to accord it the respectful hearing 
 to which its scientific merits entitle it. Dr. Gerrish con- 
 sidered the annual meeting of the national therapeutic 
 
INTRODUCTION 
 
 society a peculiarly opportune occasion for the presentation 
 of the whole subject, and conceived the project of a sym- 
 posium, in which the different aspects of psychotherapy 
 would be treated, each by a physician, whose knowledge 
 and experience qualified him to speak with authority, and 
 whose position in the medical profession was not only above 
 reproach, but was stamped with the hallmark of dignity and 
 respect. To execute this design he invoked the interest and 
 invaluable assistance of Dr. Morton Prince, whose fame is 
 world-wide; and by the personal influence of this master 
 there was gathered a remarkable coterie of experts in psycho- 
 therapeutics. Dr. Prince opened the symposium with an 
 essay on "The Psychological Principles and the Need of 
 Psychotherapy"; and was followed by Dr. Taylor on "Sim- 
 ple Explanation and Re-education as a Therapeutic Method," 
 Dr. Jones on "Psycho-Analysis in Psychotherapy," Dr. 
 Sidis on "The Psychotherapeutic Value of the Hypnoidal 
 State," Dr. Waterman on "The Treatment of Fatigue 
 States," Dr. Donley on "Obsessions and Associated Con- 
 ditions in so-called Psychasthenia," Dr. Williams on "Psy- 
 choprophylaxis in Childhood," and Dr. Putnam on "The 
 Relation of Character-Formation to Psychotherapy." Dr. 
 Gerrish took "The Therapeutic Value of Hypnotic Sugges- 
 tion" as the subject of his presidential address. 
 
 These essays were received with marked favor on the 
 occasion of their delivery, were soon published in The Journal 
 of Abnormal Psychology, and then appeared in book form. 
 The fact that a third edition of the volume has been de- 
 manded may well be taken as an evidence that it has won 
 high esteem and wide appreciation. Indeed, it has been 
 pronounced by persons well qualified to form an opinion 
 in^the premises to be the most valuable, as well as the most 
 compact, presentation of psychotherapy that has ever been 
 made. The new edition is issued in the hope that the book 
 will continue to enlighten the medical profession and the 
 
INTRODUCTION 
 
 public on a subject of great interest and practical importance, 
 and aid them in distinguishing between genuine, scientific 
 mind-cure and the many spurious articles that masquerade 
 under various alluring and deluding names. 
 
PSYCHOTHERAPEUTICS 
 
 i 
 
PSYCHOTHERAPEUTICS 
 
 CHAPTER ONE 
 
 The Psychological Principles and Field of Psycho- 
 therapy 
 by morton prince, m. d. 
 
 Professor Emeritus Tufts College Medical School 
 
 SO much that is pseudo-scientific or mere platitude, so 
 many misstatements have been set forth in the lay 
 and medical press both by those who are the advo- 
 cates of psychotherapy and by those who are its critics i 
 so many erroneous ideas abound regarding both the na- 
 ture of the disturbances of the mind and body which we 
 seek to allay and the modes by which we endeavor to do 
 it, that it is not to be wondered at that the facts of ob- 
 servation have been mistrusted and the methods of thera- 
 peutics have met with cynical criticism. 
 
 If we are to judge the soundness of the theory on 
 which this mode of treatment is based, the field of its 
 usefulness, its limitations, and the methods of its appli- 
 cation, it is absolutely necessary that we should begin 
 any discussion of psychotherapy, in a symposium of this 
 kind, with an understanding of its underlying principles. 
 There are certain facts of observation with which we 
 may begin. 
 
 1. It will be agreed that common experience has 
 shown that certain unhealthy habitual states of mind are 
 apt to be accompanied by various derangements of the 
 functions of the body. By " unhealthy " I would desig- 
 nate those which tend to misadapt a person to his en- 
 
 9 
 
10 PSYCHOTHERAPEUTICS 
 
 vironihent, dnd a'nfioug these habits or states of mind I 
 would classify depressive or disruptive emotions and 
 
 \ feelings; apprehensions, and fear of disease or of the 
 consequences of business or social acts ; fixed beliefs in 
 fictitious disease; illogical doubts, scruples, and anxie- 
 
 ^ ties; habits of thought such as constant introspection, 
 self-consciousness, the concentration of the attention on 
 the physiological functions of the body, the expectation 
 of ill consequences following any course of conduct, and 
 so on. I need not go into details, for that such condi- 
 tions of mind are accompanied by derangements of the 
 bodily functions is a fact of common knowledge which 
 is confirmed by the experience of laymen as well as phy- 
 sicians and psychologists. Furthermore, in certain per- 
 sons the modes of mental activity I have described if 
 X frequently repeated tend to become habits or habitual 
 reactions to the environment that are not easily dis- 
 carded. Often the mental states when persistent and 
 intense become disabilities in themselves, constituting 
 veritable psychoses, such as the anxiety psychosis, pho- 
 bias of various kinds, morbid shyness and self-conscious- 
 ness, association psychoses, etc. It is not to be affirmed 
 that these unhealthy mental states of mind, even when 
 they become habitual phychoses, are accompanied in 
 every individual by disturbance of bodily functions, but 
 the tendency is such in persons of a certain temperament 
 and so-called nervous organization. 
 
 S. It is also a fact of observation which is too well 
 admitted to be mistrusted that, when healthy mental 
 states are substituted for unhealthy ones of the charac-, 
 ter I have described, the functional derangements of the! 
 body tend to disappear. 
 
 The two classes of facts just enumerated become com- 
 prehensible when we remember that physiological and 
 clinical observations have shown that temporary or pass-j 
 ing mental states when accompanied by strong feeling^ 
 
FIELD OF PSYCHOTHERAPY 11 
 
 tones often alter in a marked degree the various visceral 
 functions. To mention but a few of these effects: The 
 increase of the heart's action; the increase of the blood 
 pressure; the variations of the vasomotor system; the 
 increased muscular energy and feeling of wellbeing; 
 the pouring out of the appetite juice and saliva (Paw- 
 low), etc., through the influence of ideas associated with 
 sthenic pleasurable emotions — all these have been at- 
 tested by the observations of the physiologist and of 
 the clinician. Per contra, the suppression of salivary 
 and gastric secretions ; the inhibition of peristalsis and 
 segmentation; the contraction and dilatation of the 
 blood vessels ; the increased functions of the sweat 
 glands ; the alteration in the rhythm and rapidity of the 
 respiration and heart's action ; the inhibition of many 
 functions (gastro-intestinal) ; the decrease of muscular 
 energy; the awakening of the sense and symptoms of 
 fatigue; these and many such phenomena have been 
 shown by carefully recorded tests to accompany the 
 temporary excitation of ideas that are associated with 
 depressing and painful emotions. That the persistence 
 of such mental states should be accompanied by per- 
 sistent disturbance of function is not to be wondered 
 at. 
 
 3. A third class of facts must, I think, also be ac- 
 cepted as proven; namely, that emotional shocks are apt 
 in certain persons to leave persisting after-effects mani- 
 fested by disturbances of function of the nervous system. 
 We need not inquire at this moment into the exact na- 
 ture of these disturbances or give them a name. It is 
 generally agreed that they are of the character which 
 is called functional and owe their evolution to the prin- 
 ciples which I will presently describe. In their most ob- 
 trusive form they are observed as the traumatic neuroses 
 (psychoses). 
 
 4. A fourth class of facts is of importance for psy- 
 
U PSYCHOTHERAPEUTICS 
 
 chotherapeutics, viz.: In all persons to a certain extent 
 . and in some persons to a large extent suggested ideas 
 tend to work themselves out to fulfilment. In certain 
 diseased states (hysteria) and in certain artificial states 
 (hypnosis) this tendency reaches a maximum and, con- 
 sequently, by suggestion, intentionally given to persons 
 in such conditions, disturbances of function can be pro- 
 duced artificially and removed again. Likewise ideas 
 V originating in the mind of the person himself may in- 
 duce the same phenomena (auto-suggestion). Thus on 
 the physiological side functional paralysis, contrac- 
 tures, anesthesias, spasms, etc. ; and on the mental side 
 amnesias, hallucinations, sleep, trains of ideas and feel- 
 ing, etc., can be artificially produced and afterwards 
 modified and removed. In this statement I am not in- 
 cluding the basic condition, whatever it may be, that 
 \ gives rise to the increased suggestibility, but to the 
 phenomena resulting from suggestion. How far that 
 condition comes within the influence of suggestion is an- 
 other question to which I will later return. The phe- 
 nomena of suggestion have been determined by experi- 
 ment over and over again, while the history of medicine 
 testifies to the occurrence of such phenomena under acci- 
 dental conditions. Indeed a distinguished neurologist 
 (Babinski) has recently advanced the thesis, though as 
 I believe erroneously, that all hysteria is nothing but a 
 group of suggested symptoms. 
 
 We cannot be too cautious in generalizing from lim- 
 ited facts of this kind which are observed under special 
 conditions, but the basic principle is of great impor- 
 tance and one that obviously can be made use of in psy- 
 chotherapeutics. To what extent it can be used is an- 
 other question that can only be determined by experi- 
 ence. 
 
 After this general statement of certain fundamental 
 
FIELD OF PSYCHOTHERAPY 13 
 
 facts of observation I would call attention to certain 
 principles, if not laws, which observation has shown gov- 
 ern the functioning of the nervous system. 
 
 1. COMPLEX FORMATION 
 
 It is a law that associated ideas, feelings, emotions, 
 sensations, movements, visceral functions of whatever 
 kind, tend, after constant repetition or when accompa- 
 nied by strong emotion and feeling tones, and under 
 other conditions, to become linked together into a sys- 
 tem or group in such fashion that the stimulation of one 
 element in the group stimulates the activity of the rest 
 of the group. Such a group is conveniently called a v 
 complex^ and as such I shall hereafter refer to it. This 
 tendency to linking of functions obtains whether the 
 mental and physiological processes when linked form a 
 complex which subserves the wellbeing of the ' organism 
 and adapts the individual to his environment, or whether 
 they form one which does not subserve the wellbeing of 
 the individual, but misadapts him to his environment. 
 In the former case the complex is called normal, in the 
 latter abnormal. This is only another aspect of the 
 well-accepted principle that pathological processes are 
 normal processes functioning under altered conditions. 
 Both are the expression of one and the same melanism. 
 
 The linking of function may be almost entirely of 
 ideas, as is expressed by the well-known psychological 
 law of " association of ideas." Its pathological mani- 
 festations we see in so-called fixed ideas or obsessions. "^ 
 We see it also exemplified within normal limits in so- 
 called moods, when certain large systems of ideas accom- 
 panied by"" strong emotion tones occupy the mental field 
 to the exclusion of other systems which find it difficult 
 to take possession of the field of consciousness. When 
 such moods are developed and intensified to an extreme 
 
14 PSYCHOTHERAPEUTICS 
 
 degree we have veritable pathological alterations of per- 
 sonality and even, it may be, multiple personality. But 
 in moods besides association we meet with another princi- 
 ple in an exaggerated form, namely, dissociation. Of 
 this I will presently speak. 
 
 The linking again may be of physiological processes 
 as ^exemplified by synergesis of muscular movements. 
 This is seen in the linked combination of muscles used 
 in writing, p iano p jaying, skilled use of tools, and imple- 
 ments of games (golf, tennis, etc.). Even the simpler 
 movements of a finger, hand, or arm require the coapt- 
 ative synergesis of several muscles. These synergetic 
 movements are admittedly the result of education 
 through repetition, although undoubtedly the compound 
 cerebro-spinal reflexes so beautifully studied and brought 
 to light by Sherrington are made use of. 
 
 The possibility of organizing physiological processes 
 into memories by artificial means and linking them to 
 psychological processes is shown very neatly by the ex- 
 tremely important experiments of Pawlow and his co- 
 workers on the reflex stimulation of saliva in dogs. 
 The facts which I wish here to recite are thus described 
 by Pawlow: 
 
 " In the course of our experiments it appeared that all 
 the phenomena of adaptation which we saw in the 
 salivary glands under physiological conditions, such, for 
 instance, as the introduction of the stimulating sub- 
 stances into the buccal cavity, reappeared in exactly 
 the same manner under the influence of psychological 
 conditions — that is to say, when we Inerely drew the 
 animal's attention to the substances in question. Thus, 
 when we pretended to throw pebbles into the dog's 
 mouth, or to cast in sand, or to pour in something dis- 
 agreeable, or, finally, when we off^ered it this or that kind 
 of food, a secretion either immediately appeared or it 
 
 I 
 
FIELD OF PSYCHOTHERAP\ 15 
 
 did not appear, in accordance with the properties of the 
 substance which we had previously seen to regulate the 
 quantity and nature of the juice when physiologically 
 excited to flow. If we pretended to throw in sand, a 
 watery saliva escaped from the mucous glands ; if food, 
 a slimy saliva, and if the food were dry — for example, 
 dry bread — a large quantity of saliva flowed out, even 
 when it excited no special interest on the part of the 
 dog. When, on the other hand, a moist food was pre- 
 sented — for example, flesh, — much less saliva appeared 
 than in the previous case, however eagerly the dog may 
 have desired the food. This latter eff'ect is particularly 
 obvious in the case of the parotid gland." ^ 
 
 More than this the psychical excitation may be part 
 of a wider complex; everything that is in any way psy- 
 chologically associated with an object which physiolog- 
 ically excites the saliva reflex may also produce it, — 
 the plate which customarily contains the food, the fur- , 
 niture upon which it stands, the person who brings it, 
 even the sound of the voice and sound of the steps of ^ 
 this person.^ 
 
 " Any ocular stimulus, any desired sound, any odor 
 that might be selected, and the stimulation of any part 
 of the skin, either by mechanical means or by the appli- 
 cation of heat or cold, have in our hands never failed to 
 stimulate the salivary glands, although they were all of 
 them at one time supposed to be ineflScient for such a pur- 
 pose. This was accomplished by applying these stimuli 
 simultaneously with the action of the salivary glands, 
 this action haviAg been evolved by the giving of certain 
 kinds of food or by forcing certain substances into the 
 dog's mouth." ^ 
 
 iThe work of the Digestive Glands (English Translation), p. 152. 
 
 2 J. P. Pawlow: Psychische Erregung der Speicheldriisen, Ef' 
 gebnisse der Physiologie, 1904, / Abteil, p. 182. 
 
 3 Huxley Lecture, Br. Med. Jour., Oct. 6, 1906. 
 
16 PSYCHOTHERAPEUTICS 
 
 It is obvious that reflex excitation thus having been 
 accomplished by the education of the nerve centers to 
 a previously indiff^erent stimulus the reproduction of the 
 process through this stimulus is in principle an act of 
 physiological memory.^ 
 
 In man as an example may be cited the vesical reflex 
 which may similarly, as is well known, be educated to 
 react to the sound of running water. 
 
 These pathbreaking demonstrations of Pawlow fur- 
 nish the key to the mechanism of many neuroses and 
 psychoses, for indeed the educated reactions of the gas- 
 tric and salivary glands to ordinarily indiff'erent stimuli 
 from the environment and to psychical states are in 
 reality nothing but an artificially created psycho- 
 neurosis — a perversion of the normal reactions. Such 
 artificial syndromes render comprehensible the mechan- 
 ism of such neuroses as the well-known neurotic type of 
 hay fever which belongs to the association neuroses.^ 
 
 In this type the whole physiological group of func- 
 tions composing the neurosis — lachrymation, conges- 
 tion of the mucous membranes and erectile tissues, se- 
 cretions, cough, dyspnoea, etc., — are linked into an auto- 
 matically working mechanism by repetition and excited 
 by a stimulus from the environment, e. g., the sight of 
 a rose (which may be artificial), dust, sunlight, etc. 
 Psychical expectation (auto-suggestion) of course pre- 
 pares and keeps alive the association. This neurosis, 
 
 1 Prince: The Unconscious, Journal of Abnormal Psychology, Oct.- 
 Nov., 1908. 
 
 2 Morton Prince: Association Neuroses, Journal of Nervous and 
 Mental Disease, May, 1891. 
 
 2 Morton Prince: Hay Fever, Due to Nervous Influences, Oc- 
 curring in Five Members of the same Family, Annals of Gyne- 
 cology and Pediatry, 1895. 
 
 2jolm E. Donley: Three Cases of Association Neuroses, Bos- 
 ton Medical and Surgical Journal, November 3, 1904; Study of As- 
 sociation Neuroses, Journal op Abkobmal Psychology, Vol. II, 
 p. 45. 
 
FIELD OF PSYCHOTHERAPY 17 
 
 composed mostly of physical symptoms, strikingly illus- 
 trates the principle of an educated functional disease and _^^ 
 typifies many forms of neuroses. 
 
 In other psycho-neuroses the syndrome may be made 
 up partly of psychical elements and partly of physical 
 processes. This is seen in psychasthenia, where, for in- 
 stance, fears, anxieties, scruples, confusion of thought, / 
 etc., are associated with all sorts of disturbances of the 
 body, — dizziness, palpitation, tremor, perspiration — 
 the whole constituting a phobia or anxiety neurosis. 
 
 Now without pursuing these illustrations further, the 
 point I would like to emphasize is that the whole process 
 by which these functional syndromes are created is edu- ( 
 cational. The education may be unintentional, i.e., acci- 
 dental, as in the hay fever neurosis and those resulting 
 from continued auto-suggestion; or it may be inten- 
 tional, as in Pawlow's experiments on the digestive func- 
 tions. 
 
 In these facts which I have only incompletely collated 
 we have the manifestations of a broad general principle 
 governing nervous processes in normal and abnormal 
 life. It is tV>p prinrip]^ of pedago gy. Unless nervous 
 processes could be artificially linked into coaptative 
 synergetic systems adapted to a purpose, education in 
 any field would be impossible. Intellectual acquisitions, 
 from the repetition of the alphabet to a complete knowl- 
 edge of a language or a science, and physiological ac- 
 quisitions, from the use of a tool to the mastery of the 
 piano or the vocal apparatus, not only would be unknown 
 but would be unthinkable. The education of the mind 
 and body depends upon the artificial synthesizing of 
 functions into a complex adapted to an end or useful 
 purpose. By the same principle functions may be synthe- 
 sized by education into a complex which does not serve 
 a useful purpose but rather is harmful to the individual. 
 
18 PSYCHOTHERAPEUTICS 
 
 When this is the case we call it abnormal or a psycho- 
 neurosis. 
 
 From this point of view how inadequate is the allega-; 
 tion which we often see stated that there is no such thing 
 as a functional disease. What can be the conception of 
 function which must be held by those who maintain such 
 a theory is something that passes comprehension. A 
 functional disease is a perversion of the normal proc- 
 esses brought about by some acute, intense experience or 
 by repetition of an experience, i.e., by education. The- 
 oretically it would follow that what can be done by edu- 
 cation can be undone by the same method, and in practice 
 we find this to be true. We shall presently see that there 
 are often types of functional disease, but each is based 
 on a perversion of the normal mechanism. 
 
 2. CONSERVATION 
 
 Another principle or tendency of the functioning of 
 the nervous system has been firmly established by re- 
 peated experimentation and observation. Its impor- 
 tance for psychotherapy can hardly be exaggerated. It 
 is this : All our experiences — anything that we have 
 thought, seen, heard, or felt — tend to be conserved ii 
 V such a way that they can be reproduced in a form ap^ 
 proaching that of the original experience. Upon this 
 meniorydepends. It is evident that we never could re- 
 member anything, that all experiences would be lost to 
 consciousness, unless somehow and somewhere they were 
 preserved, unless there was some physical arrangement 
 for preserving them. In what form mental and other 
 experiences are conserved we do not know, we can only 
 theorize; but we must infer that some kind of residue or 
 impression, chemical or physical, is left in the neurones 
 in consequence of which they have a disposition to repro- 
 duce, when again stimulated, the original experience, 
 
FIELD OF PSYCHOTHERAPY 19 
 
 whether an idea or physiological reaction. Hence these 
 residues are called unconscious " residua " or " disposi- 
 tions." They have a hypothetical existence like the 
 atoms and molecules of physics, but upon them the theory 
 of memory is based. They may be likened to the impres- 
 sions left in the wax cylinder or the magnetization of the 
 wire of the phonograph by the spoken word. A complex 
 of such residua is an " unconscious complex." 
 
 But besides mental experiences all observation and ex- 
 perimentation show that pure physiological reactions as- 
 sociated with a given mentar experience are conserved as 
 a part of that association. The ideas, for example, be- 
 longing to a fright complex which originally were accom- 
 panied by palpitation of the heart, tremor, perspiration, 
 muscular weakness, etc., when reproduced in memory are 
 again accompanied by all these physiological reactions. 
 So in Pawlow's dogs the repeated experiences of a sen- 
 sation of touch, accompanied with the physiological 
 reactions of saliva, became a complex which was con- 
 served and reproduced on subsequent occasions. The 
 nervous system faithfully conserves and reproduces its 
 experiences. Conservation is fundamental for educa- 
 tion ; for upon it the law of linking of complexes depends. 
 It is obvious, for instance, that the education of coap- 
 tative synergesis of muscular movements for purposeful 
 acts would be impossible unless by the act of experience 
 something capable of reproduction were impressed upon 
 the neurones. Now the more often an experience is re- 
 peated and the stronger its emotional tone, the more 
 likely it is to be conserved. Thus we repeat a verse or 
 a rule of grammar until we know it by heart ; or we re- 
 peat a movement until it becomes automatic. 
 
 But without repetition the elements of an experience 
 may become linked and conserved. We undergo an emo- 
 tional experience accompanied by various bodily reactions, 
 
\ 
 
 20 PSYCHOTHERAPEUTICS 
 
 as in a railroad accident, or we experience an abhorrent 
 idea, or one of apprehension, or repulsive desire — in 
 each case the nervous organism remembers the experi- 
 ence and upon proper stimulus can reproduce it. The 
 emotional tone seems to intensify the impression on the 
 brain organization. 
 
 Further, on the principle just described of the linking 
 together of experiences into complexes, or associated 
 groups of ideas, feelings, and physiological reactions, it 
 is evident that large unconscious complexes, representing 
 experiences, may be conserved and afterward reproduced 
 as a whole by stimulation of the neuron residua. Ob- 
 servation shows that this is exactly what happens ; and 
 when these complexes are of an unhealthy kind we call 
 them obsessions, phobias, etc., which in reality are noth- 
 ing but experiences faithfully conserved as residua and 
 reproduced from time to time. They may also be called 
 association psychoses or neuroses on the basis of their 
 mechanism. 
 
 Now another fact which has been proved by experi- 
 mentation and observation: A complex, i.e., the uncon- 
 scious residua of a complex, may be almost photograph- 
 ically conserved notwithstanding that we may not be able 
 to voluntarily reproduce it, i.e., recall the original ex- 
 perience. It may be preserved in the unconscious 
 neurons and be made to reproduce itself by some special 
 device. E.g., a childhood experience may be entirely 
 forgotten, yet that it may be still preserved is shown by 
 the fact that it can be recalled in even all its minute de- 
 tails in hypnosis, dreams, etc. When recalled in dreams 
 it often takes on a distorted form and, freed from a true 
 appreciation of its meaning, it awakens the liveliest and 
 often terrifying emotions. This latter is a matter of 
 considerable significance, for the same principle plays a 
 part in hysterical crises. 
 
FIELD OF PSYCHOTHERAPY 21 
 
 Another fact of observation needs to be grasped in all 
 its significance, for it underlies one practical method of 
 psychotherapy. The failure to appreciate this has led 
 to misunderstandings of the principle of hypnotic sug- 
 gestion and indirectly to a denial that such suggestions 
 are of therapeutic value, while at the same time it is ad- 
 mitted that waking suggestion is efficacious. The fact 
 is this : It makes no difference in what state complexes are 
 formed, whether in every day life, in sleep, trance, dis- 
 sociated personality, subconscious states or hypnosis, 
 they are or may be equally firmly organized and con- 
 served, and they are conserved whether we can volun- 
 tarily recall the experiences or not. Whether they are to 
 become organized depends upon the mode and conditions 
 under which the impression is made upon the mind or nerv- 
 ous system, but once organized they are conserved and 
 become a part of our personality. We cannot get rid 
 of them unless they are eff*aced by the corroding action 
 of time or disease. We are accustomed to think of ex- 
 periences belonging to such states as not belonging to 
 ourselves. This is a mistake. All experiences, however, 
 and wherever formed, if conserved, are a part of our- 
 selves and belong to the storehouse of our knowledge, 
 though we may or may not afterwards draw upon that 
 storehouse in practical life. We know that dreams which 
 are ^lot even remembered may be not only conserved but 
 may influence the personality during quite long periods 
 of time for good or for ill. I have now a case under 
 observation where an idea complex occurring in a dream 
 persisted after waking as an obsession, and has contin- 
 ued as such to the present time, a period of twelve years. 
 
 If a complex, then, of ideas, which make up points of 
 view, attitudes of mind, beliefs, hopes, and aspirations, 
 is once firmly formed and organized in hypnosis, it re- 
 mains as a part of our personality. 
 
 / 
 
2« PSYCHOTHERAPEUTICS 
 
 Further, experimentation and clinical observation have 
 conclusively proven that a complex of ideas formed in 
 hypnosis, whether remembered when the personality is 
 
 \ awake or not, can affect, modify, or determine the ideas, 
 beliefs, feelings, emotions, etc., of the individual. The 
 elements of the hypnotic complex enter the stream of 
 thought of every-day life and modify it. Whether it will 
 do so or not depends on various conditions. How it does 
 so is another question which we cannot enter into here. 
 That it may do so is a fact which can be proven as often 
 as we wish to try the experiment. If this is so when 
 there is complete amnesia after waking from hypnosis 
 it can be understood how much more easily it may be the 
 case when, as happens in nine tenths of such procedures, 
 
 \ hypnosis is little more than a state of relaxation and ab- 
 straction and is not followed by amnesia, but, on the con- 
 trary, the whole hypnotic experience, all the ideas of the 
 complex which were therein formed are remembered by 
 the subject. When it is remembered that in hypnosis 
 there is increased suggestibility, and that there may be 
 induced a dissociation of all ideas which clash with and 
 antagonize the suggested ideas, thereby allowing a new 
 synthesis to be formed, we can see what a powerful influ- 
 ence can be exercised on the personality by this pro- 
 cedure. 
 
 3. DISSOCIATION 
 
 The next principle to which I would call your atten- 
 tion is one to which I have already referred above, namely 
 dissociation. It is a general principle governing the nor- 
 mal psycho-nervous mechanism and therefore in a highly 
 marked form only is pathological. A characteristic t3^pe 
 is functional amnesia by which an epoch or a long period 
 of time is blotted out of the memory. You will recall 
 cases where following an emotional trauma the preceding 
 
 
 \ 
 
FIELD OF PSYCHOTHERAPY 2^ 
 
 hours or days or months are forgotten. The experi- 
 ences of this time cannot be recalled as memories; but 
 they are still preserved as brain residua, for they can be 
 reproduced by artificial means through hypnosis and 
 other methods. The amnesia for the hypnotic state and 
 dreams after waking is also due to the same principle, as 
 is also that following numerous other states which I can- 
 not spare the time to mention here. What has happened 
 in such conditions is a dissociation between the systems 
 of brain residua which correspond to the psychological 
 experiences. There is an inability to synthesize these 
 systems into one personality and hence the amnesia. 
 
 Amnesia, of course, as a technical term, includes 
 only ideas, but dissociated systems or complexes may in- 
 clude motor and sensory functions, and these we meet 
 with as paralyses and anesthesias as observed in hysteria. 
 That such dissociations are purely functional is shown 
 by the fact that they can be produced by suggestion and 
 removed (synthesis) by suggestion. When, as some- 
 times happens, a single symptom like paralysis and anes- 
 thesia cannot be removed by suggestion, if the whole dis- 
 sociated system to which this symptom belongs is synthe- 
 sized by suggestion the symptom, paralysis or anesthesia, 
 disappears. Here again we have a fact important for 
 psychotherapeutics, — the fact that we can produce dis-^ 
 sociation and synthesis by suggestion, — for if, as experi- 
 mental investigation has shown, the basis of certain 
 psycho-pathological conditions like hysteria is dissocia- 
 tion, we have a means at our command which may be used 
 for the resynthesizing of the personality, i.e., the res- 
 toration of the normal individual. It is important not 
 to lose sight of the fact that dissociation is a function of 
 the normal mechanism of the mind and nervous system, 
 and is made use of in normal life for the adaptation of 
 the individual to the constant and ceaseless changes of 
 
U PSYCHOTHERAPEUTICS 
 
 the environment. It is the enormous exaggeration and 
 perversion of this dissociating mechanism that consti- 
 tutes abnormality. A suggested idea simply stimulates 
 and makes use of the normal mechanism, otherwise it can 
 have no effect. 
 
 Among the normal phenomena of dissociation are to 
 be reckoned temporary and some permanent forms of 
 forget fulness, the limitation of the field of consciousness 
 in absent-mindedness, moods, anger, and other strong 
 emotional states and sleep. Amongst the artificial and 
 pathological conditions characterizing largely or chiefly 
 the dissociations are hypnotic and hypnoidal states; sug- 
 gested and hysterical amnesia, paralyses, contractures, 
 anesthesia?, etc. ; somnambulism, trance, psycholeptic at- 
 tacks, etc. 
 
 Emotion, again, is a powerful factor in producing dis- 
 sociation as well as the linking and conservation of com- 
 plexes. 
 
 In the so-called neurasthenic state and hysteria, disso- 
 ciation plays a very important part. All cases of hys- 
 teria and many of neurasthenia are, as I see the matter, 
 cases of dissociated personality,^ but it would carry us 
 too far from our main subject to discuss this aspect of 
 the matter at this time. 
 
 Subconscious Ideas, There are certain important phe- 
 nomena of dissociation and conservation that ought not 
 to be omitted, considering the important part which they 
 sometimes play, and the large amount of attention which 
 they have received. 
 
 When the conserved residua of an unconscious com- 
 plex are stimulated, this complex becomes a conscious 
 memory of which we are aware, but sometimes something 
 
 5 Morton Prince: Hysteria from the Point of View of Disso- 
 ciated Personality, Jouenal or Abnorsial Psychology, October, 
 1906. 
 
FIELD OF PSYCHOTHERAPY 25 
 
 else happens — it becomes a conscious memory of which 
 we are not aware. Ideas are awakened, but we are not 
 aware of them. These are what are called subconscious, 
 or better, co-conscious ideas, which means ideas disso- 
 ciated from, split off from the main consciousness. This 
 is an interpretation of certain phenomena belonging to 
 abnormal psychology which would carry us too far afield 
 to consider here; but the evidence is so strong that it is 
 impossible to resist the conclusion. Now when this is the 
 case such ideas often resemble dreams — fixed dreams. 
 The ideas, like dreams freed from the control of the per- 
 sonal consciousness which has no appreciation of their 
 existence or meaning, take on a distorted form, and when 
 accompanied by emotions acquire all the characteristics 
 of nightmares — subconscious nightmares they may be 
 called. That they should produce psychological and 
 mental disturbances is not to be wondered at. This is 
 what is sometimes found in hysteria when they produce 
 the so-called hysterical crises. To get rid of such sub- 
 conscious nightmares must plainly be an object for psy- 
 chotherapy. A simple type of the dissociated co-con- 
 scious idea is found in hysterical anesthesia. Here there 
 is no absolute anesthesia. The lost tactile sensations are 
 only split off from the personal consciousness and, al- 
 though the patient is unaware of them, they are pre- 
 served as co-conscious perceptions or tactual ideas. To 
 resyntheslze these perceptions with the personal con- 
 sciousness is to make the patient aware of them and re- 
 move the anesthesia. 
 
 I pass over as a controversial matter the mechanism 
 by which co-conscious ideas are dissociated from the main 
 content of the personal consciousness, i.e., by which the 
 person becomes no longer aware of them. Differing views 
 are maintained. By some it is held that in disease, as In 
 hysteria, the splitting of the mind is due to fatigue and 
 
£6 PSYCHOTHERAPEUTICS 
 
 emotional trauma; by others that it is due to the direct 
 volitional repression, or the pushing out of conscious- 
 ness of ideas which are unacceptable to the individual. 
 But whichever mechanism is the correct one, whether dis- 
 sociation is brought about by voluntarily repressing 
 painful or unacceptable ideas or whether by an over-in- 
 tense stimulus from an emotional trauma to which the 
 individual is not adapted, or by fatigue, in any case the 
 pathological dissociation is but an exaggeration or per- 
 version of a normal dissociating mechanism. That it 
 still remains functional is shown by the fact that a 
 functional stimulus (suggestion) is capable of producing 
 it and removing it. We have here a type of functional 
 disease which is somewhat different in form from that 
 which results from the educational process, although this 
 may come later into play in evolving subsidiary symp- 
 toms. I hardly need point out that the secondary effects 
 of dissociation — hysterical stigmata, etc. — are but the 
 products of the normal functioning of the mutilated and 
 dissociated fragments of the personality. 
 
 4. AUTOMATISM 
 
 In the mechanism of normal psychic life, automatism 
 plays a much larger part than is generally realized. 
 This principle tends to the economy of effort. We see it 
 in habit actions and absent-minded acts when our atten- 
 tion is directed to some other train of thought than that 
 engaged in the actions. Even language symbols tend to 
 become associated into set phrases and formulas, which 
 tend to become automatic and labor-saving devices for 
 the expression of thought. In expletives and explosive 
 phrases which almost unconsciously give vent to our feel- 
 ings we easily recognize these language automatisms. 
 Less conspicuous as automatisms is the activity of com- 
 plexes of ideas, however formed, which function more or 
 
FIELD OF PSYCHOTHERAPY %n 
 
 less automatically as a group and determine the direc- 
 tion of our thought and its content. The association 
 experiments have done much to bring to light this auto- 
 matic activity of complexes, and we are under deep obli- 
 gations to Freud, Bleuler, and Jung for having directed 
 our attention to this principle and emphasized these par- 
 ticular facts. In pathological fixed ideas which rush 
 into consciousness unbidden and undesired we can clearly 
 see this automatic activity. So in establishing fixed hab- 
 its of thought, in forming deeply rooted ideas and points 
 of view, beliefs, etc., we form complexes which are cap- 
 able of more or less autonomous action. 
 
 When psychological and physiological processes be- 
 come dissociated, and thereby freed from the inhibitory 
 control of the personal consciousness, automatism is ob- 
 served in its most highly developed form. The split off 
 groups of psychological or physiological elements ac- 
 quire what may be called a hyper-excitability and are 
 capable of extremely independent functioning. The 
 manifestations may be in the form of subconscious ideas, 
 hallucinations (sensory automatisms), tics, spasms, con- 
 vulsions, contractures (motor automatisms), etc. Pri- 
 marily such pathological phenomena depend upon disso- 
 ciation of the nervous organism and the stimulus by some 
 excitation from within or without of the nervous mechan- 
 ism involved. With reassociation and cessation of stim- 
 ulus the automatisms logically cease. The aim of psy- 
 chotherapy, therefore, must plainly be to reassociate the 
 split up personality, and to form such healthy complexes 
 of ideas as will not stimulate the undesired complexes, 
 but by their automatic activity will contribute to the 
 well-being of the individual and adapt him to his environ- 
 ment. 
 
 6. EMOTIONAL ENERGY 
 
 It is a fact of observation that intense sthenic emo- 
 
^ PSYCHOTHERAPEUTICS 
 
 tions and feelings are accompanied by an increase of the 
 vital functions while, per contra, certain depressive emo- 
 tions and feelings are accompanied by a decrease of the 
 vital functions. Further, it is generally recognized by 
 psychologists that most, if not all, ideas have a feeling 
 tone attached to them. Consequently if certain com- 
 plexes of ideas which have intense sthenic feeling tones 
 are brought into the personal consciousnesi? there is 
 awakened a state of energy, a feeling of wellbeing and 
 capacity, and an invigoration of the whole organism. 
 If, on the other hand, complexes of ideas which have de- 
 pressive or distressing feeling tones are brought into 
 the personal consciousness, the contrary effect is pro- 
 duced. Stating the same fact in another way, exalting 
 emotions have an intense synthesizing effect while de- 
 pressing emotions have a disintegrating effect. This 
 last we see exemplified in emotional trauma (traumatic 
 neuroses) where sometimes a complete dissociation or 
 splitting of the personality occurs, being manifested by 
 altered personality, anesthesia, paralysis, etc. Every 
 one who has studied the hypnotic states must have ob- 
 served these phenomena experimentally produced. With 
 the in rushing of depressive memories or ideas whether 
 originating autochthonously in the associations of the 
 mind of the patient, or accidentally or intentionally sug- 
 gested by the experimenter, there is suddenly developed 
 a condition of fatigue, illbeing, and disintegration, fol- 
 lowed after waking by a return or accentuation of all 
 the neurasthenic symptoms. If on the other hand exalt- 
 ing ideas and memories are introduced and brought into 
 the limelight of attention there is almost a magical re- 
 versal of the process. The patient feels strong and 
 energetic, the neurasthenic symptoms disappear, and he 
 exhibits a capacity for sustained effort. He becomes 
 revitalized so to speak. This, I believe, is the secret of 
 
FIELD OF PSYCHOTHERAPY 29 
 
 those changes of character and physical capacity which 
 William James has so brilliantly illuminated in his essay 
 on the " Energies of Men." Complexes of ideas accom- 
 panied by strong feeling tones which have long lain fal- 
 low are brought out of their dormant abode and made to 
 become a part of the working force of the mental fac- 
 tory. 
 
 In this principle, then, we see a mechanism which tends 
 to the development of the neuroses and psychoses on the 
 one hand, and to states of invigorating health on the 
 other, according as whether disintegrating or synthesiz- 
 ing emotions and feelings are brought into the conscious 
 field of the individual. In the hypnoidal state of Sidis 
 and in hypnosis it is particularly easy to bring out of 
 the dormant consciousness into this active central field 
 memories and ideas which have been pushed aside or upon 
 which the individual has lost his grip by reason of their 
 having become dissociated by fatigue, friction with the / 
 environment, or by other disintegrating factors. It is 
 thus easy to modify the personality at will by measures 
 which make use of this principle. The transformation 
 effected by the development of energy in this way is often 
 most striking and is often commented upon by the pa- 
 tient. On the other hand, I have observed that when for 
 any reason depressive memories and such idea-complexes 
 enter and remain in the mind of the hypnotized subject, 
 no matter what suggestions are given, the patient on 
 waking becomes or remains correspondingly depressed 
 and neurasthenic. 
 
 I have thus far briefly formulated the main psycholog- 
 ical principles upon which psychotherapy rests. The 
 point I wish to bring out into strong relief is that these 
 principles or tendencies govern the normal functioning 
 of the psycho-nervous system, and that it is the perver- 
 sion of these tendencies which constitute functional 
 
30 PSYCHOTHERAPEUTICS 
 
 disease; that is to say reactions which misadapt the in- 
 dividual to his environment and which result from normal 
 functioning under conditions to which the individual is 
 not adapted. Functional disease is therefore a process 
 of perverted functioning. Conversely psychotherapy 
 makes use of these same principles or tendencies to re- 
 adapt the individual to his environment, to re-educate 
 him to healthy reactions. 
 
 Psychotherapy simply makes use of the normal mechan- 
 ism of the mind and body, of the physiological machinery 
 to bring about a restitution of the disordered functions 
 and restore the individual to health. Thus suggestion 
 can only act by stimulating the physiological mechanism, 
 it can only make use of machinery already provided; it 
 cannot create anything anew, do anything that is not in 
 accord with the laws of the nervous system. As a method 
 psychotherapy is comparable in every way to what is 
 now known as physiological therapeutics which has taken 
 such an important place in modern treatment in internal 
 medicine. 
 
 I fear my exposition has been too brief to enable these 
 principles to be clearly grasped by those who have not 
 systematically studied and observed the phenomena of 
 abnormal psychology. The field of investigation is a 
 wide one, and to thoroughly comprehend the meaning of 
 the facts that are to be observed one must make himself 
 familiar with them at first hand as one would expect to 
 do in bacteriology if he would understand the principles 
 of infectious disease and immunity. 
 
 The psychological principles I have attempted to elu- 
 cidate may be summed up as: First, Complex formation; 
 second. Conservatism ; third, Dissociation ; fourth. Autom- 
 atism; fifth. Emotional Energy. 
 
 Each of these principles is made use of by psycho- 
 therapy in greater or less degree according to the con- 
 
FIELD OF PSYCHOTHERAPY 31 
 
 ditions presented. If we are dealing with a simple psy- 
 cho-neurosis of the neurasthenic type where the dis- 
 turbance can be traced to the first class of facts I have 
 mentioned,— i.e., to unhealthy ideas, self-examination, 
 worry, erroneous beliefs in and apprehension of disease 
 with the depressive emotional tones that go with such 
 states, to habits of introspection and concentration of 
 the mind on the functions of the body, etc., — the main 
 principle to be made use of is the organization and sub- 
 stitution of healthy complexes in place of the unhealthy 
 ones. This is not a simple procedure, but an art. It 
 often requires all the skill which can be acquired from a 
 knowledge of human nature, of life, the data of abnor- 
 mal psychology, and, above all, from a recognition of 
 the principles above formulated. The point of view, the 
 attitude of mind, the beliefs, the habits of thought, must 
 be modified by the introduction of new points of view, of 
 data previously unknown to the patient and drawn from 
 the wider experience of the physician ; by instruction in 
 the meaning of symptoms and in their organization and 
 causes; by the suggestion of expectations that justly 
 may be fulfilled ; of ambitions that ought rightfully to Ibe 
 entertained ; of duties to be assumed but •too long neg- 
 lected; of confidence and hope; and, above all, by the 
 suggestion of the emotion and joy that go with success 
 and a roseate vista of a new life. There is no fact of 
 life that does not have more than one aspect, no conduct 
 that does not have more than one interpretation, no 
 judgment that does not have an alternative, no conduct 
 that does not have more than one relation. Thus the 
 old systems of ideas carrying with them apprehensions, 
 anxieties, and depressive emotions are modified by being 
 interwoven with new ones, and «^w systems of ideas or 
 complexes are artfully created and substituted for the 
 old. These systems should be such as will stimulate 
 
32 PSYCHOTHERAPEUTICS 
 
 healthy reactions of the body in place of the unhealthy) 
 perverted reactions. 
 
 Finally the whole complex, by repetition, emphasis, and 
 the stimulus of emotion, is firmly linked and organized 
 until is becomes conserved as unconscious brain residua i 
 and a part of the individual's personality. If thus con- 
 served it will be reproduced whenever stimulated. To be 
 effective ideas must be fixed, conserved, else they become: 
 the sport of every passing thought and feeling. ButI 
 for this they must be accepted and to be accepted they, 
 must be the truth, as they should be on ethical and ra- 
 tionalistic grounds. Every person can bear the truth 
 but it should be the whole truth and not half the truth on 
 only one aspect of the truth or the truth that allows 
 erroneous interpretations. All this therapeutic pro- 
 cedure of course means the education, or perhaps better, 
 the re-education of the patient. It is the same process 
 that in Pawlow's dogs led to the secretion of gastric 
 juice and saliva by educated reactions to the environ- 
 ment, and in hay fever neurotics to the creation of the 
 coryza complex as a perverted reaction to mental and 
 physical stimuli. Only the therapeutic process is the 
 association through education of healthy ideas and 
 stimuli that adapt the individual to his environm.ent. 
 
 6. THE RELATIVE ADVANTAGES OF EDUCATION IN HYPNOSIS 
 AND IN THE WAKING STATE 
 
 This is a much discussed question. One meets oftei 
 rwith assertions rather than arguments which are mad^ 
 / with a warmth and acrimony of feeling that betokens 
 prejudice rather than a masterly knowledge of the sub- 
 ject. From the point of view of formation of complexes 
 it must be evident, if the psychological principles which 
 I have set forth are well grounded, that it matters little 
 in what state these therapeutic systems of ideas are 
 
I 
 
 FIELD OF PSYCHOTHERAPY SS 
 
 formed, whether in hypnosis or in the waking state. 
 When once formed they become a part of our personal- 
 ity and take part in swelling, modifying, and directing 
 the stream of mental life. This can readily be appre- 
 hended when it is remembered that in ninety per cent of 
 cases so-called hypnosis is little more, as I have already 
 said, than a condition of abstraction with relaxation in 
 which suggestibility is heightened. On returning to the 
 full waking state there is complete memory of the whole 
 hypnotic episode, so that the suggested ideas are accu- 
 rately remembered. As a matter of fact hypnosis is only 
 necessary in a small minority of cases. In obstinate 
 cases hypnosis has the advantage that, suggestibility be- 
 ing increased and antagonistic ideas being dissociated or 
 inhibited, the new ideas are more readily accepted and 
 the complexes more easily and firmly organized. Then, 
 after waking, the patient who remembers the suggested 
 complexes finds that his whole state of mind is modified. 
 But even when amnesia follows after waking the result 
 is the same. Then ^ on examination we find, however 
 complicated, that the suggested ideas and emotions 
 weave themselves into the thoughts of the conscious in- 
 dividual and modify them; or the emotions, alone, may 
 intrude themselves and determine the mood and the whole 
 psychic content. To take an actual case, I suggest to 
 B. C. A., in hypnosis, ideas of wellbeing, of recovery from 
 her infirmity ; I picture a future roseate with hope, stim- 
 ulate her ambitions with suggestions of duties to be per- 
 formed, deeds to be accomplished. With all this there 
 goes an emotional tone of exaltation which takes the 
 place of the depression and of the sense of failure pre- 
 viously present. This emotional tone gives increased 
 energy to her organization, revitalizing, as it were, her 
 
 6 Cf. The Unconscious, Journal of Abnormal Psychology, 
 April — May, 1909. 
 
T 
 
 34 PSYCHOTHERAPEUTICS 
 
 pyscho-physiological processes. The whole I weave art- 
 fully and designedly into a complex. Whatever neurotic 
 symptoms were previously present, I do not allow to en- 
 ter this complex. Indeed, the complex is such that they 
 are incompatible with it. The headache, nausea, and 
 other bodily discomforts, pure functional disturbances 
 in this instance, are dissociated and cease to torment. 
 After " waking," there is complete amnesia for the com- 
 plex. Yet it is still organized, for it can be recovered 
 again in hypnosis. It is simply dormant. But the emo- 
 tional tone still persists after waking and invades the 
 personal synthesis which takes on a correspondingly 
 ecstatic tone. The aspect of her environment, her con- 
 ception of her relation to the world, and her past, pres- 
 ent, and future mental life have become colored, so to 
 speak, by the new feeling, as if under a new light. But 
 more than this, new syntheses have been formed with 
 new tones. If we probe deep enough we find that many 
 ideas of the dormant complex have, through association 
 with the environment (point de repere), become inter- 
 woven with those of the previous personal consciousness 
 and given all a new meaning. A moment ago [her view 
 was that] she was an invalid, incapacitated, exiled from 
 her social and family life, etc. What was there to look 
 forward to.? Now: What of that? She is infinitely bet- 
 ter; what a tremendous gain; at such a rate of progress 
 in a short time a new life will be open to her, etc., — 
 radically new point of view. Now, too, she feels buoyant 
 with health and energy, ready to start afresh on her cru- 
 sade for health and life. Her neurotic symptoms have 
 vanished. Such is the change that she gratefully speaks 
 of it as the work of a wizard. But the mechanism of the 
 transformation is simple enough. The exaltation, arti- 
 ficially suggested in hypnosis, persists, altering the trend 
 of her ideas and giving new energy. The perceptions 
 
FIELD OF PSYCHOTHERAPY 35 
 
 of her environment, cognition of herself, etc., have en- 
 tered into new syntheses which the introduction of new 
 ideas, new points of view have developed; thus the con- 
 tent of her ideas has taken a definite precise shape. 
 Whence came these new ideas? They seem to her to have 
 come miraculously, for she has forgotten the hypnotic 
 complex. But forgetting an experience is not equiva- 
 lent to its not having happened or to that experience not 
 having been a part of our own psychic life. The hyp- 
 notic consciousness remains a part of one's self (as a 
 psychological complex), however absolutely we have lost 
 awareness of it. Its experiences become fixed though 
 dormant, just as do the experiences of our personal con- 
 scious life. . . . The mechanism is the same. 
 
 The following letter from this patient, received by 
 chance after these paragraphs were written, well ex- 
 presses the psychological conditions following hypnotic 
 suggestion. 
 
 " Something has happened to me — I have a new point 
 of view. I don't know what has changed me so all at 
 once, but it is as if scales had fallen from my eyes ; I see 
 
 things differently. That affair at L was nothing 
 
 to be ashamed of, Dr. Prince. I showed none of the 
 common sense which I really possess ; I regret it bitterly ; 
 but I was not myself and even as [it was] I did nothing 
 to be ashamed of — quite the contrary, indeed. . . . 
 Anyway, for some reason — I don't know why, but per- 
 haps you do — I have regained my own self-respect and 
 find to my amazement that I need never have lost it. You 
 know what I was a year ago — you know what I am now ; 
 not much to be proud of, perhaps, but I am the work of 
 your hands and a great improvement on [my poor old 
 self]. I owe you what is worth far more than life itself 
 . . . namely, the desire to live. You have given me life 
 and you have given me something to fill it with ... I 
 
66 PSYCHOTHERAPEUTICS 
 
 feel more like myself than for a long time. I am * ray 
 own man again ' so to say, and if you keep me and help 
 me a little longer I shall be well." 
 
 /^ When dissociation exists it becomes self-evident that a 
 restoration of the healthy organization can only be at- 
 tained by a reassociation of the dissociated functions. 
 It is obvious that subconscious ideas, when disturbing, 
 need either to be so modified that they cease to function, 
 i.e., to be subconscious and dissociated, or to be rein- 
 tegrated with the personal consciousness, i.e., brought 
 into the full light of conscious knowledge, and thereby 
 realized in all their meaning, rearranged and modified; 
 just as a dream becomes modified and loses its psycho- 
 logical meaning and its physiological effects after waking 
 with a full awareness of its falsity. Disintegrated per- 
 sonality needs to be reassociated into a unified complete 
 personality, with full possession of its faculties and 
 functions, etc. There are many empirical ways of doing 
 this, physical and psychological, but amongst the meth- 
 ods experience has shown that there are several psycho- 
 logical procedures which are rational and prove effica- 
 cious when physical and empirical methods fail. So- 
 called psycho-analysis, suggestion in the waking state 
 and abstraction, in so-called hypnoidal states and hyp- 
 nosis, mental and physical hygiene, all have proved to be 
 efficient in bringing about a reintegration of dissociated 
 functions. But all these methods are only different 
 forms of education. 
 
 The principle of dissociation and association is exem- 
 plified by the process of hypnotizing and awaking an in- 
 dividual. Hypnosis is dissociation ; in awaking a person 
 what we do is to re-synthesize the personality and to re- 
 store the normally functioning organism. 
 
 Finally I would point out that a prerequisite for such 
 
FIELD OF PSYCHOTHERAPY 87 
 
 psychotherapeutic measures is a preliminary painstaking 
 and exhaustive analysis of the symptoms, of the genesis 
 of the psychosis, of the logical relation of the symptoms 
 to each other and to mental and external causes, of the 
 pathology of the symptoms and their significance; what 
 are due to auto-suggestion, what to habit or education, 
 what to fatigue, what to true organic disease — in short 
 the complete meaning or philosophy of the disease must 
 be determined. If, as is often the case, incidents in 
 whf'ch the psychosis developed or which are the subcon- 
 scious cause of repeated attacks are forgotten, the memo- 
 ries of these should be revived by one or the other of 
 various technical methods of psycho-analysis. Only 
 through a knowledge gained in this way in each individ- 
 ual case can a rational psychotherapy be undertaken. 
 After such an analysis it is generally surprising to find 
 that what at first seemed a mere chaos of unrelated 
 symptoms will turn out to be governed by law and order. 
 
 '7. HYSTERIA 
 
 When we come to deal with the more^profound psycho- 
 neurotic states, those of the severer hysterias, a some- 
 what different therapeutic procedure is usually required. 
 Here we have to do with dissociations, often of a pro- 
 I found type, with paralysis, anesthesia, alj^rations of per- 
 I sonality and subconscious ideas of which th6 patient is 
 I unaware, or unconscious automatisms freed from the in- 
 I hibitions of a fully synthesized personality. For psy- 
 i chotherapy reassociation of the dissociated functions is 
 ! the essential principle, although again the formation of 
 i new healthy complexes is necessary to maintain the as- 
 I sociation. Our ingenuity is often taxed to the utmost 
 I in devising methods to reintegrate the psycho-physiolog- 
 I ical personality. Various technical devices can be made 
 1 use of. I cannot go into this here, as I am only dealing 
 
38 PSYCHOTHERAPEUTICS 
 
 with principles. Suffice it to say that sometimes rein- 
 tegration can be formed in a special state of hypnosis; 
 sometimes by suggestion in hypnosis or to the waking 
 personality; sometimes by recalling to the full light of 
 the waking consciousness the subconscious ideas or 
 " dreams " ; sometimes by recalling them to the full light 
 of the hypnotic consciousness, etc. By doing this the 
 subconscious " dream " or fixed idea — generally a mem- 
 ory of some emotional incident — becomes fully recog- 
 nized as to its meaning and character, and thereby inter- 
 woven with the logical processes of waking thought; in 
 other words, synthesized into a new, healthy complex. 
 We see the same principle when, on waking from a night- 
 mare, not only the dream but the realization that it was 
 a dream comes into the full light of consciousness. With 
 this realization the terrors and all the bodily disturbances 
 cease. 
 
 I have pointed out that one theory of the mechanism 
 by which ideas become dissociated is that of voluntary 
 repression; the individual pushes out of his conscious- 
 ness ideas which are painful and unacceptable. Conse- 
 quently it is held by those who adopt this theory that 
 those dissociated ideas must be resynthesized with the 
 personality, i.e., brought to the full light of awareness 
 — to effect a complete and permanent cure, and that the 
 mere act of making the patient aware of them effects the 
 cure. To accomplish this a special form of psycho- 
 analysis (Freud's) has been devised, not only to dis- 
 cover the dissociated ideas, but to synthesize them. 
 
 That this method is often useful and efficacious will be 
 admitted, but its mode of working, as I interpret it, is 
 not that which those who employ it suppose. Like other 
 methods too, it is not always successful nor is it the only 
 effective one. 
 
 Thus it is often not difficult by suggestion, with or 
 
FIELD OF PSYCHOTHERAPY 39 
 
 without hypnosis, along the lines I have described, to 
 effect a cure although the patient never becomes aware 
 of the troubling ideas. More than this, it is worth while 
 insisting that if psycho-analysis merely synthesizes the 
 repressed ideas theoretically it is not the logical method 
 to be employed. The assumed mechanism would require 
 something more. The repressed ideas are pushed into 
 the subconscious because they are^n conflict with other 
 wishes and feelings of the individual; \^e latter rebels 
 against and will not tolerate them. Now if nothing more 
 were done than to bring them back into the conscious- 
 ness of the individual he still would not tolerate them and 
 would push them out again. Theoretically, therefore, 
 the method would be useless. But in fact the patient 
 does, we will say, tolerate the ideas that before were un- 
 bearable; the conflict ceases. Empirically the method 
 works. Why? The reason is simple: the complex of 
 ideas has been changed by the technique of psycho-analy- 
 sis and by the very act of bringing to the light of con- 
 sciousness the repressed ideas — an elaborate process. 
 We do more than this : we give the patient an insight into 
 the meaning of his trouble; we let him see new points of 
 view; we introduce new ideas and feelings into his com- 
 plexes ; in short, re-educate him. It is impossible to 
 practice psycho-analysis without doing this ; hence, it is 
 nothing more than a special form of the educational 
 treatment and has the same therapeutic value. 
 
 When the hysterical manifestations are due to the 
 functioning of dissociated subconscious ideas it is not 
 always necessary, as some writers insist, to recall those 
 ideas to the personal waking consciousness. It is enough 
 to break up the subconscious complex or to suggest an- 
 tagonistic ideas, or to resynthesize the ideas, in the man- 
 ner already described, into a healthy complex which gives 
 a true appreciation of the facts which they represent. 
 
40 PSYCHOTHERAPEUTICS 
 
 This can be done in hypnosis. After waking., though 
 amnesia for the previous subconscious ideas may persist, 
 the symptoms disappear, for those harmful subconscious 
 ideas which caused the trouble have ceased to exist. 
 
 Some hysterical attacks are what have been aptly 
 called by Boris Sidis recurrent mental and psychomotor 
 states; that is, dissociations of the personality and the 
 reproduction of systems of ideas which originally were 
 an emotional mental accident that the patient once upon 
 a time experienced. These experiences have been con- 
 served as brain residua and come to life again from time 
 to time as attacks. If a rearrangement of these con- 
 served experiences, by education along the lines already 
 laid down, can be brought about, a disappearance of the 
 attacks may be expected. 
 
 Hysterical attacks that are due to auto-suggestion can 
 be removed, as a rule, by simple suggestion. Automa- 
 tisms, like contractures, tics, spasms, convulsions and 
 crises, tend to cease with the restoration of the fully 
 synthesized personality if the dissociating apprehensions 
 and emotions have been removed and healthy complexes 
 have been substituted therefor. 
 
 Whatever technical methods are employed, it will be 
 found that they are all based on the psychological prin- 
 ciples which have been above discussed. 
 
 It is needless to insist that a preliminary psycho-analy- 
 sis is, as always in psychotherapy, a prerequisite pro- 
 cedure. 
 
 8. PSYCHASTHENIA AND OBSESSIONS 
 
 In so-called psychasthenia we are dealing with a some- 
 what different pathological condition from hysteria. 
 Here we have recurrent mental states in the from of ob- 
 sessions, represented by doubts, scruples, anxieties, 
 phobias, impulsions, etc. The obsessional ideas are pre- 
 
FIELD OF PSYCHOTHERAPY 41 
 
 served as brain residua. When stimulated, instead of 
 becoming subconscious, they enter the consciousness of 
 the principal personality. The obsessional ideas occur 
 in the form of attacks of which psycho-analysis will not 
 only show the origin and meaning but that the attack in 
 each instance is excited by association with some related 
 thought which has flashed into the mind or other stim- 
 ulus from the environment. Apprehension and expecta- 
 tion, acting as auto-suggestion, play in my experience a 
 predisposing part in the mechanism. The pathology is 
 too complex to go into here, but the same psychological 
 principles underlie the psychotherapy, viz., psycho-analy- 
 sis and education, the latter having for an end the sub- 
 stitution of healthy complexes for those organized 
 systems of associated ideas which have become conserved 
 as residua in the unconscious and which reproduce them- 
 selves as automatisms over and over again. 
 
CHAPTER TWO 
 
 The Therapeutic Value of Hypnotic Suggestion 
 
 by feederic henry gerrish, m.d., ll.d. 
 Professor Emeritus of Surgery ^ Bowdoin College 
 
 IT is important that hypnotic suggestion should not be 
 confounded with other psychotherapeutic methods — 
 it is only one of various psychic means by which 
 curative results can be attained; and in my advocacy of 
 it as a valuable remedy there is no intention to disparage 
 or belittle any of the other psychotherapeutic methods, 
 or even to institute a comparison between it and them. 
 We ought to have a scientific acquaintance with all of 
 them, so that we can select whatever method is best 
 adapted to any case in which some psychic remedy is 
 needed. It is pertinent to remark at this point that, as 
 hypnotic suggestion is treated in this essay, it will not 
 be included in the topics of the symposium on psycho- 
 therapy. 
 
 Although the history of hypnotism is intensely inter- 
 esting, nothing of it will be given here, as our space is 
 quite sufficiently occupied with more important matters. 
 For the same reason the various theories which have been 
 advanced to account for its phenomena will not be re- 
 hearsed. My task is to set forth the practical useful- 
 ness of hypnotism in the daily routine of medical work, 
 and to clear away many misconceptions which have pre- 
 vented the general employment of this agency. 
 
 We are all amenable to suggestion in greater or 
 smaller degree. The training of the infant is almost 
 wholly by suggestion. To a less but yet to a very im- 
 
 42 
 
VALUE OF HYPNOTIC SUGGESTION 43 
 
 portant extent the same method is operative on the older 
 child — the example of his associates in the family or out 
 of it is more potent in the formation of his -character and 
 habits than are all the precepts that are dinned into him. 
 As one's years increase the susceptibility to suggestion 
 gradually diminishes, apparently just in proportion to 
 the loss of naturalness and the cultivation of the artifi- 
 cial restraints which convention imposes. Suggestibil- 
 ity is generally commensurate with simplicity of nature. 
 In full maturity we have become so cautious that we in- 
 voluntarily distrust the suggestions that come to us — 
 an incredulous, perhaps even a cynical, element has crept 
 into our natures, which prompts resistance and demands 
 that reason shall be convinced. And yet some suggesti- 
 bility remains — the hardest headed of us can be reached 
 by a sufficiently frequent and skilful repetition of a sug- 
 gestion. This suggestibility is the basis of the benefit 
 that undoubtedly comes to the patient from the cheer- 
 fulness of the physician, from his heartening words, from 
 his confident assurance that recovery is ahead, from his 
 strong personality and appearance of wellbeing — for 
 health is, in a measure, catching, as well as disease — 
 from his irradiation of strength, of comfort, and of cour- 
 age. Now, in the condition which is known as hypnosis, 
 suggestibility is marvelously increased. Suggestions 
 which in the ordinary condition of the personality are 
 unheeded, in the hypnotic state are accepted with avid- 
 ity. So large is this hospitality that almost any sug- 
 gestion will be welcomed that is not repugnant to the 
 moral sense of the hypnotized person. This eagerness 
 for suggestion may be taken advantage of in therapeu- 
 tics. If the patient is the victim of a disease to which 
 the name " functional " is usually applied, and can be 
 hypnotized, he has a good chance of getting relief 
 through the agency of suggestion; if his malady is or- 
 
U PSYCHOTHERAPEUTICS 
 
 ganic, a cure is not to be expected. (The words " func- 
 tional " and " organic " are here used in their ordinary 
 sense, as a matter of convenience.) For example, the 
 patient has insomnia, not due to any appreciable struc- 
 tural change. He is hypnotized, and the suggestion is 
 made that he will go to sleep as soon as he goes to bed, 
 and remain in slumber a given number of hours. He is 
 then brought out of the hypnotic state, and experiences 
 no immediate effect of the treatment. Perhaps he is 
 utterly incredulous, and derides the idea that a notice- 
 able impression will follow the process. But, if he is 
 as suggestible as the average, when he goes to bed, he 
 tumbles into sleep, and continues in sleep substantially 
 as predicted; or, if sleep has been suggested for a par- 
 ticular hour, he goes to sleep when the time comes, unless 
 he makes the most strenuous efforts to keep awake and 
 beat off his drowsiness. 
 
 The hypnotic state is induced not because it is in itself 
 curative, but because that condition is peculiarly favor- 
 able to the reception and retention of suggestions. It 
 is a question of the relation of soil and seed. In the 
 ordinary waking state the seed of suggestion falls on the 
 stony ground of indifference, which is hostile to its devel- 
 opment, or on ground where the rank weeds of conven- 
 tional usage spring up and choke it; but the hypnotic 
 condition furnishes the richest kind of loam for sugges- 
 tions, and in it they take root and rapidly grow up and 
 bear fruit abundantly. 
 
 Hypnosis should not be regarded as an abnormal, a 
 pathologic condition — it is simply unusual. Individu- 
 als differ widely in their capacity for hypnotization, for 
 at one extreme are some who cannot be put into that 
 state, and at the other end of the scale are some who 
 seem to be almost hypnotized all of the time. 
 
 
VALUE OF HYPNOTIC SUGGESTION 45 
 
 1. METHODS OF INDUCING HYPNOSIS 
 
 Hypnosis may be induced in various ways. That 
 which will be described has proved serviceable. (It is as- 
 sumed that the patient consents to be hypnotized, and, 
 more than that, is willing to co-operate with the physi- 
 cian.) First, the process is explained to the patient, 
 who probably has hardly a single correct idea on the 
 subject, and needs to have his misconceptions removed. 
 He is told a number of things, such as follow: 
 
 1. That all persons are more or less amenable to sug- 
 gestion in the ordinary waking condition, as is illustrated 
 in many familiar ways, such as gaping involuntarily, even 
 against one's strenuous attempts to avoid it, on seeing 
 another yawn ; beating time unconsciously on hearing the 
 measured throb of martial music; becoming wildly ex- 
 cited for no other reason than that one's companions 
 are panic-stricken; and, contrariwise, having one's fears 
 allayed by the tranquil appearance of his associates in a 
 terrible emergency. 
 
 S. That, in some way, the mental mechanism of which 
 is not thoroughly understood, when a person is hypno- 
 tized, he accepts suggestions more readily than when he 
 is in his usual condition; and that hypnosis is induced 
 only for the purpose of taking advantage of this fact, 
 and thus enabling the patient to receive the benefit of 
 suggestions, to which, in his ordinary mental state, he 
 is practically impervious. 
 
 3. That no harm to the patient in any direction will 
 result from hypnotizing, either immediately or at any 
 future time. 
 
 4. That the patient is not desired to surrender his 
 will, but, on the contrary, is asked to exercise it in co- 
 operation with the physician. 
 
 5. That he is not expected to lose consciousness, for 
 
46 PSYCHOTHERAPEUTICS 
 
 the lighter degrees of hypnosis are sufficient for the ac- 
 complishment of remedial results in all but a minority of 
 cases. 
 
 6. That the word " sleep " in this connection is a 
 term of convenience, and means only that early stage of 
 sleep that is consistent with consciousness: a transitional 
 stage which any one who has analyzed his sensations has 
 recognized as a brief period immediately preceding the 
 unconsciousness of slumber, when by an effort he can 
 become wide-awake, or by lying still and guarding his 
 mind against exciting thoughts can insure speedy and 
 perfect sleep. 
 
 7. That there will be nothing unpleasant in the process 
 — no shock, no electric-like thrill, no startling sensation ; 
 but that, if the attempt is successful, he will experience a 
 feeling as if tension was relaxed, a mental and physical 
 calm, a soothing drowsiness. 
 
 8. That he must not be discouraged by complete fail- 
 ure at the first attempt, as it often happens that the 
 excitement, incident to the novelty of the situation, de- 
 feats the efforts of both parties ; and that, when he per- 
 ceives, as he will from observing the process pursued, that 
 there is nothing ungentle or in any way objectionable 
 about it, there will probably be no difficulty in achieving 
 success. 
 
 9. That the suggestions will be made more emphat- 
 ically than will seem to him necessary ; for example, if a 
 night's sleep is desired, it will be suggested that he will 
 get twelve hours, this being on the principle followed by 
 a marksman in putting up his sight for a long shot. If 
 the barrel of the weapon is directed exactly at the bull's- 
 eye, the force of gravity will draw the projectile down- 
 ward, and the mark will be hit below the center, if at all. 
 So, too, allowance must be made for the downward 
 deflection of a suggestion in an inveterate or otherwise 
 
VALUE OF HYPNOTIC SUGGESTION 47 
 
 diificult case. As the sight of the rifle must be raised so 
 that the barrel is aimed above the mark, so the suggestion 
 must be exaggerated, must be aimed high, in order to 
 reach the desired point. 
 
 10. That the patient must not contradict or resist, 
 and must not try to open his eyes until permission is 
 given him. 
 
 The patient, thus instructed, then lies down on a couch, 
 or seats himself in a lounging chair, in which he has a 
 comfortable rest for his head. He is told to concentrate 
 his attention upon sleep, to try to go to sleep; and, to 
 assist him in this effort by preventing his taking in dis- 
 tracting ideas through his eyes, as they wander around 
 the room and see the pictures, books, and furniture, he 
 is asked to fix his gaze upon some indifferent object, as, 
 for example, the finger of the physician, which is held 
 a foot or so from the face of the patient. He is in- 
 structed not to try to keep his eyes open, and not to close 
 them voluntarily, but merely to let the lids go as they 
 will. The physician places his free hand upon the fore- 
 ! head of the patient, and, by a continuous stream of quiet, 
 ! monotonous talk, encourages the patient in his effort to 
 go to sleep. For example, he says, " Try to sleep, think 
 of nothing but sleep, keep your thoughts fixed upon go- 
 ing to sleep. Your lids are heavy, they are drooping, 
 you are going to sleep. Every moment you are getting 
 more drowsy ; you feel the sleep stealing over you. The 
 lids are closing; you are almost asleep. Now the eyes 
 have closed; you have gone to sleep." Meantime a lit- 
 tle pressure has been made upon the brows ; and, when 
 the lids slip down and cover the eyes, they are gently 
 stroked. The hand is kept upon the forehead, and the 
 • physician enforces his assurances by some such words as 
 these : " You are asleep, though you have not lost con- 
 sciousness. You hear my voice, the sounds in the house, 
 
48 PSYCHOTHERAPEUTICS 
 
 the noises in the street — and yet you are asleep. You 
 feel the sleep all through you — head, trunk, and limbs 
 are all heavy with sleep. Your nerves are all relaxed, 
 there is no tension anywhere, 3^ou are perfectly tran- 
 quilized. You will not move a muscle, except to breathe, 
 until I bid you wake." 
 
 This process may take a minute, or it may occupy a 
 quarter hour; but when it is completed the patient is 
 ready for the remedial suggestions — the soil is pre- 
 pared for the seed. Then the physician makes the nec- 
 essary suggestions, speaking them plainly, putting them 
 strongly, repeating them, emphasizing them in the most 
 positive and insistent way. Generally he cannot tell how 
 much effect has been produced; but something can be 
 judged by the degree of quietude of the patient. If he 
 is perfectly still, the probability is that all is working- 
 well; but certain limited movements are not inconsistent 
 with fine success. A constant quivering of the lids is 
 sometimes observed in the profoundest stage of hyp- 
 nosis; but swallowing commonly indicates that only a 
 slight degree has been reached. 
 
 Having finished the remedial suggestions, others are 
 made to the effect that the hypnotic state can be induced 
 more readily at each subsequent session, that the patient 
 can be hypnotized whenever he wishes it, and particularly, 
 that he can never be hypnotized by anybody without giv- 
 ing his entire consent. In this way the patient is locked 
 against the attempts of designing hypnotizers, and may 
 successfully defy any efforts to control him in this man- 
 ner. 
 
 All of the suggestions appropriate to the case having 
 been made, the patient is allowed to remain quiet for a 
 longer or shorter time, according to the seriousness of' 
 the condition — a few minutes or more than half an hour; 
 and the effect is deepened by a gentle though emphatic 
 
VALUE OF HYPNOTIC SUGGESTION 49 
 
 repetition of the suggestions. When the time for rous- 
 ing the patient comes the physician says, " You may 
 wake now." Sometimes the awakening will be prompt, 
 sometimes slow and reluctant, the latter being more 
 likely when the hypnosis has been profound. If no per- 
 mission to wake were given, the hypnotic condition would 
 gradually disappear, and the patient would rouse him- 
 self as from ordinary sleep. 
 
 This method need not be followed in detail; indeed, 
 every hypnotizer develops his' individual procedure, and 
 finds his own the best for his purposes. But there are 
 common features in all of them, the essentials — quietude, 
 confidence, gentleness, discreet sympathy, intelligent ap- 
 preciation — are practiced in various ways. 
 
 After a very few successful sessions it becomes unnec- 
 essary for the patient to begin the process with open 
 eyes ; he is instructed to close them at the first, and the 
 physician gently strokes the forehead and then the eye- 
 lids, speaking words which encourage the patient to 
 sleep, and in a few moments hypnosis is effected. JVIore 
 than this, even, in the case of some peculiarly susceptible 
 persons, the spoken command is sufficient for the induc- 
 tion of the desired condition. 
 
 In chronic cases it is generally necessary to have many 
 sessions with the patient, and speedier results are at- 
 tained, if the intervals are short. This method of treat- 
 ment is comparable with that by medicines — the doses 
 must be given frequently in order to keep the system 
 impressed, as otherwise the effect of one wears off before 
 another is administered. 
 
 Much time, great persistency, vast patience, abundant 
 
 good nature and tact are needed in the inveterate cases. 
 
 'I Perseverance in attempts to hypnotize will sometimes be 
 
 I rewarded with brilliant results, even though many early 
 
 I trials have utterly failed. 
 
 i 
 i 
 
50 PSYCHOTHERAPEUTICS 
 
 Having discussed the nature of hypnotism, and de- 
 scribed the methods of its induction, we now come to the 
 consideration of the conditions in which it can be ad- 
 vantageously employed, 
 
 2. CONDITIONS IN WHICH HYPNOTIC SUGGESTION IS 
 VALUABLE 
 
 Some authorities think that it is unscientific to separate 
 functional and organic diseases, that there is no perver- 
 sion of action independent of an alteration in structure. 
 And yet, a practical discrimination may properly be made 
 without offending pathologic proprieties; and I trust 
 that, for convenience, it is permissible for me to employ, 
 the terms in their ordinary signification. Assuming, 
 then, your indulgent forbearance, it may be said that, 
 in a general way, hypnotic suggestion finds its field in 
 the domain of functional diseases of the nervous system. 
 It may be used advantageously in relieving some of the 
 sufferings incident to organic diseases ; but in these cases 
 it is only palliative and not curative. It is not claimed 
 that all patients afflicted with such disorders as usually 
 yield to suggestion will be helped by this treatment; but 
 in this respect, as in others, the remedy resembles thera- 
 peutic agencies of physical character. It is not reason- 
 able to look for universal success with any agent, or to 
 expect that every patient will respond to any treatment 
 as does the average one. \ The ailments in which hyp- 
 nosis is of the most conspicuous value are those charac- 
 terized by pain, insomnia, abnormal nervous irritability, 
 depression of spirits, phobias, obsessions, neurasthenia, 
 moral obliquity, spasm, nausea, sexual perversions, and 
 drug habits. The cases which will be cited in illustration 
 occurred in my own practice, and are selected almost at 
 random from a vast number. The reports are neces- 
 
 I 
 
VALUE OF HYPNOTIC SUGGESTION 51 
 
 sarily limited to the essential features in order to keep 
 this chapter within reasonable bounds. 
 
 Pain. A man of 45 years of age had been operated 
 on twice for trifacial neuralgia. After each operation 
 he had experienced a year of comfort, and then the trou- 
 ble returned violently. The removal of the ganglion was 
 all that surgery offered at that time, and from this he 
 shrank on account of the danger to life ; but he was will- 
 ing to try hypnotism. When he presented himself in 
 my office, and tried to answer a question, the effort threw 
 the muscles of one side of his face into such a spasm, at- 
 tended evidently with extreme pain, that he motioned to 
 his wife to speak for him. His diet was restricted to 
 liquids, because chewing meant agony ; and he was com- 
 pelled to almost complete silence, because of the direful 
 penalty of speech. He had a treatment twice daily for 
 ten days. From the first day he was measurably re- 
 lieved, and he had no pain after the fourth day. His 
 wife went home at the end of a week, as she was no longer 
 needed as nurse and interpreter; and he followed on the 
 tenth day, declaring that there was no need of remaining, 
 as he was perfectly well, and he could return at any time 
 if his trouble came back. His abandonment of treat- 
 ment was against my judgment and advice, for the case 
 was too chronic and severe to justify the expectation 
 that it could be permanently relieved in so brief a time ; 
 but he never returned, or reported in any way. But 
 even supposing that there was not a cure, the effect of 
 the treatment illustrates the availability of the remedy 
 and its advantages over physical anodynes, which, in 
 producing an equal effect, would almost certainly estab- 
 lish a drug habit. 
 
 Insomnia. A great affliction, prolonged overwork, 
 and anxiety had so affected a man of 35 years, that his 
 capacity for sleep was seriously reduced. For three 
 
52 PSYCHOTHERAPEUTICS 
 
 months he had slept only two or three hours in the twenty- 
 four, and not only felt ill, but looked haggard and worn. 
 A single hypnotic treatment refreshed him greatly. He 
 was instructed to come daily for a while, as the case was 
 chronic and severe; but a month went by without my 
 seeing him. Then at a chance meeting he was asked to 
 give an account of himself — why he had not come often, 
 as he had promised. He joyously replied, "What's the 
 good of going to a doctor when one is perfectly well.'' 
 I slept like a log all that night, and I've slept like a log 
 every night since." Many years have passed, and he has 
 had no recurrence of insomnia. 
 
 Nervous Irritability. A young matron applied for re- 
 lief of pronounced hyperesthesia. Her sensibilities were 
 constantly on edge. The slightest sound, like that at- 
 tending the lighting of a gas jet, if it came as a sur- 
 prise, would set her nerves aquiver for an hour. In 
 railway travel she always felt obliged to take the most 
 remote available seat in the last car of the train in order 
 to be as far away as possible from the noise of the bell 
 and the whistle of the locomotive. Life was a series of 
 alarms and distresses. The first attempt at hypnosis 
 was an utter failure — the patient was wrought up to 
 the highest pitch of excitement, and therefore could not 
 concentrate her attention in the needed direction. She 
 was in despair, feeling certain that her last hope of re- 
 lief had vanished, and no encouraging assurances had any 
 effect. Two days afterward a second visit was made. 
 The patient was in tears, mourning over the assumed im- 
 possibility of being hypnotized. While she was in that 
 state of mind it was plainly useless to attempt hypnosis, 
 so the effort was made to distract her attention from 
 herself. For an hour nothing was said about patient 
 or sickness or anything depressing, and the time was 
 spent in the recital of droll stories and in whatever else 
 
 i 
 
VALUE OF HYPNOTIC SUGGESTION 53 
 
 might help to divert the self-centered and morbid current 
 of her thought. At what seemed a favorable moment 
 she was told to close her eyes, and she obeyed instantly. 
 The lids were gently stroked, and hypnotization was ac- 
 complished in that moment. Suitable suggestions were 
 made, and the cure promptly began, and was finished in 
 a few weeks. Tranquillity succeeded excitement, and life 
 took on a very different aspect. 
 
 This case shows that primary failure is no indication 
 of ultimate results. Excitement is inimical to hypnosis, 
 as it is to true sleep ; and the patient should not only be 
 willing, but calm enough to be able to concentrate his 
 attention. 
 
 Depression of Spirits, A man of 30 years, gifted, well 
 educated, and of fine character but moody disposition, 
 had been afflicted for many months with extreme depres- 
 sion, which he was utterly unable to throw off. He was 
 not a good hypnotic subject; but he was practically re- 
 stored in a fortnight of daily sessions. He became 
 cheerful, regained interest in his work, liked to mingle 
 with his friends, and now, after many years, is in full 
 enjoyment of life. 
 
 Fear of Travel on the Water. A gentleman whose 
 occupation occasionally required him to make little jour- 
 neys to the islands in the harbor had constitutionally so 
 great a dread of water-travel that sometimes he would 
 leave the steamboat just as it was about to start, aban- 
 doning the projected trip, even though he appreciated 
 the urgency of his business, which always involved the in- 
 terests of others as well as his own. After a few hyp- 
 notic sessions he was able to make excursions on the boats, 
 not only without mental disturbance, but even with some 
 enjoyment. 
 
 Extreme Timidity. A lady in early middle life gave 
 this account of her case : " Before my marriage I was a 
 
 L 
 
54 PSYCHOTHERAPEUTICS I 
 
 teacher, and experienced no trouble in addressing a room- 
 ful of people whenever my work required it. But for 
 seventeen years I have never appeared before an audi- 
 ence. To-morrow afternoon I am announced to read a 
 paper before one of the large clubs of women, and I am 
 frightened almost to death at the thought. My paper 
 is a good one, and I am not at all afraid that it will not 
 be satisfactory ; but when I try to read it aloud at home 
 and entirely alone, I break down; I cannot help seeing 
 that critical audience, and the thought of it scares me so 
 that I have to stop. Can you not hypnotize my terror; 
 out of me, and put courage in its place.'' " She was an 
 entire stranger to me, and the prospect for success was 
 not flattering. Besides, my time was so engaged that it 
 was impracticable to make an appointment before the 
 next noon. Then, only two hours before the meeting at 
 which she was to perform, she received the hypnotic sug- 
 gestion which she desired. The next day she called to 
 report. Her face was radiant, and she gave an enthusias- 
 tic account of herself, saying, " I had no fear, no diffi- 
 culty whatever in reading. A lot of the women were 
 moved to tears, and when I was through my friends 
 thronged around me with their congratulations anc 
 praised not only my essay but the way in which I read it. 
 But I told them that all the credit for that should be 
 given to hypnotism." As her name has often appeared 
 in connection with public performances since then, it is 
 fair to suppose that she has had no further difficulty. 
 
 This case may strike some as trivial, and so it is as 
 compared with many or most of those with which we have 
 to deal. But it does not seem to me unworthy of the 
 efforts of a physician. The slight ailments need wise 
 treatment, and their correction may prevent serious ill- 
 ness, may even save life. A disturbance such as this 
 woman had may easily enough be the initial step in a 
 
VALUE OF HYPNOTIC SUGGESTION 55 
 
 series that leads to an asylum; but being corrected, ob- 
 stacles are removed from the path to happy and success- 
 ful endeavor. 
 
 Obsession. A young matron from her earliest recollec- 
 tion had been in constant dread of assassination, but had 
 never mentioned the horror until she revealed it to me. 
 Even then she would not have spoken of it but that she 
 had been relieved of neuralgia by hypnotic suggestion, 
 and hoped that her greater trouble could be dissipated 
 by the same means. She was afraid of the dark, even 
 when she had a companion, and she never allowed herself 
 to be left in the house alone. Half a dozen treatments 
 cured her completely. 
 
 Neurasthenia, A lady of 43 years for a whole decade 
 had been in a condition of nervous prostration, with 
 marked digestive disturbances. She was under treat- 
 ment during the whole time, but had received no benefit. 
 She was advised to try the effect of hypnotic suggestion 
 by a physician who had declared to me with great positive- 
 ness that hypnotism was justifiable only in absolutely 
 hopeless cases, in which desperate means could be sanc- 
 tioned. After a prolonged examination the conclusion 
 was reached that no organ was appreciably diseased. 
 She was given treatment every day for a month, but 
 long before that time had elapsed she was practically 
 well. Her distresses were all banished, her feebleness dis- 
 appeared, her digestion was restored, and her spirits be- 
 came buoyant. 
 
 Moral Obliquity. A lady applied in deep distress of 
 mind concerning her ten-year-old son, a strong, healthy, 
 genial, little fellow, who had no interest in his school du- 
 ties, habitually played truant, and lied in the most aban- 
 doned manner. His nature was very affectionate, and he 
 was very fond of his mother; but she had exhausted her 
 means of influencing him without avail. She consented 
 
66 PSYCHOTHERAPEUTICS 
 
 to have hypnotism tried on him. In three weeks his par- 
 ents declared that he was a different boy. He attended 
 school regularly, took good rank in his studies, and was 
 proud of it, and his word could be relied upon implicitly. 
 
 Asthma. An old lady who had suffered from asthma 
 for many years and found no relief beyond slight pallia- 
 tion, sent for me when she was having a severe attack. 
 She had never been hypnotized, and her orthopnea for- 
 bade her lying down or even reclining, but she could en- 
 dure for a little while a slight inclination backward, so 
 that the head rested against a pillow. In this position 
 she was quickly hypnotized, and was wholly relieved in 
 a few minutes. 
 
 Seasickness. A young lady who had been across the 
 Atlantic several times, and regularly suffered nausea 
 marina, appealed to me for prophylactic treatment. She 
 had deferred the matter until a few days before her voy- 
 age, and the attention which it was possible to give her 
 seemed altogether inadequate, but the event was happy. 
 She was not at all disturbed during the journey, and took 
 her meals regularly with enjoyment, all of which was the 
 more remarkable as her room-mate was violently seasick 
 every day of the voyage, and depended upon the ministra- 
 tions of my patient constantly. 
 
 Sexual Perversion. Schrenck-Notzing says that the 
 grossest sexual aberrations, even when they are deeply 
 rooted and have changed the entire personality, are fre- 
 quently cured by hypnotic suggestion. Krafft-Ebing, in 
 his Psychopathia Sexualis, seems to depend entirely upon 
 this remedy in the cases of which he speaks. It has not 
 been my fortune to have as a patient a person afflicted 
 with any of these maladies. But a case was sent me by 
 a friend, a specialist in neurology, who was unable to help 
 the patient, and, although thinking lightly of hypnotism, 
 desired me to try it in this case. The patient was a med- 
 
VALUE OF HYPNOTIC SUGGESTION 5l 
 
 ical student, a young man of neurasthenic tendency, who 
 was hyperesthetic sexually, and was troubled especially 
 with priapism. He was hypnotized several times with 
 acknowledged benefit, but ceased his visits before being 
 discharged as cured. One day my neurologic colleague 
 called on me and reported that the patient was apprehen- 
 sive that the treatment had been carried too far ; not only 
 was he relieved of his priapism and other evidences of his 
 sexual over-sensitiveness, but he had positive sexual 
 apathy. Without difficulty the normal equilibrium was 
 found and established. 
 
 Drug Addictions. An apothecary, about 30 years of 
 age, had the alcohol habit. He did not drink intoxicants 
 every day, but once in a few weeks he drank persistently 
 until his stomach revolted, and then he was abstinent un- 
 til the furore for alcohol seized him again. His neces- 
 sities prohibited abandonment of his work, and his per- 
 sistence in it kept him constantly in an atmosphere of 
 temptation. No encouragement to expect a cure under 
 these circumstances was given him, but his urgent plead- 
 ing induced me to try the effect of hypnotic suggestion. 
 After twenty sessions the treatment was given up on ac- 
 count of my absence from town for nearly two months ; 
 and while the signs were hopeful, it was highly improb- 
 able that he would not relapse into his wretched slavery. 
 But he did not, and years afterward he remained entirely 
 cured. 
 
 3. CORRECTION OF MISCONCEPTIONS CONCERNING 
 HYPNOTISM 
 
 There is a multitude of errors concerning hypnotism, 
 which are almost as prevalent among physicians as in the 
 non-medical population, and a number of these will be 
 stated and corrected. 
 
56 PSYCHOTHERAPEUTICS 
 
 It is commonly supposed that a person must lose con- 
 sciousness in the process. In most cases the patient re- 
 tains consciousness perfectly. For the production of 
 some results the deepest stage of the hypnotic condition 
 is requisite; but for the ordinary therapeutic effects it is 
 by no means necessary. Brilliant cures are sometimes 
 achieved with patients who are hardly made drowsy by 
 being hypnotized. 
 
 It is a prevalent belief that only the weak-minded, or, 
 at best, the hysteric, are amenable to hypnotic sugges- 
 tion. Nothing could be farther from the truth. The 
 experienced hypnotizer dislikes to deal with either of 
 these classes of patients ; he would rather for every rea- 
 son have strong men with cultivated minds and disciplined 
 wills. The physician who uses only physical therapeutic 
 means prefers the well-balanced, sensible, intelligent for 
 patients, and so does the one who employs psychic means, 
 and for the same reasons. The hypnotizer asks his pa- 
 tient to exert his will in a specified direction ; he wants the 
 intelligent co-operation of the patient, and this require- 
 ment is most difficult for the feeble-minded, the untrained, 
 the heedless to meet. 
 
 Another mistaken notion is that only a minority of per- 
 sons can be hypnotized. This is true only if one has in 
 mind the idea that, in order to be hypnotized, one must 
 lose consciousness — which has already been declared to 
 be an error. The great majority of people can be hyp- 
 notized to an extent quite sufficient to make them suscep- 
 tible to remedial suggestions. 
 
 A misconception which it is very difficult to displace 
 ascribes to the hypnotizer a peculiar and rare natural en- 
 dowment. That some men are better hypnotizers than 
 otKers Is unquestionably true, just as some men are more 
 capable than others in any line of activity. He who has 
 a strong and healthy physical organism, a powerful mind, 
 
VALUE OF HYPNOTIC SUGGESTION 59 
 
 and, perhaps best of all, an engaging presence, has ele- 
 ments that make for success in any affairs where man 
 meets man ; and, of course, such a one gets the best re- 
 sults with his medicines, with his surgical operations, with 
 his electrical applications. Why should he not do better 
 than most others in the use of suggestion, hypnotic or 
 non-hypnotic? But while this type is the highest, there 
 are others who, while not quite or nearly as well endowed, 
 are yet capable of excellent work ; and as they will pass 
 muster in the other styles of therapeusis, so, too, they 
 will succeed in hypnosis. Any man who has the attributes 
 which every medical practitioner should possess can prac- 
 tice hypnotism. But he must believe in it, and he must 
 declare his belief by the confidence of his bearing. Self- 
 ; distrust, timidity, uncertainty in the physician inevitably 
 beget reluctance, fear, and antagonism in the patient, 
 whatever the former undertakes to do, and whatever the 
 method by which he essays to do it. 
 
 A common fallacy ascribes whatever result is experi- 
 enced to a mysterious, subtile emanation from the physi- 
 cian which enters and pervades the system of the patient. 
 This error is partly due to the persistence of a theory 
 i which was upset long ago; and partly, doubtless, to the 
 j likeness which is popularly thought to obtain between 
 I hypnotism and electricity. The real explanation, is sug- 
 gestion, pure and simple. 
 
 A frequent objection is that, in the hands of an un- 
 
 I scrupulous person, great wrong may be perpetrated by 
 
 j hypnosis, and therefore it should not be used. The same 
 
 j line of argument would lead us to abandon treatment by 
 
 i medicines, because it must be admitted that patients 
 
 have been killed by drugs administered by physicians, and 
 
 to give up cutting operations in surgery, because many 
 
 I persons have died on account of these procedures. That 
 
 there are scoundrels and incompetents in the medical pro- 
 
60 PSYCHOTHERAPEUTICS 
 
 fesslon, as in all others, is a lamentable fact; but they 
 constitute but a small minority, and the danger of their 
 doing harm, maliciously or innocently, by employing 
 hypnotism is exactly on a plane with the peril which 
 attends their practice in any other line. Every real 
 authority on modern hypnotism says emphatically that a 
 suggestion that offends the moral sense of the person 
 hypnotized is either disregarded, or has the effect of 
 rousing the subject immediately. If it were practicable 
 to incite to criminal acts through the agency of hypnotic 
 suggestion, there would be no lack of examples of this 
 fact; but in many years of observation not an authentic 
 case of the kind has come to my knowledge. The possi- 
 bilities of such a method in the hands of a skillful ro- 
 mancer are too obvious to escape the attention of novel- 
 ists, and we know that thrilling tales of absorbing in- 
 terest have been pivoted on this supposition ; but we never 
 encounter such occurrences in actual life, and we may 
 confidently disabuse our minds of this groundless appre- 
 hension. 
 
 It is objected that hypnosis, especially if often re- 
 peated, weakens the will of the patient and makes him 
 dependent upon the mind of the operator. Such a re- 
 sult is imaginable, but can never occur, if the physician 
 is as careful in using this agency as he always should be 
 when administering drugs or doing surgery. As a mat- 
 ter of fact the will may be strengthened by hypnotic 
 suggestion, and the moral vigor increased in every re- 
 spect. All of the cases of injury from hypnosis of which 
 I have ever heard have resulted from the reckless employ- 
 ment of it for exhibition purposes, mostly by irresponsi- 
 ble mountebanks. The shows conducted by hypnotizers 
 for the amusement of popular audiences should be 
 sternly repressed. That this treatment has not been 
 their fate is, in my opinion, in considerable degree to be 
 
 I 
 
VALUE OF HYPNOTIC SUGGESTION 61 
 
 ascribed to the attitude of physicians. Repeatedly I 
 have known doctors to accept and use complimentary 
 tickets to these wretched performances, thus tacitly be- 
 stowing their professional sanction on indefensible ap- 
 plications of hypnotism, while at the same time they dis- 
 play a strong disposition to outlaw a fellow practitioner 
 who brings to bear upon his patients the altogether 
 beneficent uses of the same agency. If used discreetly, 
 hypnotism does not induce insanity, does not weaken the 
 mind, does not do harm in any direction. 
 
 Hypnotism should be used only by educated physicians, 
 and by them only as a remedy or a means to diagnosis. 
 If it had never been employed outside of its legitimate 
 domain there would be little or nothing of the prejudice 
 against it which is constantly encountered in the com- 
 munity; and the sufferers, for whom it has an easy and 
 effectual relief, would eagerly avail themselves of its 
 help. 
 
 To some the practice of hypnotism is objectionable, 
 because there are many charlatans who employ it or ad- 
 vertise to do so. Those who argue thus, to be consist- 
 ent and logical, should abandon the use of all medicines, 
 all hygienic measures, everything, indeed, by which they 
 try to affect their patients, for there is nothing that the 
 quacks do not exploit. One can hardly look at a daily 
 paper or a popular magazine without having forced upon 
 his attention some flamboyant announcement of a drug, 
 a method of exercise, a kind of battery, a drink, a food 
 — something presented with an attractive picture and 
 an adroitly worded statement, which, it is promised, will 
 positively put disease to flight, prolong life to the ripest 
 old age, and supplant misery with exuberant happiness. 
 But none of us are so disgusted with these mendacious 
 advertisements that we think it necessary to throw away 
 the pharmacopeia, cease to recommend physical culture, 
 
62 PSYCHOTHERAPEUTICS 
 
 give up electricity, forbid the use of alimentary remedies. 
 We continue to employ whatever means we think will 
 benefit those persons who honor us with their confidence 
 by seeking our advice and skill. Why, then, should we 
 select one particular kind of agent, and avoid it on the 
 ground that it Is used by pretenders? The breadth of 
 mind which we like to believe characterizes our profes- 
 sion should enable us to welcome any agency, whatever 
 its origin, however unwisely or dishonestly it is used by 
 others, whatever compromising associations it has pre- 
 viously had, provided only that it will enable us more 
 readily, more agreeably, more perfectly, to diminish suf- 
 fering, prevent disease, or restore health. Therefore, 
 when one hears hypnotism likened to any of the popular 
 mind-cure movements, which to his trained intellect are 
 manifestly unscientific and illogical, let him ascribe the 
 statement to ignorance, and enter upon the investiga- 
 tion of this form of psychotherapy with confidence that 
 the more he learns about it the greater will be his respect 
 for it. 
 
 It has been alleged that a belief In the remedial virtues 
 of hypnotism would do away with the necessity for diag- 
 nosis. Nothing could be wider of the mark. The phy- 
 sician who includes this agency in his armamentarium 
 does not change his attitude toward pathology, etiology, 
 or physical diagnosis. He sees, as plainly as one can, 
 that the first thing is to find out what is the matter, to 
 ascertain the character of the malady, and he does not 
 use hypnotic means in treatment unless his investigation 
 persuades him that the trouble Is of a kind to which this 
 remedy is scientifically applicable. 
 
 One of the commonest criticisms of hypnotism is to 
 the effect that the ailments which it relieves are all im- 
 aginary. If a patient is said to have been freed from 
 pain, some astute skeptic asks, " Was the pain real? " 
 
 I 
 
VALUE OF HYPNOTIC SUGGESTION 63 
 
 To such the answer should be : " When a patient comes 
 to you complaining of pain, do you distrust his word? 
 After he has taken the anodyne which you administer, 
 and declares to you that his pain has disappeared, do 
 you question his veracity? You cannot prove by the evi- 
 dence of any or all of your senses that either statement 
 was true or false, for his symptom is absolutely sub- 
 jective. But you do know your patient, and have no 
 reason to doubt his truthfulness in this matter any more 
 than in any other ; and so you do not hesitate to give him 
 the remedy that your experience has taught you is 
 suitable to his condition. Now, suppose such a patient 
 is treated with hypnotic suggestion, and the suffering is 
 promptly abolished, is there any sense, reason, or fair- 
 ness in thinking that his pain was imaginary, and not as 
 real as that which was relieved by your drug? " 
 
 It has been charged that hypnotism is not scientific ; 
 but it is difficult to perceive upon what ground this opin- 
 ion is based. Tested by any of the rules which we apply 
 to the remedies which we all employ it is not found want- 
 ing; and it is not just to subject it to severer tests than 
 we think sufficient for all the others. If it is objected 
 that we do not know the mental mechanism by which hyp- 
 nosis is induced, it is fair to remind the critic that he 
 cannot explain the mechanism of memory, a fundamental 
 and comparatively simple intellectual process. If it is 
 alleged that there is a large empirical element in hyp- 
 notic treatment, it is proper to ask if, in this respect, it 
 is on a lower plane than our usual method of using drugs. 
 
 It has been alleged that the therapeutic effects of hyp- 
 notic suggestion are but transient: that, if any benefit 
 results from it, in a short time the patient will relapse 
 into his former condition. Nobody acquainted with the 
 facts could possibly make this criticism. The effects of 
 no remedy, with which a comparison can fairly be made. 
 
64 PSYCHOTHERAPEUTICS 
 
 are more enduring than are those of hypnotic suggestion. 
 
 Equally inapplicable is the comment that groups hyp- 
 notism with methods of treatment in which prominence is 
 given to a mystical element, which appeal to the supersti- 
 tious, which associate theology and therapeutics, which 
 demand faith in a dogma. The psychology on which 
 hypnotic suggestion is based is as far removed from mys- 
 ticism or religion in any form as is physiology — indeed, 
 it may be said to be physiology applied to mental proc- 
 esses. The hypnotist is not spiritistic in any sense of the 
 word; he asks his patient for no faith, save that which 
 every physician has a right to expect in any person who 
 confides health and life and reputation to his care. In 
 treatment by any method it is universally recognized that 
 confidence in an expected, or even hoped for, result is a 
 helpful factor. No well-informed person thftt doubts 
 that wonderful cures are sometimes wrought under the 
 ministrations of the most dishonest charlatans, as the 
 result of religious exaltation, in consequence of absorb- 
 ing belief in absolutely senseless doctrines ; and he knows, 
 too, that these beneficent effects are as abundantly mani- 
 fested among the worshippers of idols and the practisers 
 of obscene and degrading rites as among the people of 
 his own creed. That expectation is desirable in hyp- 
 notic treatment, as in any other, must be manifest; but 
 in none is it less essential. Particularly may it be in- 
 sisted that in hypnotism there is no occult or esoteric 
 element, there is nothing to conceal, there is no desire to 
 take advantage of credulity, or to play upon the confid- 
 ing nature of the ignorant and superstitious. 
 
 That hypnotism is often but little understood by men 
 to whom the profession has a right to look for enlight- 
 enment in such matters is frequently demonstrated. 
 Some of the high priests of neurology are the greatest 
 sinners in this direction; but none, probably, have dis- 
 
VALUE OF HYPNOTIC SUGGESTION 65 
 
 played their incompetency and ignorance quite as con- 
 spicuously as has Dubois, the author of a book on the 
 psychic treatment of nervous disorders. This has been 
 translated into English and has evidently deeply influ- 
 enced many physicians and awakened a wholesome interest 
 in a certain form of psychotherapy. His treatment by 
 persuasion has undoubted merit, though little novelty; 
 but it is pitiful that he should assume the attitude which 
 he does toward hypnotism — an attitude which reveals 
 at once ignorance, narrowness, prejudice, and inconsist- 
 ency. He girds at hypnotism, at every opportunity, he 
 holds it up to ridicule and contempt ; and yet he admits 
 that, on occasion, he uses it, as he certainly should not, 
 if it is the evil thing that he would have us believe. In 
 doing this he unconsciously pays it the highest tribute. 
 Let me quote a passage: 
 
 " This is one of those exceptional cases where I would 
 not fear to have recourse to hypnosis, although the atti- 
 tude of the wonder-worker that one has to take is so 
 repugnant to me that it brings a blush to my cheeks when 
 I decide to use it." 
 
 " Wonder-working " to him evidently means rapidity 
 of effect, for in another paragraph he says: 
 
 " The practice of hypnosis has accustomed one to im- 
 mediate success, to theatrical effects." 
 
 Are we to refrain from employing any method because 
 its results are prompt? We have been accustomed to 
 consider speed in attaining a desired end a decided merit. 
 The motto on the seal of this society, " Curare cito, tuto, 
 et jucunde," which we adopt from the ancient Asclepiades, 
 is universally acclaimed as the ideal rule of action; and 
 hypnotism fulfils all of these conditions, for it does cure 
 quickly, safely, and pleasantly. Apply the objection to 
 another class of cases: a patient comes to a physician 
 with a chronic irritative cough. Examination reveals a 
 
[: 
 
 \ 
 
 66 PSYCHOTHERAPEUTICS 
 
 relaxed uvula dangling onto the tongue and constantly 
 tickling the pharynx. Does anybody advocate the cut- 
 ting off of the sixteenth of an inch a day for the sake 
 of avoiding the suddenness of cure effected by complete 
 ablation? But the method by which instant and perma- 
 nent relief is afforded is open to the criticism of being 
 theatrical. Dubois objects to " wonder-working," if the 
 quick cure is brought about by hypnosis, as if one ap- 
 pealed to the thaumaturgy of the ancient magician ; and 
 yet he says: 
 
 " The art of the physician lies just in choosing in each 
 case the most rapid and powerful means of improvement." 
 
 Can inconsistency go further? If his vaunted method 
 achieves an immediate result, it is praiseworthy; but, if 
 hypnotism does the same thing, it is damnable. 
 
 To show how utterly ignorant of the principles of hyp- 
 
 ^ notic treatment this author is, one more sentence may be 
 
 fe^' quoted: "What is more absurd than to fall asleep by 
 
 j daylight, when one has no need of sleep, by stupidly 3rield- 
 
 ing to the command of the hypnotizer ? " 
 
 It seems almost incredible that a physician who poses 
 as a neurologist and a psychotherapist, should not know 
 that the purpose of the hypnotizer in inducing the sleep; 
 is solely to put the patient into a more suggestible con-, 
 dition. When a man of the eminence of Dubois is ca- 
 pable of so humiliating an exhibition as this, we may lookl 
 with more charity and patience upon the men who con- 
 stitute the rank and file of the profession, when they, as 
 a result of dense ignorance, declare hypnotism to be dan- 
 gerous, foolish, quackish, fraudulent, necromantic, and 
 altogether unjustifiable. 1 
 
 It ought to be unnecessary to say that the employ- 
 ment of any form of psychotherapy is not incompatible 
 with the use of physical agents of any description. In 
 many cases it is important to associate different kinds of 
 
 I 
 
VALUE OF HYPNOTIC SUGGESTION 67 
 
 therapeutic agents, which are not psychic, as we all know ; 
 the case in which a psychic method is desirable makes no 
 exception. Psychotherapy should be regarded as an ad- 
 ditional means of promoting the welfare of the patient, 
 whatever other kind of treatment has been instituted. 
 
 In this essay I have not attempted an exhaustive treat- 
 ment of my subject, but I have tried to show as well as 
 possible in the time allowed what hypnotism is, and what 
 can be done with it by any well-educated, competent phy- 
 sician for the benefit of the sick and suffering; and, 
 finally, I have endeavored to make it clear that the ob- 
 jections to its use are not based upon knowledge, but 
 upon ignorance and prejudice. The points touched upon 
 are those about which questions are most frequently 
 asked or adverse criticism made, and the answers and ex- 
 planations are founded upon a large observation of the 
 practical workings of the method. 
 
 I have no expectation of effecting a wholesale conver- 
 sion of opponents to these views — I know too well the 
 ingrained conservatism of our profession regarding psy- 
 chic remedies; but I entertain a little hope that what I 
 have said will arouse in some minds an intelligent interest 
 in the sub j cct ; and I am confident that no open-minded 
 physician can look into it fairly, as he would into any 
 other therapeutic method, without being persuaded that 
 in hypnotic suggestion are possibilities for good, which 
 our profession should no longer neglect. 
 
CHAPTER THREE 
 
 Simple Explanation and Re-education as a 
 Therapeutic Method 
 
 BY E. W. TAYLOR, M.D. 
 
 Assistant Professor of Neurology, Harvard Medical School 
 Chief of Service, Neurological Dept., Mass. Gen. Hospital 
 
 TWO difficulties are evident in the present aim to 
 rationalize psychotherapeutic procedure. One is 
 its supposed simplicity and the other its reputed 
 complexity. A very considerable group of men in the 
 medical profession apparently considers that nothing 
 new has been discovered within the past few years rela- 
 tive to the treatment of disease by mental means. An- 
 other group is equally insistent that the whole subject 
 constitutes a special branch of medicine and is quite be- 
 yond the practical reach of the general practitioner. 
 Both of these positions are wrong. In the first place, it 
 is apparent that the investigation of recent years has so 
 far rationalized old methods that the physician now has 
 in his hands a perfectly definite means of attack against 
 many abnormal and distressing conditions. However 
 widely psychotherapeutic measures have been practised 
 from the earliest period of medicine, the time has now 
 come when such measures may be used with a degree of 
 scientific accuracy hitherto unattained, a precisely sim-| 
 ilar situation to that prevailing in all other departments 
 of therapeutics. The means of treatment have always 
 been at hand. The use to which those means are put 
 constitutes advance. On the other hand, it is true that 
 the final solution of the complex problems upon which 
 we have now entered is no doubt far distant, and the 
 pioneer work in this somewhat limitless field must be left 
 
 68 
 
RE-EDUCATION AS A METHOD 69 
 
 to a special student. There is, however, no longer a 
 question that sufficient facts have been established to 
 render certain of these therapeutic measures available 
 for the practitioner. Here again the situation is not 
 different from that of other departments of medicine. 
 The problem of immunity, for example, remains obscure, 
 and in great measure unsolved, but the practical applica- 
 tions of this laborious work are already in a measure 
 available. 
 
 It should in general be our aim to place this whole 
 much discussed question of psychotherapeutics on pre- 
 cisely the same plane as other therapeutic problems. So 
 far as facts are ascertained and capable of practical 
 application, it is the manifest duty of practitioners to 
 employ such facts for the benefit of their patients. So 
 far as facts are still in doubt it is the natural work of 
 special students of the subject to bring what order is 
 possible out of the existing chaos. Our methods of pro- 
 cedure should be the same, so far as the character of the 
 subject permits, our results should be subjected to the 
 same strict scientific judgment, and our liberality toward 
 this branch of therapeutics should be precisely similar 
 to that toward any other which promises much for the 
 future. 
 
 The object of this symposium, so for as I understand 
 it, is for the time being to lay aside theoretical consid- 
 erations and to bring to the attention of this society such 
 facts and practical considerations as the time at our dis- 
 posal and our individual experience permit. It is my 
 purpose in what I shall have to say under the somewhat 
 inadequate title selected to draw attention to the simplest 
 and therefore most widely available method of psycho- 
 therapeutic procedure and to attempt to show how such 
 a method may be made practically useful by the physi- 
 cian in a degree hitherto not always attained. 
 
70 PSYCHOTHERAPEUTICS 
 
 In discussing the general psychotherapeutic problem 
 with physicians, the purely practical question of method 
 is almost invariably raised. What the practitioner needs 
 and rightly demands from those who claim any special 
 knowledge of the subject are directions as to treatment 
 of individual patients. The evident difficulty heretofore 
 in treating even the simple neuroses has been the failure 
 on the part of physicians to recognize clearly that such 
 neuroses very frequently have a mental cause in the life 
 of the individual precisely as a murmur over the heart 
 area, for example, has a physical cause in the life of the 
 individual. Our first object, as practitioners, is the de- 
 termination so far as lies in our power of the exact cause 
 of the condition we are called upon to treat. In other 
 words, a diagnosis is demanded. This we make readilj^ 
 enough in the physical sphere or admit our incapacity to 
 do so. In the mental sphere, we too often make no at- 
 tempt, however apparent the cause might be after ade- 
 quate investigation. The first point, therefore, I would 
 make is that we must be as conscientious in one field of 
 medicine as in another. We must search the mind of the 
 individual for the source of his discomfort in appropriate 
 cases in exactly the same spirit in which we search his 
 body for the source of other discomforts. This cer- 
 tainly requires no special personal attributes on the part 
 of the physician, and is surely available for practition- 
 ers of no special education in this field. The word " ex- 
 planation " used in the title describes somewhat inade- 
 quately the actual procedure, which consists essentially 
 in the following steps: 
 I First. After eliminating or properly estimating 
 physical causes , the mental attitude of the patient to- 
 ward his ailment should be carefully determined; in other 
 words, a diagnosis should be made. 
 5 Second. This is best accomplished by allowing him to 
 
RE-EDUCATION AS A METHOD 71 
 
 tell his complete story rather than by a primary process 
 of interrogation on the part of the physician. 
 
 Third. Having determined the false point of view 
 almost invariably revealed which has led up to the neu- 
 rosis .the attempt is made to explain why such a series of 
 events as that disclosed would be likely to lead to this 
 result. 
 
 H Fourth. Having impressed the patient with the cor- 
 rectness of the physician's point of view the process of 
 readjustment begins, or, to use the more popular but 
 possibly too comprehensive term, his re-education. 
 
 Fifth. This is accomplished by pointing out in a 
 painstaking way the correct way to mental health through 
 a realization on the part of the patient of his previous 
 misconceptions and through an accompanying effort to- 
 ward the establishment of more rational mental adjust- 
 ments. 
 
 The method outlined above is the simplest possible 
 psychotherapeutic procedure. As in more complex meth- 
 ods described by other writers in this symposium its es- 
 sential feature is the analysis of the mental state. Its 
 value lies in its simplicity and in its appeal to the reason 
 through the medium of commonsense. We are justified 
 in calling it a method because it works in practice, when 
 mere unmethodical encouragement and reassurance fail. 
 That such a method stripped as it is of all appeal to the 
 mysterious or to any form of sensationalism is capable 
 of wide and legitimate application is self-evident. It is 
 also apparent that it must often prove unsuccessful in 
 those cases in which the course of a developed neurosis 
 is so deeply buried in the past life of the individual that 
 it cannot be brought to the surface by this simplest and 
 in one sense most superficial of the analytic methods. 
 
 It may with truth be said that no person is wholly free 
 from false conceptions of his own mental and physical 
 
72 PSYCHOTHERAPEUTICS 
 
 condition, and this naturally applies to those who con- 
 sult physicians in the most varied fields of practice. It 
 is an error to stigmatize such persons forthwith as ab- 
 normal or neurotic or neurasthenic or psychasthenic. 
 Many of the common neuroses met with in practice rep- 
 resent nothing more than aberrations of normal nervous 
 systems into temporary useless or detrimental channels. 
 As a matter of fact, a large proportion of so-called nerv- 
 ous invalids are incapacitated through no inherent fault 
 of their nervous systems as such, but rather through the 
 use to which their nervous systems have been put by cir- 
 cumstances or training or false instruction or unwise and 
 superficial medical advice. 
 
 Quite apart from any psychophysical speculation as to 
 the relation between the mind and the body which is 
 wholly unessential from a practical standpoint, the clear 
 recognition of the predominant mental origin of the 
 neuroses, whether or not they have accompanying phys- 
 ical manifestations is of the utmost importance and un- 
 questionably constitutes the essential advance of recent 
 years in their intelligent treatment. We have gained 
 much, if, for example, we may authoritatively tell our 
 patients that their apparently disordered nervous symp- 
 toms have reacted in a perfectly normal way to the cir- 
 cumstances in which they have been placed, and to the 
 ideas to which they have been exposed, and that their 
 difficulties have been due to the character of these ideas 
 and circumstances rather than to the much feared in- 
 herent weakness of the nervous system itself. The func- 
 tion of the physician at once becomes apparent. He 
 hears the story, he sees wherein the individual has failed, 
 wherein he has dissipated his energies in side issues, or, 
 in popular parlance, wasted his opportunities. Out of 
 this he recognizes that a so-called neurosis has devel- 
 oped which it becomes his task to diagnosticate accu- 
 
i RE-EDUCATION AS A METHOD 73 
 
 rately, to explain in an understandable way the steps by 
 which he has arrived at his diagnosis, and to readjust 
 
 I the patient's mental attitude on the basis of this knowl- 
 edge. 
 
 In order to avoid any possibility of confusion I have 
 used the word " explanation " to describe this rational 
 process. It requires little actual experience to demon- 
 strate that in order to explain these matters effectively 
 to our patients we must follow some definite method. 
 Otherwise, as in other departments of endeavor, we shall 
 simply confuse and not benefit. It is furthermore im- 
 perative, with all the present day talk in the popular press 
 as well as in medical literature regarding treatment by 
 mental means, that we adopt a definite, commonsense ba- 
 sis of procedure, free from all subtlety or demand for 
 highly specialized training. 
 
 / From the foregoing discussion I wish to emphasize the 
 following pomts:)First, the wide prevalence of neuroses 
 based on ignorance rather than inherent or acquired 
 weak nervous organization. «lSccondly, the vital impor- 
 tance of recognizing the normal character of the nerv- 
 ous systems in which these neuroses have developed. 
 Thirdly"; the possibility as a rational means of treatment 
 of explaining to an intelligent patient the mechanism of 
 the development of his symptoms, ihd finally the prob- 
 ability of a readjustment of his mental state based on 
 this explanation with the disappearance of the neurosis. 
 The analogy of the mental state of the child is useful 
 in this connection. Explanation forms the chief means 
 of increasing a child's mental stability. Fear of the 
 dark, to take a commonplace example, is not met on the 
 part of the wise parent by harsh criticism and summary 
 dismissal of the subject, but rather by explanation suited 
 to the child's comprehension that the dark in reality has 
 no terrors, and by a demonstration of the truth of this 
 
74 PSYCHOTHERAPET TICS 
 
 fact. Similar fears in adult life are manifestly treated 
 with far less consideration; on the part of the patient 
 there is a tendency toward concealment of special anxie- 
 ties, on the part of the physician there is often a wholly 
 unsympathetic attitude in which explanation plays no 
 part. The position of the adult is, however, precisely 
 analogous to that of the child. Neither is the victim of 
 disease or, necessarily, possesses a damaged nervous sys- 
 tem. Both are victims of insufficient knowledge and both 
 demand sympathetic explanation in order that their false 
 points of view may be corrected. Both are real and 
 often extreme sufferers from conditions which are not 
 self-limited, but which tend to progress and become more 
 complex in their organization. Our attitude toward 
 children has on the whole been correct; our error has 
 been the failure to realize that wisdom does not neces- 
 sarily come with the years. 
 
 Examples may make this clearer. A patient consults 
 a physician in a highly disturbed nervous state popularly 
 known as neurasthenic. The analysis of the entire situa- 
 tion reveals the fact that this patient considers that he 
 has lost his memory. He has arrived at this conclusion 
 because he finds that he is no longer able to read at- 
 tentively and remember what he has read. From this as 
 a starting point he argues, legitimately enough from his 
 knowledge, as follows: I cannot remember what I havo 
 read ; my memory must therefore be weakened ; memory 
 is a fundamental quality of the normal mind; my mind 
 therefore must be failing, and forthwith one of the com- 
 monest and most distressing and incapacitating phobias 
 is developed, namely, the imminent fear of insanity. In 
 such a commonplace instance as this it is clear that the 
 patient's mind has worked out a rational conclusion from 
 false premises, the original false premise being that be- 
 cause he could not remember what he read, therefore his 
 
RE-EDUCATION AS A METHOD 75 
 
 mind was failing. It is easy to set such a person right 
 by the simple explanation that his original difficulty arose 
 from lack of concentration, a common human weakness, 
 and that out of such lack of concentration the mental 
 alienation which he feared is extremely unlikely to de- 
 velop. This rational point of view is on the whole easy 
 to impress, and its result on the developed neurosis with 
 its various accompanying manifestations of sleeplessness, 
 anxiety, incapacity for work, loss of appetite, and all 
 the other phenomena of a disturbed mental state, forth- 
 with becomes apparent. The essence of the benefit in 
 such a case is to be attributed purely to a reasonable 
 explanation of a series of events which the patient has 
 himself been unable to estimate properly. 
 
 A further example illustrative of the point of view I 
 am attempting to impress is the mental condition ordi- 
 narily associated with insomnia. There is a deeply 
 rooted feeling in the popular mind that sleep is an abso- 
 lute essential to continued mental health and conversely 
 that deprivation of sleep is a direct sign of both physical 
 and mental breakdown. Assuming this statement to be 
 correct the ordinary person finds himself in a state of 
 extreme anxiety when for any reason his sleep is inter- 
 fered with. The result of this anxiety very naturally is 
 such a fixation of the attention upon his physical and 
 mental condition that sleep for this very reason becomes 
 increasingly difficult. Thus, the ordinary vicious circle 
 is formed. I have in mind a patient, a middle-aged man 
 of active business interests, who was so strongly im- 
 pressed with the idea that without sleep he must neces- 
 sarily go to pieces, that his life was becoming a burden 
 to himself and to his friends. Reasoning from his 
 premises, he assumed that inasmuch as sleep was essen- 
 tial to continued health and he was certainly not having 
 a normal amount of sleep, he could not continue well. 
 
76 PSYCHOTHERAPEUTICS 
 
 The treatment of this situation stated in barest outline 
 was in the first place to explain that he had a wrong con- 
 ception of the significance of sleep, that complete phys- 
 ical and mental rest without sleep would suffice to restore 
 him for the work of the succeeding day, and finally that 
 could he compose himself to such complete physical and 
 mental rest, sleep would naturally follow. This, as a 
 matter of fact, is what actually happened. The cause 
 of the sleeplessness in this instance was essentially the 
 mental state induced by the fear that he would not sleep. 
 A more striking instance is that of a man from the Prov- 
 inces, also of middle age, who for some six years had been 
 unable to sleep and had developed various so-called neu- 
 rotic symptoms as he supposed in consequence of this 
 sleeplessness. The origin of his difficulty he definitely 
 attributed to a single occasion when he had more or less 
 voluntarily remained awake practically all night in an- 
 ticipation of a very early morning journey. From this 
 simple and commonplace event, the habit of sleeplessness 
 apparently was formed, and from that time to this it has 
 been kept alive evidently by the anxiety which has devel- 
 oped in consequence of his conception of the necessity of 
 sleep, precisely similar to the case just cited. Here also 
 it was not difficult, after three or four interviews in which 
 explanation alone was used, to show the patient wherein 
 his knowledge had been deficient regarding various physi- 
 ological processes connected with sleep and to make clear 
 to him the pernicious part his faulty mental attitude had 
 played in the development of his neurosis. The patient 
 was easily relieved of his difficulty, at least until he left 
 Boston to return home. I have not heard from him since. 
 It would be easy to multiply cases of this sort, illus- 
 trative of the part which incorrect deductions play in 
 the development of most varied neurotic conditions. The 
 foregoing instances, however, may suffice to illustrate in 
 
RE-EDUCATION AS A METHOD 77 
 
 simplest form the principle underlying this method of 
 psychotherapeutic procedure. 
 
 The possibilities and limitations of the method I have 
 attempted to outline may be summarized but not detailed 
 in so brief a communication as this. Its possibilities are 
 that it may be used by any intelligent physician who 
 I realizes its importance; the personality of the physician 
 ' about which we still continue to hear plays a small part 
 in its success. It requires no special training, psycho- 
 logical or otherwise, beyond that which every educated 
 physician might easily acquire. It is not limited to the 
 treatment of so-called " nervous " cases. It should, for 
 example, be applied antecedent to surgical operations, 
 particularly on the pelvic organs of women. It is a 
 commonsense method of approach to many of the minor 
 ills and some of the major disorders to which all per- 
 sons are exposed. It does not demand hypnotic pro- 
 cedure, or the use of suggestion as that word is ordi- 
 narily employed. Its essential basis is an appeal to 
 reason and herein naturally lies its wide applicability. 
 Its limitations are no less apparent. It will naturally 
 fail in the psychoses, in hysterical states associated with 
 fundamental disorders of personality, and in obsessional 
 conditions of a high degree of fixity, matters to which 
 no doubt others taking part in this discussion will refer. 
 
CHAPTER FOUR 
 
 The Treatment of Fatigue States 
 by g. a. waterman, m.d. 
 
 TAKING the various forms of the psycho-neuroses 
 as a group there is no one symptom so frequently 
 encountered as that of fatigue. Whether it be 
 present early in the course of the disease, and seems to 
 be the soil from which other symptoms develop, or 
 whether it makes a later appearance as if in consequence 
 of the struggle against existing symptoms, it too often 
 presents a barrier to recovery which at times seems un- 
 surmountable. Any effort on the part of the patient to 
 struggle against this symptom so increases the fatigue 
 as to accentuate other symptoms, and cause great dis- 
 comfort, while on the other hand continued rest is courted 
 in vain. In order to determine how this condition is to 
 be met, let us turn our attention to the elements which 
 go to make up this fatigue. 
 
 1. PHYSIOLOGICAL FATIGUE 
 
 That the production of energy of every sort Is the re- 
 sult of a katabolic process in the tissue called into activ- 
 ity is a fact too well established to require discussion, 
 but unfortunately fatigue cannot be explained on the 
 simple ground that the consumption of muscular sub- 
 stances alone produces exhaustion. 
 
 In addition to the diminished supply of the substances 
 in the muscle necessary for the production of energy 
 which results from muscular activity, we have also to 
 
 recognize the role played by the action of the toxic 
 
 78 
 
TREATMENT OF FATIGUE STATES 79 
 
 products of oxidation accumulating in the tissue. The 
 laboratory experiment of stimulating the isolated frog's 
 muscle until it can perform no more work, and then flush- 
 ing out its blood vessels with normal salt solution to en- 
 able it to again respond to stimulation, represents the 
 normal physiological process constantly going on in the 
 human organism during its daily life. 
 
 While these two processes — the combustion of sub- 
 stances, and the local action of the products of katabo- 
 lism — diminish the power of the muscle to carry on its 
 function, the liberation of the poisonous substances into 
 the general circulation gives rise to the general sense of 
 fatigue in the individual. This has been well shown by 
 Mosso, who demonstrated that the introduction of the 
 blood of dogs that had been tetanized a few minutes, into 
 the cerebral circulation of healthy dogs, gave rise to 
 the signs of fatigue (difficulty in breathing, and more 
 rapid beating of the heart), and Mosso believes that these 
 noxious products, acting on the nervous system through 
 the circulation, not only contribute largely to the feeling 
 of fatigue, but also lessen the power of the nerve cells 
 to carry on their function. 
 
 Parallel to these manifestations of muscular activity 
 is a group of physiological and histological changes tak- 
 ing place in the central nervous system as a result of 
 cerebral and reflex activity. Hodge demonstrated in 
 1892 that definite changes are to be found in cerebral 
 and spinal ganglion cells of various animals resulting 
 from normal activities of daily life as well as from ex- 
 cessive stimulation. He found that a comparison of 
 nerve cells of animals killed in the morning with those of 
 similar animals killed at the close of a day of activity, 
 showed a diminution in the size of the neuclei with loss 
 of the open reticulate appearance, and shrinkage in cell 
 protoplasm with vacuolation and lessened staining power. 
 
80 PSYCHOTHERAPEUTICS 
 
 That this change in structure is associated with libera- 
 tion of harmful products has been shown by Halliburton 
 in his lecture on " The Chemical Side of Nervous Activ- 
 ity," in which he maintains that under normal physio- 
 logical conditions the injurious choline products of nerve 
 katabolism can be demonstrated in the body, while in 
 states attended with abnormally rapid nerve degenera- 
 tion marked changes may be produced. 
 
 2. PSYCHOLOGICAL FATIGUE 
 
 Aside from these physiological processes which con- 
 tribute to make up what may be called physiological fa- 
 tigue, there is a varying psychological factor which is 
 present in all of us, tending to accentuate or diminish 
 the degree to which it shall be recognized and admitted, 
 whether consciously or not. The power of music to 
 quicken the lagging steps of tired soldiers; the influence 
 of the emotions in redoubling one's strength; the driving 
 force of exhortation or promised reward, are well-known 
 examples of the way in which the feelings of fatigue may 
 be dispelled. Is it that the marching soldier is actually 
 rendered less tired by the music, or that the threat or 
 
 <; promise of reward makes any change in the physical 
 condition of the individual? Such an assumption would 
 be obviously absurd. This sudden change in the feeling 
 
 ^r' described involves what might be termed the psycholog- 
 ical element in the symptom of fatigue. In the minds of 
 all of us a feeling of fatigue indicates a call for rest on 
 the part of nature. When one begins to feel tired his 
 
 J mind becomes impressed with the fact, and the continued 
 ^consciousness that this state exists serves to intensify 
 ^he sensation to a greater or less degree, depending on 
 the suggestibility of the individual. A veritable fatigue 
 hyperesthesia develops. In some this psychological ele- 
 ment may play by far the greatest part in the production 
 
TREATMENT OF FATIGUE STATES 81 
 
 of the symptom, so that the slightest muscular activity 
 produces a feeling of exhaustion lasting for days, while 
 in others, determination of purpose or interest in work 
 may engender a disregard or an anesthesia for the symp- 
 tom and thus enables them to do tremendous amounts of 
 work with little discomfort. It is to this latter class 
 that James refers in his " Energies of Men " in which 
 he describes the process as a breaking through the zone 
 of fatigue, or getting one's second wind. That the 
 adoption of this habit has its merits to a certain extent 
 'n the former class is undoubted, but I am convinced that 
 it is a dangerous recommendation for the latter class, 
 which is naturally the one to carry it out most zealously. 
 
 3. PSYCHOPATHOLOGICAL FATIGUE 
 
 It is an interesting problem for solution as to what 
 takes place in those cases of pronounced fatigue in neu- 
 rotic individuals, who at times are so quickly relieved of 
 the symptom by a suggestion, as well as in those who ar« 
 suddenly overwhelmed by a sense of exhaustion as a re- 
 sult of a nervous shock or a fright. Surely such sudden 
 and decided changes cannot permit an explanation on 
 the grounds of any of the physiological causative factors 
 of fatigue. Is it not that a synthesis takes place in the 
 former, and a dissociation in the latter, much as other 
 manifestations of these processes may occur under simi- 
 lar conditions? The verification of this hypothesis 
 might be found in the appearance and disappearance of 
 fatigue encountered in the alternations of personalities 
 described by Prince, Janet, and others. 
 
 That fatigue states, whether physiological, psycho- 
 logical, or psychopathological, may form a fertile soil 
 for the development of psycho-neurotic symptoms is too 
 often demonstrated to us to admit of question. In the 
 routine of daily life, if one is assiduously devoting his 
 
82 PSYCHOTHERAPEUTICS 
 
 energies to accomplishing certain ends, the rested indi- 
 vidual who starts the day presents a very different men- 
 tal attitude to his surroundings, to the one who returns 
 home at night weary from his labors. The one starts 
 out fresh and vigorous and filled with the joy of living, 
 the other too often returns with slower step and perhaps 
 with tired or aching head, irritable to those about, and 
 critical of things he overlooked so easily in the morning. 
 It requires, however, but the reconstructive power of 
 sufiicient nourishment and a good night's rest for the 
 pendulum to swing back and establish the diurnal state 
 of freshness. Fortunate is he who can carry on his life 
 from day to day unruffled by the stress of extra bur- 
 dens or the worry of added cares. In those who volun- 
 tarily undertake excessive amounts of work, or who are 
 the unfortunate victims of the " slings and arrows of 
 outrageous fortune," the periods of recuperation may 
 not prove sufficient to maintain the state of equilibrium, 
 and a more or less prolonged state of fatigue may result 
 with its various concomitant symptoms. 
 
 Continued fatigue with insufficient periods of rest may 
 develop in strong, healthy individuals various forms of 
 physical and mental symptoms similar to those seen in 
 well-defined neuroses and psychoses. Attention has been 
 called to this by Tissie and Fere, and it was well illus- 
 trated in the condition developed in the bicycle riders of 
 the six-day race in Madison Square Gardens a few years 
 ago. Various sorts of delusions and hallucinations were 
 manifested by these men towards the close of the race — 
 the idea that spectators were doing things to prevent 
 their winning led to their repeatedly turning to escape 
 imaginary obstacles, etc. 
 
 The ill effects of over-fatigue from excessive muscular 
 exercise are usually quickly recovered from, but the con- 
 ditions resulting from prolonged mental strain and worry 
 
TREATMENT OF FATIGUE STATES 83 
 
 are more liable to persist from the very nature of their 
 cause, in being more continuous and unremitting. The 
 story is a common one. One's duties necessitating men- 
 tal application have been requiring too many hours ; they 
 are not dropped in the evening ; sleep is more difficult, and 
 the diminished hours of recuperation lessen the power of 
 application; recognition of this fact brings worry to ^/ 
 the attack to precipitate the uncomfortable feelings of 
 fatigue. Aside from lassitude and loss of power to con- 
 centrate, the most frequent symptom experienced in this 
 state is a sense of discomfort in the head varying in char- 
 acter and location. This engenders the idea that some- 
 thing must be wrong within, and too frequently suggests 
 that insanity is imminent, and gives rise to overwhelming 
 fear and constant introspection, with all its harmful in- 
 fluences. 
 
 Distinct from the fatigue states of such etiology which 
 may exist as a simple condition of weariness and dimin- 
 ished power of application, or may present the compli- 
 cation of morbid ideas developing from it, is the state / 
 of so-called " nervous exhaustion " found in individuals "^ 
 with a neurotic family history. Patients suffering from 
 this condition have often experienced a series of nervous 
 breakdowns, and never seem able to struggle to the nor- 
 mal level. Such individuals, though they present the 
 same symptoms as the class described have the psycho- 
 logical element of fatigue developed out of all proportion 
 to the physical, and every attempt at a departure from 
 their life of rest and quiet is made under protest, and 
 with the firm conviction that disaster is sure to follow. 
 
 That the type of fatigue brought about by prolonged 
 overwork or strain requires rest, relaxation, and change J 
 of surroundings, combined with advice best adapted to 
 counteract the morbid mental state which may be present, 
 is apparent. This class comprises the cases which do 
 
84 PSYCHOTHERAPEUTICS 
 
 well by giving up absolutely the sort of life which has! 
 
 J absorbed them, and combining rest with activities of a- 
 
 different nature which will afford sufficient interest to 
 
 divert the mind and prevent reflection. j 
 
 The point must be recognized and seized, however,' 
 when this regime has played its part, and the time has 
 / come for putting the hand to the plough again, for it is . 
 all too easy for the memory of a previous breakdown and 1 
 fear of its recurrence to render one loath to resume his 
 former life again. It is on account of this fear and hesi- 
 tation that it is advisable to keep in touch with the pa- 
 tient and prevent backsliding until he is well launched 
 in his old life. 
 
 The larger class of patients so often descended from 
 neurotic parents and presenting a history of attacks of 
 previous nervous breakdowns, attempting again and 
 again to take up the duties of life, but never seeming able 
 to get sufficient reserve to carry on the struggle for any 
 prolonged period of time, require management of a dif- 
 ferent sort. Such cases, as has been said, represent the 
 psychological element of fatigue in its fullest develop- 
 ment. The conviction that exhaustion will follow any 
 amount of effort, physical or mental, is already a guar- 
 antee that it will result. On being told to do certain 
 things a patient recently remarked, " Very well, I'll do 
 it, but I know what will happen, and you must take the 
 consequences." Of course if she had followed orders in 
 such a spirit the result must have been as she determined. 
 
 Frequently these patients have indulged in rest for 
 months, or even years, without beneficial results. Phys- 
 ically sound, but unable to assume duties and responsibili- 
 ties of life, they form a group too often misunderstood, 
 and classed as uninteresting by the physician, yet woe- 
 fully in need of proper direction. 
 
 Various systems for the management of this type of 
 
TREATMENT OF FATIGUE STATES 85 
 
 cases have been advanced by different men. The earliest 
 complete method was that recommended by Dr. S. Weir 
 Mitchell, and has since been referred to as the rest cure. 
 In 1875 he published his first paper treating of this sub- 
 ject under the title of " Rest and the Treatment of Nerv- 
 ous Diseases," and a few years later brought forth the' 
 first edition of his monograph " Fat and Blood." As is 
 well known, the essence of his method consists in pur-' 
 suing his course along certain definite lines, treating all 
 cases alike. Seclusion, rest, massage, electricity, and 
 feeding have been the points on which he has laid par- 
 ticular stress. That he has been eminently successful in 
 carrying out this method can be attested by the large 
 number of patients who have been benefited under his 
 care. That the principles he employs exercise their re- 
 sults according to his theories is, however, a question. 
 It has been poinded out by Prince and others that the 
 point on which he lays special stress, namely the increas- 
 ing of the body weight and the production of more blood, 
 does not by any means lead to the amelioration of func- 
 tional nervous symptoms ; that although change of sur- 
 roundings may prove beneficial in many cases, complete 
 isolation undoubtedly does harm in certain types, and 
 that the general result produced by the completeness of 
 the regime owes its success rather to the suggestive in- 
 fluence than to any physical change that takes place. 
 This system has been more or less widely adopted with 
 modifications by most of the sanitaria devoted to the 
 treatment of nervous invalids, and the criticisms which 
 may be applied to this method as employed by its orig- 
 inator are even truer here. For, lacking the unusual 
 personality of the father of this regime, and the confi- 
 dence inspired by his continued successes, the patient is 
 too ready to accept the " rest cure " as such, in every 
 sense of the word, and thus derive from it the feature 
 
86 PSYCHOTHERAPEUTICS 
 
 which should be minimized, while he misses in so -doing the 
 factor which should be working against his psychic atti- 
 tude toward his condition. 
 
 This has been so much recognized by many of the sani- 
 taria during recent years that the facilities for exercise 
 
 %and occupation have to a large extent replaced those of 
 rest and seclusion with gratifying results. 
 
 A new impetus has been given to the interest in psycho- 
 therapeutics by the widespread reading of the methods 
 of Dubois, as set forth in his book, " The Psychic Treat- 
 ment of Nervous Disorders," published in 1905. This 
 method, which has been termed the system of rational 
 
 / therapeutics, has for its aim the education of the patient 
 oftentimes through more or less Spartan discipline, and 
 through the presentation of bare facts and truths re- 
 gardless of the patient's attitude towards his own condi- 
 tion. Whereas the method followed by Mitchell with its 
 modifications as advocated by Dejerine and Barker have 
 been to rest and isolate the patient and gradually win 
 him from his symptoms by education as to their nature, 
 and encouragement, meanwhile treating the various dis- 
 comforts and increasing the patient's powers for activ- 
 ity, Dubois, on the other hand, begins by explaining to 
 
 / the patient the actual condition of things, and forces his 
 opinion as to the psychic nature of the discomfort, and 
 refuses treatment of this by drugs or chemical means. 
 " Never," said Dubois, in discussing the use of drugs a 
 short time ago, " will I give a sleeping powder to a nerv- 
 ous patient except in cases of actual melancholia." 
 Whether this method can be generally adopted by prac- 
 titioners is a great question. The remarkable personal- 
 ity of Dubois, and his firm conviction as to the ethical 
 and therapeutic value of his method, render it peculiarly 
 efficient. It is difficult to conceive of a patient not being 
 strongly moved by his remarks, which are presented by 
 
TREATMENT OF FATIGUE STATES 87 
 
 him so forcibly, and clinched by his frequent repetition 
 
 of his favorite phrase, " C'est la verite." . 
 
 It is apparent that the mental attitude of patients v-^ 
 suffering from this chronic state must be changed. New / 
 groups of complexes must be formed. The knowledge 
 that experience has shown that certain sensations have 
 resulted from certain activities must be replaced by a 
 conviction that these efforts may be made without harm. 
 
 Whether the result may better be brought about by 
 the establishment of new complexes in the hypnotic state, O 
 or by persuasion and conviction established in the waking 
 state, may be a question in some cases. If we are to 
 consider that the unhealthy complexes dominant in these 
 cases, rendering them unable to respond in a normal way 
 to their surroundings, are to be looked upon as a disso- 
 ciation, much as moods of depression are to be regarded, 
 hypnosis may be offered as a rational method for estab- 
 lishing the normal state. Both Tuckey and Bramwell 
 have reported cases in which the fatigue state has been 
 successfully treated in this way. 
 
 Personally I have used the conversation method prac- 
 ticed by Dubois. Needless to say, the physical condi- 
 tion must be thoroughly investigated and any deficiencies 
 recognized, while it should be assured that the bodily 
 secretions are functioning in a normal manner. 
 
 At the start, the attitude of the patient toward his ^ 
 condition must be changed. The discouraged doldrum \ 
 state must be attacked by a careful and truthful state- 
 ment of the existing condition, and the possibilities set 
 forth which must be attained, and will result as surely 
 as the physical law of cause and effect is true. He must 
 regard his condition in a new light, and new groups of 
 complexes must be called into play and associated with 
 his individual symptoms as well as with his attitude to- v 
 ward the future. 
 
88 PSYCHOTHERAPEUTICS j 
 
 When physical or mental effort is called into play the} 
 fatigue or discomfort resulting should call up the new' 
 complexes established, and in order that this may follow, 
 the association of the new complex groups must be more 
 strongly welded to the symptoms than are the old groups 
 of discouragement, indifference, fears, etc. It is here 
 that the mistake is too frequently made of using general 
 unmethodical encouragement, in place of strengthening 
 the association between the desired complexes and the 
 tasks to be performed. This is not to be accomplished 
 in a hasty consultation, but the physician must spend 
 sufficient time to feel himself thoroughly " en rapport " 
 with his patient, so that both have a tacit understanding 
 that they are taking up a task together which is going 
 to be accomplished. Enthusiasm for the undertaking, 
 increasing amounts of activity, and occupation best 
 suited to the individual, form steps by which the patient 
 may mount to his normal plane. 
 
 The rational acceptance of the feeling of fatigue must 
 be forced upon him until it becomes for him a natural 
 reflex, and this carries him a long way towards disregard- 
 ing it, and its final disappearance. Frequently the pa- 
 tient remarks, " Yes, doctor, I have done as you said, 
 but I feel so tired." " That may be true," is the reply, 
 " but you were just as tired last week, and then you were 
 accomplishing nothing. The difference is, that to-day 
 you are so much nearer the goal." 
 
 I am not in accord with the belief of Dubois that abso- 
 lute disregard of all symptoms depending on the psychic 
 state should be enforced upon the patient. Certainly the 
 road is a much easier one for him to travel if the dis- 
 tressing head feelings are alleviated by a static current, 
 or if a gastric disorder is controlled by some simple 
 remedy. The danger is to be avoided, however, of too 
 much treatment of this sort. 
 
TREATMENT OF FATIGUE STATES 89 
 
 The following cases are illustrative of the conditions 
 which may be benefited by these methods. 
 
 Case I. This patient was a student twenty-one years 
 of age. His father and mother were both of neurotic 
 families, and were themselves subject to moods of depres- 
 sion, while his sister was of a high strung and sensitive 
 temperament. The patient had always been strong and 
 rugged physically, and, except for certain disturbing 
 ideas in real life such as come to imaginative children, 
 had never had any nervous disorders. Slow to learn, he 
 had found it difficult to pass the entrance examinations 
 to college, and had some difficulty in keeping up with his 
 class work. This was the more difficult o'^ account of 
 his love of sports. His whole ambition seemed to be to 
 make the 'Varsity team in football. His continued ef- 
 forts to do well in his studies, with his constant worry 
 lest he should not be able to do well in his athletics, caused 
 him toward the middle of his first year in college to be- 
 come more and more fatigued. This sense of weariness 
 once started developed more rapidly, and made it nearly 
 impossible for him to accomplish any work. In fact, so 
 pronounced was the symptom, that repeatedly, on simply 
 crossing the college yard, he returned to his room so 
 exhausted that he felt obliged to lie down and rest. 
 
 His inability to keep up with his duties caused him 
 greater and greater worry, and he suffered constantly 
 from his head feeling tired, which rendered it impossible 
 for him to concentrate his mind any length of time. This 
 tired feeling in the head soon gave way to a constant 
 sense of pressure over the forehead and the vertex, which 
 caused him much alarm. Frequently when this was very 
 distressing, he would be seized with the idea that he 
 was going to lose his mind. 
 
 A careful examination of the patient showed an almost 
 perfect physical condition. Never have I seen more 
 
90 PSYCHOTHERAPEUTICS 
 
 splendid muscular development. There was no evidence 
 of any disturbance of the organs of the thoracic or the 
 abdominal cavities. The pupils were normal in size and 
 reacted well. The knee jerks were equal and slight. The 
 contrast between his story of utter physical exhaustion, 
 and the picture he presented of such strength was very 
 striking. Nor was he able to understand why he could 
 not enter Into things with his customary vigor. After 
 explaining in detail to him the nature of his condition 
 and the factors which were helping to keep him frcma 
 recovery, he was made to realize what his possibilities 
 were, and how he must apply himself to gain his ends. 
 The tasks put upon him were made rapidly more and more 
 difficult, so that at the end of six weeks he was doing a 
 normal amount of studying, and was rated as one of the 
 first-class men in putting the shot and throwing the ham- 
 mer. 
 
 His condition continued to improve so that the fol- 
 lowing fall he played on the 'Varsity football team, and 
 then as well as during the two succeeding years of play 
 was considered a tower of strength. 
 
 Except for a temporary difficulty of an entirely differ- 
 ent nature this patient has been quite well since his re- 
 covery, a period now of several years. 
 
 Case II. The second patient was a strong, well-look- 
 ing man of twenty-two, who for years had been inca- 
 pacitated for carrying on the work of daily life on ac- 
 count of his nervous condition. 
 
 A few years ago he was working very hard in college, 
 and studying In a law office in addition. This he was able 
 to keep up for a year, although he grew progressively 
 more tired, and found himself more and more limited In 
 his capacity for performing his duties. At the end of 
 this time, one evening when he arrived at his home, as 
 he was going upstairs he was suddenly overpowered with 
 
TREATMENT OF FATIGUE STATES 91 
 
 a sensation as if he were let down through a stairway, 
 and were melting away into nothingness, and was con- 
 scious of a feeling of overpowering fear. A cold sweat 
 broke out all over him, so that he got hot water bottles 
 and crawled into bed under heavy coverings, still feeling 
 strange. From that night on, the feeling of exhaustion 
 which had been increasing for a number of months be- 
 came doubly strong, and rendered him unable to carry 
 on his work and studies. In the mean time similar at- 
 tacks of fear and unreality returned at various intervals, 
 and he was advised to leave his home and to enter a 
 sanatorium. 
 
 The following two years were spent in various sana- 
 toria and retreats, the patient meanwhile getting no 
 stronger, but more and more losing confidence in him- 
 self. At the time when he made his first visit to me he 
 was unable to go about alone on account of his great 
 sense of fear that something would happen. The out- 
 side world seemed strange in a way which he found it 
 difficult to explain. There was no power to concentrate 
 the attention in following a conversation or in attempt- 
 ing to read; to such a degree did this symptom exist 
 that he found it impossible to read a single paragraph 
 in the newspaper understandingly. Attempts to move 
 about simply rendered him more tired, and on the whole 
 he declared himself utterly discouraged in trying to make 
 any progress against his illness. 
 
 The treatment of the condition was rendered difficult 
 in the beginning by the inability of the patient to give 
 his attention long enough to grasp a continued line of 
 argument. This was overcome gradually by forcing 
 him to devote all his energies to mastering the content 
 of longer and longer passages of reading at stated in- 
 tervals, till he found himself able to read or attend lec- 
 tures without effort. Meanwhile his fears were dis- 
 
9^ PSYCHOTHERAPEUTICS 
 
 pelled by the substitution of new complexes, so- that now 
 for a year he has been carrying on more work than is 
 done by the average law student, and performing his du- 
 ties in an eminently satisfactory manner. 
 
 Whereas the first case cited represents the psychical 
 fatigue (hyperesthesia) as related more to physical ef- 
 fort, the second case is the type in which a physiological 
 fatigue state developed into a psychopathological fa- 
 tigue and finally into a condition of psychasthenia. 
 Such cases at times have the distressing attacks of un- 
 reality and the overpowering fears developed to such a 
 degree that hypnosis is necessary to overcome them. 
 That new complexes may be forced upon them in the 
 waking state when the distressing symptoms are not too 
 deeply grounded is evidenced by the frequency with 
 which this end has been accomplished. 
 
 I 
 
 I 
 
CHAPTER FIVE 
 
 Psycho-analysis in Psychotherapy 
 
 BY EENEST JONES, M.D., M.R.C.P. (lOND.J 
 
 London 
 
 THE evolution of psychotherapy, like that of all 
 other modes of treatment, is marked by an ever- 
 increasing precision in method and an ever-deepen- 
 ing comprehension of the conditions to which it is ap- 
 plicable. Progress in these two respects must always 
 go hand in hand, for the moment therapeutics becomes 
 divorced from pathology and diagnosis it leaves its scien- 
 tific basis and stands in danger of approximating to that 
 medical charlatanery which it is the highest interest of 
 our profession to resist. The two studies are peculiarly 
 interwoven in the case of the psycho-analytic form of 
 psychotherapy, for, as I shall presently indicate, treat- 
 ment is here carried out by' simultaneously laying bare 
 and remedying the pathological mechanisms at the basis 
 of the malady. From this point of view we can discern 
 two stages in the development of any new method of 
 treatment, and these I can best illustrate by a reference 
 to more familiar methods, for instance the operations of 
 trephining or of laparotomy. When the possibility of 
 these operations was first realized we saw the first stage 
 in development, in which, namely, they were regarded 
 merely as an adjunct to the therapeutic armamentarium, 
 and were applied in the relief of conditions that were al- 
 ready well known and studied on established patholog- 
 ical lines. The second stage arose when, through the 
 repeated performance of such operations, conditions that 
 
 93 
 
94 PSYCHOTHERAPEUTICS 
 
 could be relieved by them came to be studied anew, fresh 
 aspects of pathology opened up, and questions of pre- 
 cise diagnosis that had previously been academic prob- 
 lems of trivial interest now became urgent matters of 
 life and death. A moment's reflection on the history ot 
 appendicitis will remind you of how little we knew of 
 the pathology, the diagnosis, or even the existence of the 
 affection until the surgeon's knife showed that it could 
 be cured. We might, in fact, paraphrase the motto un- 
 derlying British Imperialistic policy, to wit, that trade 
 follows the flag, and say that in medicine diagnosis fol- 
 lows treatment. 
 
 Now in psychotherapy most of the medical world is at 
 present only entering on the first stage. That the med- 
 ical world of America will definitely enter on this stage 
 as a prelude to further advancement will, I trust, be one 
 of the results of this present symposium. In this 
 stage we clearly recognize that we have secured a new 
 therapeutic weapon of the utmost value, which we may 
 describe as the capacity to alleviate certain complaints 
 by purely mental measures, in other words as psycho- 
 therapy in its broadest sense. Our attitude towards the 
 nature of these complaints, however, remains in this stage 
 substantially the same as it was when they were treated 
 only by physical remedies. Hence we may see the 
 strange picture of a physician removing by verbal sug- 
 gestion a symptom which he considers is produced by a 
 toxin circulating in the blood. However, a thoughtful 
 person who employs any form of psychotherapy soon 
 realizes that a symptom which can be removed by mental 
 measures is in all probability of a mental nature. It 
 may parenthetically be remarked that he further real- 
 izes how the suffering endured by the patient, so far from 
 being unreal, is all the more dreadful and formidable for 
 having a mental and not a physical origin. A non-ap- 
 
 
PSYCHO-ANALYSIS IN PSYCHOTHERAPY 95 
 
 preciation of this important fact is still all too common. 
 Only recently an article appeared in one of the leading 
 medical journals in which the writer remarked: "In this 
 manner I hope that we will always be able to trick a 
 malingerer or hysterical subject into betraying the 
 falsity of his claim." This attitude, though rarely in 
 such an outspoken form, is frequently implied in medical 
 writings, and cannot be too strongly condemned. Apart 
 from yielding an inkling of the mental nature of various 
 disorders, the first stage in the evolution of psycho- 
 therapy is characterized by an indeterminate attitude 
 towards the origin and pathogenesis of them. The 
 older conceptions have begun to dissolve, but the knowl- 
 edge won by the new method of treatment has not yet 
 been formulated. Psychotherapy is in this stage em- 
 ployed in a quite empiric way, and the physician either 
 does not concern himself with the intrinsic modus operandi 
 of his treatment, or else offers explanations of it which 
 are so superficial as to be of little scientific value. 
 
 Psycho-analysis represents the second stage in the 
 evolution of psychotherapy. Here a deeper insight is 
 sought into the essential nature and origin of the morbid 
 phenomena with a view to obtaining a fuller understand- 
 ing of the aims of treatment and so to achieving a 
 greater precision in the application of it. The psycho- 
 analytic method we owe almost completely to the genius 
 of Professor Freud of Vienna, who' in the past sixteen 
 years has wrought it into an elaborate science of which 
 I can here give only the most summary outline. The 
 method is based on the knowledge that the symptoms 
 present in the psycho-neuroses owe their origin to a con- 
 flict between two groups of ideas or mental processes 
 which cannot be brought into harmony with each other. 
 One complex of mental processes is for some reason or 
 other of such a kind as to be inacceptable to the main 
 
96 PSYCHOTHERAPEUTICS 
 
 body of the personality. The personality fails, to assim- 
 ilate it, will have nothing to do with it, tries to forget it, 
 to submerge it, to repress it. The repressed complex 
 then takes on an automatic existence, and acts as an ir- 
 ritating foreign body in the same way as any physical 
 foreign body that has not been absorbed. From this 
 point of view we may define the pathology of the psycho- 
 neuroses as a defect in assimilation. 
 
 Let me illustrate my meaning with a concrete instance. 
 A man conceives an attraction toward the wife of a near 
 friend or relative, and in his imagination perhaps plays 
 with the thought of what might happen were the friend 
 to meet with a fatal accident. If he honestly faces his 
 wish and realizes its nature he will instantly see that, 
 though possibly a perfectly natural one, it is of such a 
 kind that for social and ethical reasons it must obviously 
 be suppressed. If he adopts this healthy attitude he will 
 probably think no more about the matter except in the 
 most harmless way. The wish-complex is here assimi- 
 lated by the main body of the personality. If on the 
 other hand he regards the mere possibility of entertain- 
 ing such a wish as a sin and a sign of the most desperate 
 iniquity he may refuse to own up to himself that he has 
 ever felt it, even momentarily ; whenever the thought oc- 
 curs to him he endeavors to put it from him, to get away 
 from it, in other words to repress (' verdrangen ') it. 
 The complex here is not assimilated, it therefore con-' 
 tinues to act, and the more the man strives to escape 
 from it, the more hauntingly does it torment him. He 
 has now become the prey to a fixed idea which is out of 
 his control, and which evinces its independence by ap- 
 pearing irregularly whether he wills it or not. In actiial 
 practice we never meet with cases so simple as this, but 
 the instance will serve to illustrate the notion I am trying 
 to convey, namely that certain mental processes, par- 
 
PSYCHO-ANALYSIS IN PSYCHOTHERAPY 97 
 
 ticularly strivings, desires, and impulses, if they are not 
 absorbed in the main stream of the personality are apt 
 to manifest an independent activity out of control of the 
 will. This activity is usually of a low order, of an auto- 
 matic and almost reflex kind, and — if I may be allowed 
 to use the term in a clinical and non-philosophic sense 
 — it is generally an unconscious activity, that is to 
 say it operates without the subject's being aware of 
 it. 
 
 As I have just said, matters are not so simple in prac- 
 tice, and what actually happens is that the activity of 
 the repressed complex is manifested not directly but in- 
 directly in some distorted form that is often hard to rec- 
 ognize. In the above example, for instance, the subject 
 might have counterbalanced his real attitude towards 
 his friend by developing an exaggerated solicitude for 
 his welfare, and have shown great concern and dread 
 whenever the friend ran the slightest risk of accident or 
 danger. Again, an abnormally strong emotion might be 
 evoked by anything accidentally associated with the per- 
 sons in question, a condition that Professor Morton 
 Prince described some ten years ago under the name of 
 " association neurosis." This distortion in the mani- 
 festation of the activity of the mental complex is often 
 exceedingly involved, and one of the main difficulties in 
 the psycho-analytic method is the unravelling of the con- 
 fused end-product, which clinically we call a symptom. 
 The psychological mechanisms by means of which the 
 distortion is brought about are very intricate, so that in 
 the time allotted it would be impossible for me to de- 
 scribe them. They have been worked out with great 
 accuracy and detail by Freud and Jung, and an exact 
 study of them is essential to the use of the psycho- 
 analytic method. 
 
 Investigation on the lines presently to be indicated 
 
98 PSYCHOTHERAPEUTICS 
 
 discloses the fact that every psycho-neurotic symptom is 
 to be regarded as the symbolic expression of a submerged 
 mental complex of the nature of a wish. The wish itself 
 on account of its inacceptable nature is concealed, and 
 the symptom arises as a compromise between it and the 
 repressing force exerted by the main personality. The 
 stream of feeling that characterizes the wish is dammed 
 up, it can find no direct outlet, and so flows into some 
 abnormal direction. The metaphor of " side-tracking " 
 is, I believe, used in American psychiatric circles to in- 
 dicate this process. In more technical phraseology we 
 may say that the affect of the original complex is in- 
 hibited, and so becomes transposed on to an indifferent 
 mental process. This indifferent mental process has now 
 become invested with the strength of feeling that prop- 
 erly belongs to the original complex, and so may be said 
 to replace the complex. Thus arises what Professor 
 Adolf Meyer calls a substitution neurosis, in which an 
 abnormal outlet has been found for a pent-up affective 
 process. The outlet may be in a purely mental direc- 
 tion, in which case we have such a symptom as a phobia, 
 or towards various bodily processes, a condition that 
 Freud calls conversion-hysteria, in which case we have 
 such symptoms as a tremor or a paralysis. In the 
 symptom the patient obtains a certain unconscious grat- 
 ification of the repressed wish, and this means of obtain- 
 ing the gratification, however perverse and abnormal it 
 may be, is still the only means possible to the patient 
 under the circumstances. This fact explains the ob- 
 stinacy with which such a patient may instinctively cling 
 to his symptoms, and is one of the causes of the resistance 
 that the physician encounters when trying to remove 
 these. I need hardly remind you that this obstinacy is 
 often erroneously interpreted even by physicians as in- 
 dicating mere wilful perversity, a mistake that does not, 
 
 J 
 
PSYCHO-ANALYSIS IN PSYCHOTHERAPY 99 
 
 conduce to success in treatment. Not only does the ob- 
 server commonly fail to understand the significance of 
 the sjmptom, but the patient himself has no knowledge 
 of its meaning or origin. In fact, enabling the patient 
 to discover and appreciate the significance of the mental 
 process that manifests itself as a symptom is the central 
 aim of the psycho-analytic method, 
 ' In carrying out this method several procedures may be 
 adopted according to circumstances. The hypnotic 
 state, for instance, may be utilized in the search for for- 
 gotten memories. Only a very few of those acquainted 
 with the psycho-analytic method employ this procedure 
 at all extensively, for it has grave disadvantages which 
 I need not here discuss. Personally I employ it only as 
 a rare exception and for special reasons ; under certain 
 circumstances, however, it undoubtedly has a legitimate 
 place. The procedure introduced and developed by 
 Freud is the one most generally used, and gives by far 
 the most satisfactory results. It is one of the ways of 
 obtaining what is known in psychology as " free associa- 
 tion," and is carried out by getting the patient ta con- 
 centrate his mind on a given idea, generally one in rela- 
 tion to a symptom, and asking him to relate in the order 
 of their appearance the various thoughts that come to 
 his mind. It is essential for him to do this quite hon- 
 estly, and fortunately we have several objective tests of 
 his behavior in this respect. He must suspend his nat- 
 ural tendency to criticize and direct the thoughts flow- 
 ing in, and must therefore play a purely passive part 
 during this stage. At first he will omit to mention a 
 number of thoughts on the ground that they are appar- 
 ently irrelevant, unimportant, or nonsensical, and others 
 because they are of a painful or unpleasant nature. 
 After a time, however, the length of which largely de- 
 pends on his intelligence and sincerity, he acquires the 
 
100 PSYCHOTHERAPEUTICS ^ 
 
 capacity of adopting the non-critical and passive atti- 
 tude essential to success. 
 
 Other means of reaching buried mental complexes may 
 briefly be mentioned. A study of various mannerisms, 
 symptomatic movements and tricks of behavior, and slips 
 of the tongue or pen, often reveals the automatic func- 
 tioning of some repressed train of thought. The word- 
 reaction association method as developed by Jung is of 
 the highest assistance, particularly in furnishing us with 
 a series of clues to serve as starting points for future 
 analyses. In this method a series of test-words are 
 called out to the patient, who has to respond with the 
 first word or thought thus called to his mind. From a 
 general review of the kind of responses given much can 
 be learned about the mentality of the patient and the 
 type of psychosis present. Further, by noting certain 
 peculiarities in the individual reactions we may discover 
 certain complexes or trains of thought which possess for 
 the patient a high emotional value, and these can then 
 be followed and studied more fully. The peculiarities I 
 refer to are ten or twelve in number. The chief are: 
 undue delay in the time of reaction, failure to respond 
 at all, response by repetition of the test-word, persevera- 
 tion affecting the succeeding reactions, anomalous clang 
 associations, assimilation of the test-word in an unusual 
 sense, and erroneous reproduction of the reaction when 
 the memory for it is subsequently tested. Last but not 
 least is the analysis of the patient's dreams by means of 
 the special technique introduced by Freud. The study 
 of dreams is in this connection of supreme importance, 
 for of all the means at our disposal it is the one that best 
 enables us to penetrate into and understand the most 
 hidden parts of the mind. No one can have more than 
 an outsider's notion of the psycho-analytic method who 
 has not thoroughly studied Freud's Traumdeutungy for 
 
 I 
 
PSYCHO-ANALYSIS IN PSycHOTHERAPY 101 
 
 in this work he has laid down the ^etifiiiiqiie ' oi' his iatthr 
 ods, and discussed the principles on which they are based, 
 with a fulness to be found nowhere else in his writings. 
 
 By means of the methods just outlined we are enabled 
 to determine the origin of the symptom by retracing the 
 steps along which its pathogenesis proceeded. It is im- 
 possible to deal with the underlying complexes, to dis- 
 charge their pent-up affect, to render them more assim- 
 ilable by the patient, unless one succeeds in this task and 
 brings them to the full light of day. The symptoms 
 constitute a veiled language in which hidden thoughts 
 and desires find the only means allowed them of coming to 
 expression. We have to get the patient to translate his 
 symptoms into more direct language, and thus to under- 
 stand and appreciate the origin of them. In so doing 
 we give the patient a deeper insight into the workings 
 of his mind, so that he is enabled to correct abnormal 
 deviations, to overcome internal inhibitions and impedi- 
 ments, and to acquire a more objective standpoint to- 
 wards the repressed mental complexes, the automatic 
 functioning of which has produced the morbid manifesta- 
 tions. He is in this way able to free his personality 
 from the constraining force of these complexes, and, by 
 taking up an independent attitude towards them, to gain 
 a degree of self-control over his aberrant thoughts and 
 wishes that was previously impossible. The method is 
 thus in almost every respect the reverse of treatment by 
 suggestion, although several would-be critics have 
 naively exposed their ignorance of the subject in main- 
 taining that the successful results are produced by sug- 
 gestion. In suggestion treatment the physician adds 
 something to the patient's mind, — confidence, belief, etc., 
 — and thus makes the patient more dependent on him. 
 The psycho-analytic method does not add; it takes away 
 something, namely inhibition. It enables the patient to 
 
102 PSYCHQTHERAPEUTICS 
 
 disentangi^ confu'sed mental processes, and, bj giving 
 him control over the disharmonies of his mind, leads him 
 to develop a greater measure of self-reliance and inde- 
 pendence. The training received by the patient is thus 
 an educative one in the highest sense of the word, for he 
 not only achieves a richer development of will power and 
 self-mastery, but acquires an understanding of his own 
 mind which is of incalculable value for future prophy- 
 laxis. He grows both in capacity to know and in ability 
 to do. 
 
 The conditions that lend themselves to psycho-analytic 
 treatment comprise practically all forms of psycho-neu- 
 rosis, the different types of hysteria, the phobias, obses- 
 sions, anxiety neuroses, and even certain kinds of sexual 
 perversions. I shall refrain from relating any individ- 
 ual cases, for to do so would be only to weary you with 
 the recital of a list of typical and atypical instances of 
 these various conditions. It is further impossible for 
 me to narrate any single instance of an analysis, for in 
 every case the richness of material is so great that it 
 would take several hours to give even an outline of the 
 main points in the case. 
 
 The results obtained by the treatment, though by no 
 means ideal, are yet very gratifying. They surpass 
 those obtained by simpler methods in two chief respects, 
 namely in permanence and in the prophylactic value they 
 have for the future. Although most symptoms can be 
 removed by other methods, such as hypnotism, yet any 
 one who has devoted much time to the study of these cases 
 knows how great is the tendency to relapse, to recurrence, 
 and to the appearance of fresh groups of symptoms. 
 Mild^cases can indeed be not only alleviated but even 
 cured by the simpler psychotherapeutic measures, so that 
 these all have tl]ieiT~sphere of usefulness; severe cases, 
 on the other hand, need a more radical treatment, an 
 
PSYCHO-ANALYSIS IN PSYCHOTHERAPY 103 
 
 uprooting of the actual morbid agents. It is easy to 
 understand how this must be so. Hypnotic jind, other 
 suggestion acts merely by blocking the outward mani- 
 f estafioiT of theiinderlymg pathogenetic idea. The 
 idea itseir persists, because it has not been reached and 
 dealt with, and sooner or later it will again manifest it- 
 self either in the same direction or in some fresh one. 
 The analogy of a tubercular, or better still of an 
 actinomycotic abscess occurs to me in this connection. 
 If the suppurating sinus is forcibly plugged then the 
 symptom of discharging pus is removed, but sooner or 
 later the pent-up pus will find a vent in either the same 
 or a fresh direction. Before satisfactory healing can 
 take place the tension must be relieved by instituting 
 free drainage for each pus pocket, and the more thor- 
 oughly the focus of the disease is dealt with the better 
 will be the result. 
 
 A few words are now necessary on the clinical ap- 
 plicabilities and limitations of the method. It is a 
 method that makes great demands on both physician and 
 patient. Apart from technical knowledge the physician 
 must evidently possess, not only unimpeachable integrity, 
 but also a considerable measure of tact, patience, and 
 sympathetic understanding; without these qualifications 
 he is unlikely to gain the patient's confidence to the 
 requisite degree. The treatment further makes a great 
 call on his time. Freud often finds it necessary to de- 
 vote to a patient an hour a day for three years, but he 
 acknowledges that the cases sent to him are generally of 
 a very severe nature. In milder cases one can achieve 
 very satisfactory results in a few months, a fact to which 
 I can fully attest from my own experience. The amount 
 of time may appear excessive unless one remembers the 
 hugeness of the task imposed, for in all cases the roots 
 of the trouble go back to early childhood, and important 
 
104 PSYCHOTHERAPEUTICS 
 
 modes of reactions have to be altered which have been 
 fixed and stereotyped for many years. When we con- 
 sider how much trouble and time frequently has to be 
 expended in the orthopedic straightening of a deformed 
 limb, we should not grudge the same to the far more 
 intricate task of the orthopsychic training of a deformed 
 mind, especially when this results in converting an in- 
 tolerable existence into a happy life, and a person para- 
 lyzed by doubts, fears, and suffering into an active and 
 useful citizen. 
 
 The demands made on the patient are no less great. 
 The results of the treatment will vary with the intelli- 
 gence, courage, honesty, and perseverance he shows. 
 With stupid aiid,quite uneducated patients relatively lit- 
 tle can be done, so that TiappITy we can most help those 
 whose value to the world is greatest. Again, age sets a 
 f orrnidable barrier_to our efforts. In old age/when the 
 plasticity of the mind is dTmlnrshed, far less can be done 
 than at an earlier period, and furthermore the time nec- 
 essary to trace back the erroneous mental reactions 
 through so many years is naturally longer. Still I have 
 had a few fairly satisfactory results even above the age 
 of fifty. 
 
 It will be realized that the method is at present not 
 one generally applicable by the practising physician. 
 Not only is the time necessary for the treatment a great 
 hindrance, but also a laborious special training is neces- 
 sary before the technique of psycho-analysis can be ac- 
 quired to an adequate extent. It is generally admitted 
 that this demands three years' incessant practice, a good 
 previous knowledge of neurology being assumed. Here, 
 as elsewhere, therefore, good work exacts arduous labor, 
 and there is no royal road to the art of handling the most 
 intricate and delicate machine we know of, the human 
 mind. 
 
PSYCHO-ANALYSIS IN PSYCHOTHERAPY 105 
 
 You may now legitimately ask why I have taken up so 
 much of your time in describing a mode of treatment 
 which I acknowledge not many will have the opportunity 
 to learn or to apply. My answer is a twofold one. In 
 the first place I am not one of those who hold that the 
 general physician should be cut off from all advancing 
 knowledge except that which he can immediately apply 
 in his daily work. No physician can apply all methods 
 of diagnosis and treatment but it is surely well that he 
 should at least be aware of the existence of them. I can- 
 not believe that because a country practitioner is not 
 expected to apply the Wassermann test in the diagnosis 
 of syphilis, or to perform excision of the Gasserian 
 ganglion for the relief of trigeminal neuralgia, It is there- 
 fore better for him not to know about such methods. 
 In the second place I wish to contribute to the general 
 effect that this symposium must have in bringing home 
 to you in some degree the present unsatisfactory state 
 of medical education so far as psychology is concerned, 
 for this is thejimliLcause^^f tl^ of the med- 
 
 ical profession against the very maladies that are the 
 triumph of the quack, religious or otherwise. The 
 sooner we honestly face the shameful but undeniable fact 
 that unqualified empirics can relieve distressing affections 
 in cases that have defied medical skill, can produce re- 
 sults where we fail, the sooner will this flagrant lack in 
 our system of education be remedied, and the better will 
 it be for the dignity and honour of the medical profes- 
 sion. While the present state of affairs lasts, in which 
 most physicians are given not five minutes' training in 
 psychology in the five years of their student life, and in 
 which there is no teacher of clinical psychology in any 
 university or medical school in the country, our profes- 
 sion must submit to being the prey of the charlatan and 
 the mock of the scoffer. 
 
CHAPTER SIX 
 
 The Psycho'?herapeutic Value of the Hypnoidal 
 
 State 
 
 by boris sidis, m.a., ph.d., m.d. 
 
 HYPNOSIS has long ago been brought before the 
 scientific world as a state in which maladies of 
 a functional or of a psychic origin, such as th( 
 various forms of hysterias, obsessions, and phobias, can 
 be helped and even cured. The works of Braid, Char- 
 cot, Liebault, Bernheim, Forel, Vogt, Breuer and Freud, 
 Schrenck-Notzing, Prince, Bechterew, Janet, Babinski, 
 and others, are well known to the student in abnormal 
 psychology. Recently, however, many medical men of 
 reputation, such as Dubois, Freud, Prince, Putnam, Tay- 
 lor, Waterman, Donley, and many others, could not help 
 being impressed by the practical limitations of the hyp- 
 notic state. Many patients refuse to submit to treat- 
 ment, being afraid of occult influences. Then again a 
 great number of patients are difficult to hypnotize. 
 There is no denying the fact that there exists a strong 
 feeling of distrust among many conservative men wh< 
 are not acquainted with the amount of scientific work 
 that has been lately done in the domain of abnormal psy- 
 chology. This strong feeling against the use of th( 
 hypnotic state as a therapeutic agent in psychopathic 
 diseases is unfortunately often found among many rep-^ 
 resentative men of the American medical profession. 
 
 An American editor of a well-known American medical 
 journal unhesitatingly rejects work on psychopathology 
 
 106 
 
 1 
 
VALUE OF THE HYPNOIDAL STATE 107 
 
 and psychotherapy. The editor is apparently under the 
 impressicWT that he is keeping up the high standard of 
 American medical science, — that papers, disquisitions, 
 and discussions on diarrhea, constipation, enemas, 
 eczema, hemorrhoids, and cognate scientific investiga- 
 tions are essentially valuable, dignified, and suitable to 
 the mind and needs of the medical reader. In Germany, 
 France, Italy, Austria, Russia, work in abnormal psy- 
 chology has long ago gained recognition as a science of 
 theoretical and practical importance to the physician and 
 even to the lawyer, while in the United States conserva- 
 tism in regard to abnormal psychology is still paraded 
 as a badge of orthodox medical respectability. The op« 
 position to psychopathology is manifest, when it comes 
 to the use of the hypnotic state. 
 
 Since hypnosis meets with so much opposition the 
 question naturally arises, — Is it possible to affect and 
 modify pathological mental states outside hypnosis? 
 The problem is practical and requires a solution. In 
 " The Psychology of Suggestion " I pointed out on the 
 strength of a number of experiments that suggestibility 
 can also be induced in the fformal waking state. I have 
 also shown that among the conditions of normal and ab- 
 normal suggestibility monotony and limitation of activity 
 play an important role. Any arrangement tending to 
 produce monotony and limitation of voluntary activity 
 brings about a state of suggestibility termed by me 
 subwaking or hypnoidal, a state in which mental life can 
 be affected with ease. The induction of the state is 
 termed hypnoidization. 
 
 In the hypnoidal state consciousness becomes some- 
 what vaguer than in the waking condition; memory is 
 more diffused, so that experiences apparently long forgot- 
 ten come in bits and scraps to the foreground of con- 
 
108 PSYCHOTHERAPEUTICS 
 
 sciousness. Emotional excitement subsides, -voluntary 
 activity is changed to passivity, and suggestions meet 
 with little resistance. The subwaking state is above all 
 a rest-state, a state of physical and mental relaxation. 
 
 The favorable therapeutic results obtained by me led 
 to a closer study of what I, some thirteen years ago, re- 
 garded as a peculiar mental condition. The subwaking 
 or hypnoidal state is essentially an intermediate state 
 belonging to the borderland of mental life. On the one 
 hand the hypnoidal state closely touches on the waking 
 state, on the other it merges into hypnosis and sleep, 
 A close study of the subwaking state shows that it differs 
 from the hypnotic state proper and that it cannot be 
 identified with light hypnosis. In my years of study of 
 patients and subjects I have observed the presence of the 
 subwaking state before the development of hypnosis and 
 also before the oncome of sleep. When again sleep and 
 hypnosis pass into waking, the hypnoidal state reap- 
 pears. The hypnoidal state may therefore be regarded 
 as a transitional, intermediate state. 
 
 The subwaking state may be said to partake not only 
 of the nature of waking and sleep, but also to possess 
 some characteristics of hypnosis, namely suggestibility. 
 It is clear that from the character of its mixed symp- 
 tomatology the hypnoidal state is variable and unstable. 
 The subwaking state should, in fact, be regarded as an 
 equivalent of sleep. Like sleep the hypnoidal state has 
 many levels of depth. It differs, however, from sleep 
 by the rapidity of its oscillations from level to level. In 
 the experiments of various investigators sleep is found 
 to be represented by a rapidly rising curve during the 
 first couple of hours, and by a gradually descending curve 
 during the rest of the hours of sleep. No such regularity 
 of curve can be observed in the subwaking state. The 
 depth of the hypnoidal state changes very rapidly and 
 
VALUE OF THE HYPNOIDAL STATE 109 
 
 with it the passive condition and suggestibility of the 
 patient. 
 
 Thus far the work was confined to observations and 
 experimentation on human subjects and patients, both 
 from a theoretical and practical therapeutic standpoint. 
 Recently, however, I undertook at the physiological 
 laboratory of Harvard Medical School, and also in my 
 own psychopathological laboratory, a series of experi- 
 ments on the manifestations of sleep in the ascending 
 scale of animal life, — from the frog and guinea pig, the 
 cat, the dog, to the infant and adult. ^ The experiments 
 prove that the hypnoidal state is by no means confined to 
 man, but is also present in the lower stages of animal 
 life. Furthermore, the experiments clearly show that 
 the further down we descend in the scale of animal life, 
 the more prominent, the more essential does the subwak- 
 ing state become. From the facts one is forced to come 
 to the conclusion that the hypnoidal state is the primitive 
 rest-state out of which sleep has arisen in the later stages 
 of evolution. Sleep and hypnosis have taken their origin 
 in the hypnoidal state; both hypnosis and sleep are 
 highly differentiated states and have become evolved out 
 of the primitive, undifferentiated, subwaking state, which 
 is the rest-state, still characteristic of the lowly organ- 
 ized forms of animal life. In short, we may say that 
 the hypnoidal state is the primordial sleep-state. In 
 man the subwaking state is but in a rudimentary condi- 
 tion, — it has shrunk to an abortive, transitory, momen- 
 tary stage in the alternation of waking and sleep. 
 
 While in the hypnoidal state the patient's consciousness 
 keeps on fluctuating from moment to moment, now fall- 
 ing deeply into a subconscious state in which outlived 
 experiences are easily aroused, and now again rising to 
 
 1 Sidis : An Experimental Study of Sleep, Joubnal of Abkob- 
 MAL Psychology, 1908. 
 
110 PSYCHOTHERAPEUTICS 
 
 the level of waking consciousness. The experiences come 
 often in fragments which gradually coalesce and form a 
 connected series of interrelated systems, apparently long 
 gone and forgotten. The recognition is fresh, vivid, in- 
 stinct with life, as if the experiences had occurred the 
 day before. The revived experiences are in many cases 
 confirmed by some relative or intimate friend. This char- 
 acteristic of getting access to subconscious experiences 
 lost to the patient's personal consciousness is what makes 
 the hypnoidal state such a valuable instrument in the 
 tracing of the origin and development of the symptoms 
 of the psychopathic malady. Important, however, as 
 the following-up of the history or of the psychogenesis 
 of the symptoms may be, both to the physician and to 
 the patient, for an intelligent and scientific comprehen- 
 sion of the case, it does not cure^ as some are apt to 
 claim, the psychopathic malady. The value of tracing 
 the growth of the disease to its very germs lies entirely 
 in the insight gained into the nature of the symptom-com- 
 plex. The tracing of the psychogenesis has no special 
 therapeutic virtues, as the Germans claim, but, like all 
 theoretical knowledge, is of the utmost importance for a 
 clear understanding of the causation of the psychopathic 
 state, thus helping materially in the treatment of the 
 case. The information of the psychogenesis given to 
 the patient is valuable only in so far as by a systematic 
 course of direct and indirect suggestion, by mediate asso- 
 ciative and immediate associative suggestion, by substi- 
 tution, disintegration, and synthesis, both in the waking 
 and the hypnoidal states, we help to transform the asso- 
 ciative course and emotional tone of the patient's mental 
 life.^ The treatment is a highly complex process of dis- 
 integration and integration of mental systems. 
 
 From a practical standpoint the therapeutic value of 
 
 2 Sidis : Psychopathological Research ; Multiple Personalityi 
 Psychology of Suggestion. 
 
 
VALUE OF THE HYPNOIDAL STATE 111 
 
 the hypnoidal state is by far the most important. Now 
 as we have pointed out, our experiments on sleep have 
 revealed the significant fact that the hypnoidal state is 
 the primordial rest-state, — sleep is but a derivative form 
 of rest. In many forms of diseases, especially nutri- 
 tional, it is often advisable to revert to a more simple 
 and more primitive form of nutrition. Similarly in psy- 
 chopathic maladies a reversion to a simple form of rest- 
 state proves to be of material help to the patient. In 
 plunging the patient into the subwaking, hypnoidal state 
 we have him revert to a primitive rest-state with its con- 
 sequent beneficial results. The suggestibility of the hyp- 
 noidal statey if skilfully handled^ increases the therapeutic 
 efficacy of the hypnoidal subwaking state. Relaxation 
 of nervous strain, rest from worry, abatement of emo- 
 tional excitement are known to be of great help in the 
 treatment of nervous troubles of the neurasthenic or of 
 the more fashionable psychasthenic. We find something 
 similar in the treatment of psychopathic diseases by 
 means of the agency of the hypnoidal state the thera- 
 peutic eflScacy of which is all the more heightened by the 
 presence of the trait of suggestibility. Most important, 
 however, is the access gained through the agency of the 
 hypnoidal state to the stores of potential subconscious 
 reserve-energy, which, by a liberation of energy, bring 
 about a reassociation and synthesis of the dissociated 
 mental systems underlying the symptoms of the disease. 
 The therapeutic value of the hypnoidal state consists in 
 the liberation of reserve energy requisite for the syn- 
 thesis of the dissociated systems. 
 
 The theory of reserve energy is of the utmost impor- 
 tance to abnormal psychology. The theory was ad- 
 vanced independently by Prof. James ^ and myself,^ and 
 
 3 James: The Energies of Men, Philosophical Review, 1907. 
 4Sidis: Studies in Psychopathology, Ch. xiv. The Principle of 
 Reserve Energy, B. M. fJ. J.. 1907. 
 
112 PSYCHOTHERAPEUTICS 
 
 seems to me to form the very foundation of psycho- 
 pathology and psychotherapeutics. It is by no means 
 easy to present adequately the principle of reserve en- 
 ergy in this brief paper. The principle is based on a 
 broad generalization of facts, psychological, physio- 
 logical, and biological, namely, that far less energy is 
 utilized by the individual than there is actually at his 
 disposal. In fact, but a very small fraction of the total 
 amount of energy possessed by the organism is used in 
 its relation with the ordinary stimuli of its environment. 
 The energy in use may be regarded as the kinetic or 
 circulating energy, while the energy stored away is the 
 potential reserve energy. There must always be a re- 
 serve supply of energy requisite for unusual reactions 
 in emergency cases. Those organisms survive which 
 have the greatest amount of reserve energy, just as those 
 countries are stronger and victorious in the world-mar- 
 ket which possess the largest amount of reserve capital 
 to draw upon in critical periods. 
 
 As life becomes more complex inhibitions increase, — 
 the thresholds of stimulations of a complex system rise 
 in proportion to its complexity. With the rise of evo- 
 lution there is a tendency to increase of inhibitions with 
 a consequent lock-up of energy which becomes reserve. 
 Now there are occasions in the life of the individual, un- 
 der the influence of training and emotional trauma, when 
 the inhibitions become unusually intense and tend to 
 smother the personality which is weakened, impoverished 
 in its reactions, and is unable to respond freely to the 
 stimuli of its environment. The inhibited system becomes 
 inactive and may be regarded as dissociated from the 
 cycle of life. In case of an emotional trauma there is 
 often a breach in continuity of association, the affected 
 system becomes dissociated from the rest of mental life, 
 and is like a splinter in the flesh of the individuality. Its 
 
 i 
 
VALUE OF THE HYPNOIDAL STATE 113 
 
 own threshold when tapped may be very low, but is not 
 directly accessible through the mediacy of other sys- 
 tems. On that account its threshold appears unusually 
 or pathologically high. When the inhibitions are very 
 high they must be removed. This removal of inhibitions 
 brings about an access to the accumulated energy of the 
 inhibited system. In case of disjunction or break of 
 continuity we must stimulate the reserve dormant energy 
 of the systems and thus assist the process of repair and 
 bridge the breach of associative continuity. A new 
 fresh active life opens to the patient. He becomes a 
 different, a " reformed " personality, free and cheerful, 
 with an overflow of energy. 
 
 To quote from a former work of mine : ^ ^ 
 
 " The thresholds of our psychophysiological systems ■ 
 are usually raised, mental activity working in the course 
 of its development and growth of associative processes 
 under ever increasing inhibitions with ever higher thresh- 
 olds. . . . On account of the high thresholds and in- 
 hibitions not the whole amount of the psychophysiolog- 
 ical energy possessed by the system is manifested; in 
 fact, but a very small portion is displayed in response 
 to stimuli coming from the habitual environment. What 
 becomes of the rest of the unused energy.'* It is storedy 
 reserve energy, 
 
 " Biologically regarded, we can well see the importance 
 of such stored or reserve energy. In the struggle for ex- 
 istence, the organism whose energies are economically 
 used and well guarded against waste will meet with better 
 success in the process of survival of the fittest, or will 
 have better chances in the process of natural selection. 
 The high thresholds and inhibitions will prevent hasty 
 and harmful reactions as well as useless waste of energy, 
 unnecessary fatigue, and states of helpless exhaustion. 
 5 studies in Psychopathology, B. M. S. J., 1907. 
 
114 PSYCHOTHERAPEUTICS 
 
 Moreover, natural selection will favor organisms with 
 greater stores of reserve energy which could be put forth 
 under critical conditions of life. In fact, the higher the 
 organization of the individual, the more varied and com- 
 plex the external environment, the more valuable and 
 even indispensable will such a store of reserve energy 
 prove to be. (/ \ 
 
 " The course of civilization and education, by contin- 
 uously raising the thresholds and inhibitions, follows the 
 line of natural selection and keeps on increasing the dis- 
 posable store of potential, subconscious or reserve energy 
 both in the individual and the race. It is in this forma- 
 tion of an ever-greater and richer store of disposable, 
 but well-guarded, reserve energy, that lies the superiority 
 of the educated over the uneducated and the supremacy 
 of the higher over the lower races. 
 
 " Civilization and education are processes of economy 
 of psycho-neural force, savings of mental energy. But 
 what society is doing in a feeble way natural selection 
 has done far more effectively. What education and civ- 
 ilization are doing now on a small scale and for a brief 
 period of time the process of survival of the fittest in the 
 ever-raging struggle for existence has done for ages on 
 a large scale. We should, therefore, expect that the nat- 
 ural reserve energy would far exceed that of the culti- 
 vated one. 
 
 " In the treatment of the phenomena of psycho-physio- 
 logical dissociation, in the protean symptoms of nervous 
 and mental exhaustion we should not forget this bio- 
 logical principle of reserve energy and should make at- 
 tempts to use it. In many cases the inhibitions become 
 too heavy and the thresholds too high. We must loosen 
 the grip of some of the inhibitions and lower the thres- 
 holds, thus utilizing a fresh supply of reserve energy." 
 
 A similar train of thought was developed by Dr. S. J. 
 
VALUE OF THE HYPNOIDAL STATE 115 
 
 Meltzer in his excellent paper on " The Factors of Safety 
 in Animal Structure and Animal Economy." ^ By a 
 striking series of instructive facts Dr. Meltzer points out 
 that " All organs of the body are built on the plan of . 
 superabundance of structure and energy." I cannot re- 
 sist the temptation of quoting Dr. Meltzer's conclusions 
 at some length as they so clearly elucidate our principle 
 of reserve energy which is all the more valuable as Dr. 
 Meltzer has formulated it independently on widely differ^ 
 ent grounds. " Of the supplies of energy to the animal 
 we see that oxygen is luxuriously supplied. The supply i 
 of carbohydrates and fats is apparently large enough to j 
 keep up a steady luxurious surplus. . . . The liberal in-? 
 gestion of proteid might be another instance of the prin-; 
 ciple of abundance ruling the structure and energies of 
 the animal body. There is, however, a theory that in 
 just this single instance the minimum is meant by nature 
 to be also the optimum. But it is a theory for the sup- 
 port of which there is not a single fact. On the con- 
 trary, some facts seem to indicate that Nature meant 
 differently. Such facts are, for instance, the abundance 
 of proteolytic enzymes in the digestive canal and the 
 great capacity of the canal for absorption of proteids. 
 Then there is the fact that proteid material is stored 
 away for use in emergencies just as carbohydrates and 
 fats are stored away. In starvation nitrogenous prod- 
 ucts continue to be eliminated in the urine which, accord- 
 ing to Folin, are derived from exogenous sources, that 
 is from ingested proteid and not from broken down or- 
 gan tissues. An interesting example of storing away of 
 proteid for future use is seen in the muscles of the salmon 
 before they leave the sea for the river to spawn. Ac- 
 cording to Mescher the muscles are then large and their 
 productive organs are small. In the river where the 
 6 Science, 1907. 
 
116 PSYCHOTHERAPEUTICS 
 
 animals have to starve, the reproductive organs becom 
 large, while the muscles waste away. Here in time o 
 affluence the muscles store up nutritive material for th 
 purpose of maintaining the life of the animal during 
 starvation and of assisting in the function of reproduc 
 tion. This instance seems to be quite a good illustratioi 
 of the role which the factor of safety plays also in th( 
 function of the supply of the body with proteid food 
 The storing away of proteid like the storing away oj 
 glycogen and fat for the use in expected and unexpecte 
 exceptional conditions is exactly like the superabundance 
 of tissue in an organ of animal or like an extra beam 
 the support of a building or a bridge, — a factor of 
 safety. 
 
 " It seems to me that the factors of safety have an im- 
 portant place in the process of natural selection. Thos 
 species which are provided with an abundance of usefu 
 structure and energy and are prepared to meet many 
 emergencies are best fitted to survive in the struggle foi 
 existence." 
 
 The hypnoidal state is essentially a rest-state charac 
 terized by anabolic activity. There is a restitution of 
 spent energy; inhibitions become removed and access is 
 gained to what Dr. Prince so aptly describes as " dor- 
 mant " systems or complexes. The awakened " dor- 
 mant " complex systems bring with them a new feeling- 
 tone, a fresh emotional energy resulting in an almost 
 complete transformation of personality. 
 
 As an illustration of the transformation effected I 
 take at random the following extracts from some of the 
 letters written to me by patients who have experienced 
 this welling up of reserve energy: 
 
 " Indeed were I to fill this entire sheet with expression 
 of the gratitude which wells up from my inmost heart i 
 would be only a beginning of what I feel. Surely the 
 
 i 
 
 I 
 
VALUE OF THE HYPNOIDAL STATE 117 
 
 darkness of the world has been dispelled since this new 
 light has illuminated my soul, and I feel that this won- 
 drous light will never fail me. It were vain to attempt 
 to thank you for this wonderful transformation." 
 
 Another letter reads : " You will be glad to know that 
 all is well with me. Life is one happy day, I am a marvel 
 to my friends in the way of happiness and cheer. I have 
 to confess that I feel almost wicked to be so happy." 
 
 Another letter runs as follows : " Next to the gladness 
 in my own restoration, I am rejoiced at the wonderful 
 transformation that has come to my dear friend T. from 
 your marvelous treatment. She writes me most enthu- 
 siastically of her steady and sure progress toward the 
 goal of perfect health, of her strength to take up the 
 home duties which had been so burdensome and which she 
 now finds a delight in the doing of them, and of her 
 husband's and friends' joy in the transformation that 
 has been wrought in her." 
 
 Dr. Prince in his " Unconscious " '^ gives an extract 
 of a patient's letter which tells of a similar transforma- \ 
 tion and awakening of dormant reserve energy. " Some- j 
 thing has happened to me — I have a new point of view. 
 I don't know what has changed me all at once, it is as if 
 scales had fallen from my eyes; I see things differently 
 — you have given me life and you have given me some- / 
 thing to fill it with. I owe you what is worth far more 
 than life itself, namely the desire to live." 
 
 Those extracts are typical of many others and clearly 
 show the enjoyment of new strength and powers until 
 now unknown to the patient. Fresh levels of reserve en- 
 ergy have been tapped and have become available in an 
 hour of dire need. The patient has light and strength 
 where there were darkness and depression. We are con- 
 fronted here with the important phenomenon of liberation 
 7 Journal of Abnormal Psychology, 1909. 
 
118 PSYCHOTHERAPEUTICS 
 
 of dormant reserve energy. The patient feels the flood 
 of fresh energies as a " marvelous transformation," as a 
 " new light," as a " new life," as " something worth far 
 more than life itself." 
 
 The hypnoidal state helps us to reach the inaccessible 
 regions of dormant energy, it helps to break down in- 
 hibitions, liberate reserve energies, and repair the 
 breaches of mental activity. The painful systems be- 
 come dissociated, disintegrated and again transformed, 
 reformed, and reintegrated into new systems full of en- 
 ergy and joy of life. 
 
 It is quite probable that Weir Mitchell's rest-cure has 
 derived some therapeutic value from the empirical use of 
 the subwaking hypnoidal rest-state. Similarly it is 
 highly probable that Freud's success in the treatment of 
 psychopathic cases is not so much due to " psycho-analy- 
 sis," as to the unconscious use of the hypnoidal state. 
 The use of the hypnoidal state or hypnoidization has 
 been recently employed with great success by other in- 
 vestigators, among whom I may mention Dr. John E. 
 Donley, who has made a valuable contribution to the 
 therapeutic aspect of the hypnoidal state.^ I am firmly 
 convinced that the hypnoidal state, if rightly and intelli- 
 gently utilized, will prove an important factor in the 
 domain of psychopathology and psychotherapeutics. 
 
 Now as to the method of hypnoidization. There is 
 nothing rigid about the method, — it admits of many 
 modifications. The principal object consists in bring- 
 ing about the conditions of monotony and limitation of 
 voluntary movements requisite for normal and abnormal 
 suggestibility. The patient is put in a relaxed, recum- 
 bent position ; he is asked to put himself into as com- 
 fortable a position as possible, close his eyes, and attend 
 
 8 The Clinical use of Hypnoidization, Journal of Abnormal 
 Psychology, 1908. 
 
 I 
 
VALUE OF THE HYPNOIDAL STATE 119 
 
 to some monotonous stimulus such as the regular beats 
 of a metronome or the buzzing of an inductorium. 
 Gentle massage and a warm bath may be of material help 
 in excitable cases. Exercise, fatigue both physical and 
 mental, predisposition to sleep, and the late hours of 
 night or the small hours of morning, are favorable con- 
 ditions. When respiration and pulse become reduced, 
 sensory-motor reaction diminished, sensory hypoesthesia 
 becoming occasionally hyperesthesia, with occasional dis- 
 turbances of pulse and respiration, with sudden appar- 
 ently unaccountable starts, with tendencies of retention of 
 position of limbs, and now and then with a slight tendency 
 to resist actively any change of posture of limbs or of 
 body without the actual presence of catalepsy, the whole 
 feeling tone becoming one of acquiescence and indiffer- 
 ence, while memory with amnesic gaps begins to find the 
 lost links and even to become hypermnesic, — when we ob- 
 serve all those symptoms we know we have before us the 
 subconscious hypnoidal state.^ Pneumographic tracings 
 taken at the same time help to detect the state, charac- 
 teristic by the numerous transient changes and the 
 various oscillations of depth of level which take place in 
 this unstable subwaking state, intermediate as it is be- 
 tween the waking state on the one hand, sleep and hyp- 
 nosis on the other. 
 
 From this general discussion about the nature of the 
 hypnoidal state and the methods of its induction we may 
 now turn to a brief review of some of the cases treated by 
 hypnoidization. The tracing of the growth and develop- 
 ment of the various symptoms by means of the memories 
 restored in the hypnoidal state is here omitted, as the 
 
 " The subconscious," notwithstanding the ill-based attacks now • 
 fashionable among some psychologists, forms the very foundation of \ 
 psychopathology. The subconscious is as vital and essential in • 
 psychopathology as "ether" is in physics. I shall discuss this sub- 
 ject in its proper place. / 
 
120 PSYCHOTHERAPEUTICS 
 
 p 
 
 object of the present paper is not the study of the causa- 
 tion and origin of the psychopathic systems or " com- 
 plexes," but rather their reassociation and cure effected 
 by the reserve energies liberated in the hypnoidal state. 
 I give cases of partial as well as complete success so as 
 to give the reader a more or less adequate notion of the 
 therapeutic value of the treatment. Cases of partial 
 success are presented first. 
 
 I. Miss P. R. Age 23. American. Mother is very 
 nervous. Sister is " high strung." Father is well. 
 When young, patient was regarded as sensitive. Her 
 present trouble began three years ago. She suffers from 
 digestive disturbances, dizziness, circulatory irregulari- 
 ties, numbness in hands and legs, and especially from 
 continuous feeling of fatigue. Her sleep is restless, she 
 dreams a good deal. Attention is good, but her mental 
 state is one of indecision. If left to herself, she would 
 remain in the same place. To make a change in her sur- 
 roundings is hard and painful to her. The fear of meet- 
 ing people and specially strangers is quite intense; in 
 fact, it constitutes her central obsession. At the age of 
 eighteen she fell in love with a young man to whom she 
 became engaged. A year later the engagement was 
 broken off under very distressing circumstances. Since 
 then the present condition has gradually developed. 
 The patient was in a chronic state of mental depression 
 and was not unaware of the real origin of her trouble, 
 but the awareness was vague, often falling below the mar- 
 gin of clear consciousness. 
 
 The patient expected to be hypnotized, but she could 
 not go into hypnosis. After a few trials at hypnotiza- 
 tion the hypnoidal state was used. At first the hyp- 
 noidal state was brief in duration, but with its repetition 
 it became prolonged and deepened with gradually in- 
 creasing beneficial effects. The patient was but three 
 
VALUE OF THE HYPNOIDAL STATE 121 
 
 weeks under my care. She felt greatly improved and 
 returned home before the recovery was made complete. 
 
 II. Mr. A. C. Actor. Age 47. American. There 
 are no special diseases in the family except " nervous- 
 ness." The patient is imaginative and emotional. 
 When about the age of ten his grandfather gave him 
 Faust to read. Since then he has been troubled with the 
 insistent idea of having sold his soul to Satan. In his 
 childhood he was very religious, — prayed much, was 
 afraid of sins, and suffered from nightmares. About 
 fifteen years ago had syphilis, for which he was treated 
 for a period of two years. Up to the age of 32 patient 
 led a gay life. Seven years ago he suddenly felt that 
 " something snapped in his head " and he became greatly 
 frightened. He thought it was paresis or tabes, " as so 
 many actors suffer from those diseases." This fright, 
 however, soon wore off. A month later, after a strenuous 
 and fatiguing series of plays, he suddenly woke up in 
 the middle of the night with the idea of paresis and in- 
 tense fear. The overconscientiousness and fear of sin 
 characteristic of his childhood and boyhood have now 
 reappeared, and he is obsessed by the fear of sin, decep- 
 tion, blasphemy. He suffers from vague pains all over 
 the body and from digestive disturbances, but he is spe- 
 cially obsessed by the fear of parasyphilitic diseases, 
 tabes and paresis, the symptoms of which are reflected in 
 his attacks. 
 
 In the hypnoidal state he became quieted, much of 
 the fear and depression was gone. In addition to other 
 information obtained, though interesting from a psycho- 
 pathological standpoint, space does not permit to give 
 here, it was found that the last attack was occasioned by 
 a long visit to a friend of his, also an actor, who suf- 
 fered from gastric crises of tabes. A series of treat- 
 
in PSYCHOTHERAPEUTICS 
 
 
 ments by hjpnoidization improved considerably the pa 
 tient's condition, and he returned to his occupation, which 
 he could not possibly give up for any length of time 
 
 HI. Mr. C. S. Age 39. Russian. Builder. Fathei 
 died of apoplexy at the age of 72. Mother is 77j 
 but has always been nervous. Brothers and sisters 
 are well. Patient is rather undersized and weighs ninety- 
 seven pounds. He is very emaciated, looks cachectic, 
 suffers from anorexia, nausea, indigestion, and from 
 vague abdominal pains. Detailed inquiry into the pa- 
 tient's sexual life disclosed no abnormality. Anything! 
 unpleasant awakens a feeling of nausea. This can b( 
 traced to an infectious disease from which the patient 
 suffered some twelve years ago. He was frightened over 
 it and worried about the consequences. Nausea and vom- 
 iting were present during the course of the disease and 
 persisted afterwards. The patient is introspective and 
 suggestible in regard to sickness. If any of the family 
 happen to have any trouble, he is sure to fall sick with 
 the same symptoms. Thus about two months ago the 
 patient's mother fell and broke her left arm, he, too, soon 
 began to feel pain in the left arm, for which he had to 
 be treated. Every new moon he experiences intestinal 
 disturbances, because about that time, in his childhood, 
 his mother used to administer to him a purgative. J 
 
 Put into the hypnoidal state patient felt much relieved.! 
 The beneficial results of the treatment became manifested 
 at the end of a few weeks. 
 
 I 
 
 IV. Mr. M. G. Irish. Age 38. Married. Occupa- 
 tion, liquor dealer. Father alive and well. Mother died 
 of pneumonia at the age of forty. Brother and sister 
 died of some obscure form of " heart trouble." Physical 
 condition is good. Patient has no appetite, worries, has 
 
VALUE OF THE HYPNOIDAL STATE 123 
 
 no confidence in himself. He is extremely methodical, 
 things must be arranged in certain order or he feels un- 
 easy and quite unhappy. Has no headaches, but suffers 
 from insomnia. Does not drink, but smokes excessively. 
 Sexual life normal. Has been sensitive and nervous from 
 his very childhood. He broods much over his incapacity 
 of spelling. Has been lately working very hard on a new 
 business intrusted to his care. He doubts his business 
 capacities and fears to ruin the business. He became 
 greatly depressed and had to give up his work and go 
 to the country, but with no beneficial results. 
 
 The patient was brought to me in a state of deep de- 
 spondency, close on the brink of suicide. He could not 
 be hypnotized. I put him into a hypnoidal state, kept 
 him in a state of relaxation for fifteen minutes. When 
 he came out of it he felt " a little better, but not much." 
 After two weeks' treatment the patient felt so far im- 
 proved that I advised him to return to his work, while 
 the treatment was being continued. Gradually his de- 
 spondency gave way, his worries, fears, and doubts dis- 
 appeared, and confidence in himself became strengthened. 
 Patient declared he " never felt so well before." The 
 treatment covered a period of three months. It is now 
 more than two years, the patient continues to be in ex- 
 cellent condition. 
 
 I V. Mrs. J. F. Age 28. American. Married. Fam- 
 ily history good. For many years patient has been 
 suffering from severe headaches, backache, general fa- 
 tigue, and weakness of the eyes which occasionally be- 
 came intolerably painful. The headaches became some- 
 times so intense that the patient suffered agonies. The 
 pains extended all over the head and even down the arms 
 and back. There were present sore spots in the back of 
 the head, the pressure on which somewhat relieved the 
 
IM PSYCHOTHERAPEUTICS 
 
 pain. Various pains of a more indefinable character were 
 also complained of in the right ovarian region, pains 
 which increased on exercise. The patient had usually 
 no appetite, nothing tasted well, — there was some un- 
 pleasant odor in the food; nutrition was poor. Occa- 
 sionally she suffered from bulimia alternating with 
 anorexia. The sense organs were hyperesthetic ; field of 
 vision was normal. The heart was normal, though occa- 
 sionally irregularity of heart-beat could be observed, due 
 to the patient's extreme nervousness. A gynecologist 
 diagnosed salpingitis and advised an operation on ac- 
 count of adhesions formed. The patient, however, re- 
 fused to be operated on, and the family physician carried 
 out a long course of gynecological treatment. The ocu- 
 list treated her eyes, and after a long examination and 
 treatment fitted her with glasses; but the eyes were no 
 better and the headaches were as severe as before. 
 
 After a fair trial had been given to various treatments 
 I had to resort to hypnoidization. A year's treatment 
 by the hypnoidal state made the symptoms disappear. 
 The patient gained in flesh and in strength, and felt, as 
 she put it, " younger than ever." 
 
 VI. Miss G. A. Age 55. American. Three broth- 
 ers died of various forms of cardiac affections. 
 Father died of pnemonia ; mother died of fatty degenera- 
 tion of the heart. One of the sisters suffered from 
 akromegaly and died of heart trouble. There are his- 
 tories of tuberculosis in the collateral branches of the 
 family. Patient looks poorly nourished, her appetite is 
 completely gone. She suffers from insomnia, headaches, ^ 
 backache, general diffused pains all over the body; com- 
 plains of lassitude and of lack of interest in what goes 
 on around her. She feels despondent and has crying 
 spells. The depression reaches such an acute stage that 
 
VALUE OF THE HYPNOIDAL STATE 125 
 
 the patient is afraid of losing her mind. When a child 
 she suffered from pavor nocturnus and when about the 
 age of twelve she took a long fatiguing journey which 
 brought on such a state of exhaustion that on her return 
 she became aphasic and hemiplcgic and was confined to 
 bed for six months. The present condition set in a few 
 years ago, — she lost the sense of smell and of taste, 
 while she fell into a state of deep depression. Neurolo- 
 gists regarded her as a case of some obscure " neurosis," 
 obstinate and incurable. 
 
 I must confess that when I undertook the case I did 
 not expect any favorable results. It was an old, 
 chronic, insidious case. The age of the patient, the ap- 
 parent obscurity of the trouble, as well as the family 
 history were by no means encouraging. The patient 
 did not go into a hypnotic state and I had to use the 
 hypnoidal state. The first couple of months the treat- 
 ment dragged along indifferently. All I could then say 
 was that the patient did not get worse under the treat- 
 ment. The hypnoidal state, however, gradually ad- 
 mitted me into the patient's early history, and I obtained 
 important clues to her symptoms. Here comes in the 
 value of a knowledge of the course and the development 
 of the malady and the consequent help in the therapeutic 
 treatment of the dissociated systems. With a better in- 
 sight into the abnormal psychology of the case the hyp- 
 noidal state could be used to better advantage. The pa- 
 tient began to improve rapidly and at the end of the 
 fourth month of treatment by hypnoidization completely 
 recovered. It is now more than four years since the end 
 of the treatment, and I may say that the patient has not 
 had a single relapse, — she continues to stay well ; she 
 has become an energetic social worker, greatly valued for 
 her indomitable energy as well as cheerfulness of mind. 
 People who know her say that " wherever she goes she 
 
126 PSYCHOTHERAPEUTICS 
 
 brings sunshine with her." A new life was awakened in 
 her. The subconscious reserve energy which has re- 
 mained dormant in her for so many years has become 
 unlocked and utilized in her ordinary daily life. 
 
 VII. Miss A. W. Age 35. Irish. Housekeeper. 
 Physical condition is good. Occasionally suffers from 
 cephalalgia, but on the whole headaches do not trouble; 
 her. She suffers often from auditory hallucinations, 
 thinks she is possessed by demons. From her ninth year 
 she had hallucinations of spirit voices which tell her veryi 
 unpleasant things. The auditory hallucinations are ac- 
 companied by attacks of automatic speech. It seems to 
 the patient as if another being forces her to tell what 
 she thinks. It is on that account that she shuns hen 
 friends and acquaintances. Occasionally she has visual 
 hallucinations of angels and saints. 
 
 It would take too much space to give an account of' 
 this interesting case. We can only refer here to this 
 case in its main outlines. Our object is not the psycho- 
 pathological, but the psychotherapeutic aspect of the cases. 
 
 The patient could not be hypnotized, but she v/ent 
 easily into the hypnoidal state. At first the improve- 
 ment was rather slight. In fact, now and then the hal- 
 lucinations and the automatic speech became even more 
 frequent and more annoying than before. In a couple 
 of months, however, the outlook began to be brighter, the 
 auditory and visual hallucinations began to give way. 
 The automatic speech considerably diminished, and after 
 a few months the symptoms completely disappeared. 
 
 In the control of alcoholism the treatment by hypnoi- 
 dization yields extremely satisfactory results. The prin- 
 ciple of subconscious reserve energy stands out clear and 
 distinct in such cases. We shall return to this aspect 
 of psychotherapeutics in its proper place, our object 
 
VALUE OF THE HYPNOIDAL STATE 127 
 
 lere is simply to bring out the therapeutic value of the 
 hypnoidal state. 
 
 VII. Mr. G. S. American. Single. Age 37. Fam- 
 ily history is good, — except that one maternal un- 
 cle was a victim of drink habit. A physical examination 
 shows an irregular heart due to nervousness, excessive 
 smoking. Liver is enlarged and cirrhotic. The patient 
 was brought to me just after a debauch, was nervous, 
 shaky, with quite an extensive tremor of the hands. He 
 began to drink when in school as a matter of boon com- 
 panionship and has since become addicted to drink. He 
 kept at it regularly, at times actually soaking in alcohol. 
 The family induced him to try the treatment of various 
 establishments for the cure of alcoholics, but with no ap- 
 preciable results. As soon as he left the sanitarium he 
 immediately went off on a debauch. He suffered a few 
 times from severe attacks of delirium tremens. The pa- 
 tient was in such a bad state that he wanted his share of 
 property to devote the remainder of his life to drink. 
 
 Under a rigorous treatment by the hypnoidal state 
 the patient ceased drinking, lost all craving for liquor. 
 His physical and mental condition grew in strength. 
 After a few months' treatment he was enabled to return 
 to his business. The man has become completely re- 
 formed. He is now manifesting an intense activity, 
 great devotion to and steadiness in his work. No one 
 suspected in him such capacities of foresight and energy 
 in business management. New stores of subconscious, 
 dormant reserve energy have welled up from the depths of 1[* 
 his being. He has become a different man. His own 
 brothers are surprised at the radical transformation of 
 his character. 
 
 VIII. Mr. J. L. Irish. Protestant. Age 57. Fam- 
 ily history is good, except for the fact that his 
 
 i 
 
1^8 PSYCHOTHERAPEUTICS 
 
 brother is also addicted to drink and was under my care 
 for a few weeks, with the result that he left off drink for 
 two years. Patient is a printer by trade and has been 
 drinking for over thirty years. While he is usually kind 
 natured, when under the influence of drink he is violent, 
 abusive, offensive to his wife and children, who are afraid 
 of him. From his sister and wife I have the information 
 that the patient goes off periodically on a long spree and 
 spends all his money, neglecting his wife and children; 
 when he comes home he abuses everybody in the house. 
 " It is not a home, it is a hell," as his sister puts it. In 
 his better moments the patient himself admits he is a 
 brute, that drink has the best of him. He must keep 
 away from drink completely, because the mere taste of 
 it sets him going. An examination reveals the presence 
 of arteriosclerosis. 
 
 I attempted to put the patient into the hypnotic state, 
 for I found the hypnoidal state would meet with less re- 
 sistance and suspicion on the side of the patient. Hyp- 
 noidization then was the order of the day. The patient 
 began to improve, was less nervous, slept better, and 
 what was more important, stopped drinking, lost all 
 craving for liquor. After three weeks of treatment by 
 means of hypnoidization the patient was discharged. He 
 did not drink for a whole year, but coming in contact 
 with other workmen in the union he was invited to drink, 
 could not refuse, and once more was started on his old 
 career. He came back to me, and this time I treated 
 him daily for a month. Throughout the treatment the 
 hypnoidal state was used. The patient has given up his 
 drink habit, has no craving for liquor, works regularly 
 at his job and no longer associates with companions who 
 are given to drink. His sister and wife keep me regu- 
 larly informed about his condition, and the report for 
 the last two years has been " John is very good, he is a 
 
 f 
 
VALUE OF THE HYPNOIDAL STATE 129 
 
 gentleman, treats the children well." He has become a 
 model father and a good husband. 
 
 IX. Mr. C. T. Age 32. American. Father was 
 an inveterate drunkard and was drowned while in a state 
 of intoxication. A maternal as well as a paternal uncle 
 were confirmed drunkards. There was also drunkenness 
 in the collateral branches of the family. The patient 
 learned to drink when very young. His mother, who 
 volunteered the information, told me that she suspected 
 that her son began to drink wine at the age of seven. 
 Since that time the drink-obsession grew on him and he 
 became a confirmed drunkard at the age of twenty. The 
 patient's physical condition is good. The emotional 
 state is one of passive indifference, the intellectual activi- 
 ties are rather in abeyance, the general disposition is 
 inoffensive and even mild. It seems that the alcohol has 
 soaked out of him all his strength. He has no ambition 
 and is not fit to do anything, as he is constantly under 
 the influence of liquor. His will power is weak, he has 
 no sense of personal responsibility, and nothing of any 
 importance can be intrusted to him. Socially he is ostra- 
 cized by his relatives, but he seems to mind it little. 
 
 Considering the family and personal history of the 
 case I was not enthusiastic over the outcome of the treat- 
 ment. The family, however, insisted on treatment and 
 the mother was anxious to have me undertake the case 
 as he was her only son. The treatment lasted for about 
 a year and was carried out by means of the hypnoidal 
 state. To my great surprise and contrary to my ex- 
 pectations the patient has given up his drink. He 
 changed so much that even his mother wondered at the 
 transformation. From being apathetic he became am- 
 bitious, from being dependent he became self reliant. 
 He manifested a self control which none of his intimate 
 
180 PSYCHOTHERAPEUTICS 
 
 friends ever suspected in him. He became methodical, 
 systematic, conscientious in his work, and displayed an 
 unusual ability in management. From being weak, ir- 
 regular, and unreliable, his character became energetic, 
 firm, and trustworthy. His abilities were soon noticed, 
 appreciated, and he has since become a manager of a 
 large concern. Nowhere have I observed such limita- 
 tions, such moral infirmity, such lack of capacity, change 
 so radically to strength of will combined with a sense of 
 personal responsibility and vigor of intellectual activity. 
 Since then I began strongly to doubt the so-called fatal, 
 hereditary dipsomania of psychiatric text-books. I must 
 say that I now completely disbelieve that medico-calvin- 
 istic doctrine of " total inability and damnation," in 
 regard to dipsomania. There may be hereditary tenden- 
 cies to nervous instability, tendencies to excitement with 
 consequent craving for stimuli inducing exaltation, but 
 certainly there is no hereditary alcoholism. What sort 
 of stimuli a person is sensitive to depends on training 
 and environment. It may be art, science, politics, reli- 
 gion, or drink. There is no more hereditary dipsomania 
 than there is congenital gambling. From a mere anam- 
 nesis no snap prognosis should be made without giving 
 the case a good trial and proper treatment; no alcoholic 
 patient should be declared as hopeless. 
 
 With the advance of my psychopathological studies 
 and psychotherapeutic work I begin to have more confi- 
 dence in the principle of dormant reserve energy and 
 have more trust in the therapeutic value of the hypnoidal 
 state. 
 
CHAPTER SEVEN 
 
 Obsessions and Associated Conditions in So-called 
 psychasthenia 
 
 BY JOHN E. DONLEY, M.D. 
 
 Physician for Nervous Diseases^ St. Joseph's Hospital, 
 Providencey R. L 
 
 BY the term obsession I shall understand any recur- 
 ring, extra-voluntary idea, feeling, or emotion 
 which presents itself automatically in conscious- 
 ness, either alone or in combination; and the clinical 
 syndrome characterized essentially by such obsession 
 and associated states, I shall, following many others, call 
 psychasthenia. As psychotherapeutists we are inter- 
 ested in obsessions, not only as to their content^ that is 
 to say, the particular form and character they assume, 
 but also and equally, if not indeed chiefly, as to their 
 mechanism, — the manner in which they arise, the factors 
 by which they are perpetuated, and the methods whereby 
 they may be either alleviated or cured. 
 
 Approaching the subject, then, from this angle, we 
 may set out with the observation that ever y obses sion 
 has its h istory just as truly as has a paintmg, a poem, 
 or a symphony. Obsessions are not, therefore, as is so 
 often apparently believed, discontinuous and uncaused 
 mental experiences, arising nowhere and disappearing no 
 whither ; they are just as much products as are any other 
 of the contents of consciousness ; and only in this are 
 they sui generis, that they are products of a very special 
 and peculiar kind, whose genesis it may or may not be 
 within our power to discover. To seek out the psycho- 
 genetic mechanism of obsessions is accordingly the first 
 
 131 
 
132 PSYCHOTHERAPEUTICS 
 
 step toward a rational psychotherapy; for only if, and 
 in so far as, a careful inquiry of this sort has been pre- 
 liminary to any attempt at therapeusis, can the latter 
 hope to be, in some manner and degree, successful. 
 
 The pursuit of this genetic method leads straight into 
 the complexities and difficulties, sometimes, indeed, into 
 the frustrations of normal and abnormal psychology. 
 Yet, however difficult this domain may appear to be, to 
 enter it is an absolute prerequisite to the progressive 
 treatment of psychasthenia. 
 
 The most striking attribute of obsessive mental states 
 is their more or less constantly recurring automatism. 
 They do not appear as normal and harmonious elements 
 /Within the conscious stream; on the contrary they are 
 ^ intruders whose constant entrance and exit disrupt the 
 customary processes of mental life. In the language 
 of abnormal psychology, they are said to arise as men- 
 tal states or complexes which have been dissociated or 
 split oiF from the main stream of the self-conscious per- 
 sonality. Whether an obsession appears in conscious- 
 ness as a complex whose nucleus is an idea, a feeling, or 
 an emotion, it is to be looked upon as having its origin 
 in the same psychological mechanism, namely, dissocia- 
 tion. The psychological details of this dissociation may 
 vary within comparatively wide limits in particular ob- 
 sessions, but the general underlying principle would ap- 
 pear to be the same in all. 
 
 In the evolution of an obsession, dissociation is but one 
 aspect of the process; for association comes to play an 
 equally important role in the drama. Given a disso- 
 ciated mental element, whether idea, feeling, or emotion, 
 this mental element will not for long remain isolated and 
 unattached, but in accordance with the laws of associa- 
 tion will connect itself with some other conscious content 
 to form a definite complex, upon the character of which 
 
CONDITIONS IN PSYCHASTHENIA 133 
 
 will depend the type of obsession which appears in con- 
 sciousness ; for obsession is just another name for a par- 
 ticular, actively functionating complex. 
 
 Now this obsessive complex may be of multifarious 
 composition; it may be composed chiefly of ideational 
 feeling, or emotional constituents; it may be thick or 
 thin, wide or narrow; it may contain many elements or 
 few; as time goes on it may function in its original in- 
 tegrity or may become split, thus giving rise to curious 
 and perplexing clinical manifestations; finally, the com- 
 plex may be wholly or only partially conscious or sub- 
 conscious; or to state it another way, the obsessed 
 individual may be aware of much or of little concerning 
 that which is really operative in the production of his 
 abnormal mental condition. 
 
 We said a moment ago that association plays an 
 equally important part with dissociation in the mechan- 
 ism of obsessions. Obviously it is impossible here even 
 to name the numberless associations that may occur be- 
 tween the conscious, subconscious, and co-conscious lev- 
 els of mind, and the various obsessive complexes which 
 may thus arise. One may point out, however, the impor- 
 tant fact that these associations may be found to have 
 taken place not only between ideas as such, but also be- 
 tween any and all of the other elements of conscious- 
 ness, as well as between these latter and purely physio- 
 logical processes, such as those mediated by the voluntary 
 and involuntary musculature and by glands. Thus it 
 may be seen that the variety of obsessions is coterminous 
 with the possibilities of abnormal association and disso- 
 ciation ; hence also the impossibility of placing a limit to 
 the patterns according to which obsessions may be 
 formed. 
 
 When once an obsessive complex has been definitely 
 established, it may be roused to future activity in a 
 
134 PSYCHOTHERAPEUTICS 
 
 variety of ways. What I desire especially to* call at- 
 tention to here is the law of the substitution of stimulus, 
 which may oftentimes explain the active functioning of 
 an otherwise most puzzling obsession. Suppose the case 
 where a person has had a painful and emotionally upset- 
 ting experience with a cat. Out of this experience may 
 arise an obsessive complex, namely, fear of cats. In 
 order to arouse this complex to activity, it is not neces- 
 sary in the future to experience the actual presence of 
 a cat. All that is required is some stimulus, e.g., the 
 mere word cat, that has a symbolic relationship with the 
 original experience. Or take the case of a patient of 
 mine who overheard the doctors at a consultation re- 
 mark that a certain pathological condition in her breast 
 might be a carcinoma. As a matter of fact it turned 
 out to be nothing of the sort, yet the obsessive fear of 
 carcinoma of the breast remained with her for many 
 months. In order to rouse her obsession it was neces- 
 sary merely to present to her something having a direct 
 or indirect symbolic relationship with the breast. On 
 one occasion she was calling upon a friend who had re- 
 cently given birth to a daughter. Out of the clear sky 
 of conversation came something about the nursing of 
 the child, when straightway an attack of obsession oc- 
 curred which compelled her to terminate the visit. If 
 we bear this fact of substitution of stimulus well in mind 
 we may perhaps be able to explain an otherwise perplex- 
 ing assault of obsessions. 
 
 Enough has now been said perhaps to give a reason- 
 ably clear idea of the psycho-genesis of obsessions, — 
 their origin usually in some previous experience of the 
 individual, which experience is either not remembered at 
 all, or if so, is not recognized as being the point of de- 
 parture for the obsession; their formation through dis- 
 sociation of certain mental elements ^nd the subsequent 
 
 i 
 
CONDITIONS IN PSYCHASTHENIA 135 
 
 association of these elements with other contents of con- 
 sciousness to form an obsessive complex ; and finally the 
 automatic and recurrent functioning of the complexes 
 thus formed within the field of the conscious personality. 
 
 If now we approach the treatment of these psychas- 
 thenic obsessions we have at our disposal a variety of 
 methods ranging from simple explanation and persuasion 
 on one iide to hypnoidization and hypnosis upon the 
 other. In order to render our discussion of these thera- 
 peutic measures as concrete as possible, I shall give a 
 brief report of some cases actually treated, together with 
 an account of what was done in each individual case. 
 
 Case I. Mrs. M., aged thirty-five, came into the hos- 
 pital upon the advice of her physician, complaining of a 
 peculiar constantly repeated and involuntary hacking, 
 which sounded as though she were trying to clear her 
 throat. Her movements involved the muscles of the 
 larynx, those of the neck and thorax, together with the 
 diaphragm; in a word they had the characteristics of a 
 respiratory tic. Drugs, local applications to the throat, 
 and electricity had been tried at intervals during more 
 than four years without avail. Asked regarding the 
 origin of her nervous ti^ouble, the patient could give no 
 information except the fact that she could not volun- 
 tarily control the hacking. She was then placed in the 
 hypnoidal state as described by Dr. Sidis, when the fol- 
 lowing history was obtained: Five years ago while em- 
 ployed as an operative in a mill she suffered from a sore 
 throat which lasted for three days, at the end of which 
 time she consulted a physician, who told her that she had 
 tonsilitis and informed her that it would be necessary to 
 hum out her tonsils. She was much frightened by this 
 information and for several days thereafter felt herself 
 quite disturbed. Her tonsillar symptoms soon disap- 
 peared and she returned to work. Three weeks later, 
 
i 
 
 136 PSYCHOTHERAPEUTICS | 
 
 however, she was attacked for the second time and again 
 consulted another physician who told her that her tonsils 
 were diseased and advised her to have them cut out. The 
 fear of cutting added to her previous fear, now revived, 
 of burning her tonsils, threw her into such a nervous state 
 that she was able to think of nothing else. At this time 
 she noticed a disagreeable, stinging, tickling feeling in 
 her throat, which she tried to remove by hacking, but 
 without success. As the tickling remained, her hacking 
 became more and more frequent and at the time she came 
 under observation had taken on the character of a tic; 
 for she said she felt an uncontrollable impulse to hack 
 although she confessed there was little if any abnormal 
 feeling in her throat. Here, then, was an obsessive com- 
 plex discharging itself through motor pathways as a tic 
 and having its origin in the experiences we have described. 
 At the time of my examination she admitted that the fear 
 of a possible future cutting or burning of her tonsils 
 still possessed her. While in the hypnoidal state she was 
 encouraged and helped to recall the complete experience 
 in as great detail as possible. She was then told with 
 much emphasis that her tonsils were perfectly healthy, 
 that no cutting or burning ever was or ever would be re- 
 quired; that the tickling sensation in her throat arose 
 from the constant fixation of attention upon this part; 
 that she would feel no more desire to hack because her 
 supposed reason for hacking had ceased to exist, and 
 finally, that when she should open her eyes she would feel 
 better than she had in a great many years. Much em- 
 phasis was placed upon this feeling of health because it 
 was desired to leave her on the crest of a pleasurable 
 emotion, which of itself has a very great suggestive value. ^ 
 What had been predicted in her regard actually occurred. 
 When she sat up, her tic had disappeared, and she ex- 
 pressed herself as feeling quite grateful and happy. The 
 
CONDITIONS IN PSYCHASTHENIA 137 
 
 seance of hypnoidization lasted an hour, and except for 
 two slight recurrences easily removed by waking sugges- 
 tion, this patient has had no further difficulty. 
 
 Case II. A young married woman came under obser- 
 vation complaining of a very distressing type of obses- 
 sion, — namely, the fear of losing control of her bladder. 
 For nine years, with an interval of some six months, dur- 
 ing which she was comparatively free, this imperative fear 
 had dominated her mind, so that her life had been ordered 
 with regard to the demands of her obsession. Not only 
 did she have the mental fear, but also a distressing sensa- 
 tion in the bladder whenever her obsession was active. It 
 is scarcely possible to describe the suffering which she 
 had endured. She could not engage in the social func- 
 tions which she enjoyed for fear of a humiliating acci- 
 dent. The theater was closed to her; she could not ride 
 fdT any distance upon cars, nor accept invitations to visit 
 j^ny one save friends in whose houses she felt at ease. In 
 ; her own home she experienced rather a different feeling, 
 — not the fear of incontinence, which did not often occur, 
 but the depressing idea that her life was to be circum- 
 scribed by a malady over which she had no control. On 
 the theory that her trouble was due to cystitis, her blad- 
 der had been washed out with various solutions, among 
 them boric acid and nitrate of silver, and she had swal- 
 lowed a host of drugs like citrate of potassium, buchu, 
 and oil of sandalwood. From a careful consideration of 
 her history it seemed reasonable to suppose that her blad- 
 der sensations were secondary to her obsession, rather 
 than that her obsession was consequent upon a real cys- 
 titis. An examination of her urine, which contained noth- 
 ing abnormal, confirmed this view. Upon the principle 
 that every obsession has a history, if only we can dis- 
 cover it, an attempt was made to determine the origin of 
 this one. No special devices were employed other than 
 
138 PSYCHOTHERAPEUTICS 
 
 a precise reconstruction of the clinical history. It then 
 appeared that some nine years ago, a few days after the 
 birth of her first child, she was troubled while in bed with 
 a slight degree of cystitis and as a fact did lose control 
 of her bladder. This made her, as she says, rather 
 ashamed of herself, and struck her as being an unfortu- 
 nate occurrence. Some few weeks later, while out walk- 
 ing, she suddenly felt a curious burning sensation in her 
 bladder. Immediately she was seized with the fear that 
 there was to be another loss of control ; this, however, did 
 not happen. Nevertheless the fear continued, and has 
 persisted to within a very recent period. Here, then, was 
 an obsession of disagreeable type, which had arisen upon 
 the basis of a previous experience. The memory of an 
 actual loss of bladder control plus a certain sensation 
 referred to the bladder had become associated in a com- 
 plex which functioned as an obsessive fear of incon- 
 tinence. While the patient could recall perfectly her ex- 
 periences as given above, she had no idea that they had 
 anything to do with her present fear until this was 
 pointed out to her, whereupon she acquiesced readily in 
 this explanation. Before her treatment had progressed 
 further than the second consultation, an opportunity 
 presented itself of testing the truth of our hypothesis, 
 namely, that her bladder symptoms were the tail to a 
 mental kite. On this special occasion she was compelled 
 to wait some little time, and when I began to talk to hen 
 it was very evident that her obsession was in full swing. 
 An attempt was made then and there to disrupt her ob- 
 sessive complex by forcibly replacing for the association 
 represented by " bladder loss of control," another asso- 
 ciation, " bladder full control." This was accomplished 
 by stating and restating very positively and in detail 
 that she could certainly control her bladder, as the event 
 would surely prove. For about twenty minutes her emo- 
 
 I 
 
CONDITIONS IN PSYCHASTHENIA 139 
 
 tional agitation was intense, but finally subsided with the 
 result that although she was anything but calm, her faith 
 in her obsession had been somewhat diminished. By dint 
 of subsequent and repeated persuasion her fear was 
 finally removed, so that ultimately at the end of eight 
 months she entered upon her social pleasures and duties 
 with normal satisfaction. Untiring persuasion in the 
 face of obstacles had succeeded in disrupting an obsessive 
 complex which for nine years had proved rebellious to all 
 other medical treatment. 
 
 Case III. A man, aged 32, presented a very interest- 
 ing obsession, which was this: he could not get upon a 
 street car whose number was odd. Cars with even num- 
 bers gave him no trouble, but if an odd numbered car 
 came along he was compelled to let it pass no matter 
 what his hurry might be. He could recall nothing which 
 would shed light upon this curious obsession, but when v'^ 
 placed in hypnosis he gave the following story: When 
 about eighteen years old he was one day walking upon 
 the street when he witnessed a street car strike and in- 
 jure a child who unexpectedly ran out from behind a 
 wagon. The sight of this accident gave him a very , 
 
 marked emotional shock, which upset him for several days Lyjr 
 thereafter. Standing near the scene of the accident he ' 
 noticed that the car bore the number 213, and thought to 
 himself, " Well, there is always ill-luck in 13." Ever 
 since the time of this experience he has had his strange 
 aversion to riding upon cars bearing odd numbers, al- 
 though his waking self could give no account of or even 
 conjecture regarding the derivation of his obsession. 
 During hypnosis it was suggested to him that the child 
 whose accident he witnessed was not really injured and 
 had recovered completely. Furthermore, he was told 
 that odd numbers were quite the same as even numbers; 
 that they would no longer cause him any trouble, and in 
 
140 PSYCHOTHERAPEUTICS 
 
 fact would give him no concern whatever ; and finally that 
 like all other normal persons he would pay no attention 
 to the number of the car he desired to ride upon. These 
 hypnotic treatments were continued daily for eight days 
 and resulted in the complete removal of the obsession, 
 which, so far as I know, has not returned. 
 
 Case IV. A young woman, by occupation a stenog- 
 rapher, complained of an obsession which took the form 
 of a more or less troublesome fear of insanity. She was 
 conscious that her intellectual activity was practically 
 normal, because she was engaged daily in an exacting 
 profession, which she carried out with complete success. 
 This fear, however, of insanity, while not painfully im- 
 perative, was nevertheless present on occasion as a dis- 
 turbing under-current in her mind. She did not appre- 
 ciate the origin of her fear until it was disclosed to her 
 as follows: About two years previously, while sitting in 
 her room one night, she was locked in by another woman 
 in the house who had become unbalanced in mind. Be- 
 ing unable to release herself from her confinement, on 
 account of the door having been locked from the outside, 
 she spent something over an hour in dread of what might 
 happen to her should the woman return and attempt to 
 enter the room. As a matter of fact, nothing of this 
 sort occurred, for she was released from her confinement 
 by another dweller in the same house. Naturally, she 
 was very much upset, and from that time until she came 
 under observation suffered from this disquieting fear of 
 insanity. It was not difficult to trace the origin of the 
 obsessive complex. Psychologically, it was merely the 
 persistence in her mind of the memory of her former 
 experience, bereft of its characteristics as a memory. 
 There had thus arisen an obsessive complex which func- 
 tioned automatically and appeared in consciousness as 
 a present fear of mental disease. By means of j)er suasion 
 
 I 
 
CONDITIONS IN PSYCHASTHENIA 141 
 
 and ^planation, the whole matter was explained to her, 
 and in the couTS^ of about four weeks she found her fear 
 gradually fading until eventually she had substituted a 
 complete understanding of the situation for her obses- 
 sion, and this brought about its ultimate removal. 
 
 In the cases just described, one may observe the suc- 
 cessful results that sometimes follow the use of hypnosis, 
 hypnoidization, and persuasion, in the treatment of psy- 
 chasthenic obsessions. I would not, however, wish to con- 
 vey the impression that every case which clinically mani- 
 fests itself by psychasthenic symptoms is treated with 
 equally great success. Some of them are extremely ob- 
 scure as to their genesis, and equally difficult in the way 
 of successful treatment. In conclusion, I wish to de- 
 scribe such a case, which was characterized by obsessions, 
 feelings of unreality, incompleteness, and strangeness, 
 and to some extent by depersonalization. 
 
 Case V. Mr. X., by occupation a postman, complained 
 that from the time he was about seventeen years of age 
 he had been afflicted with feelings of incompleteness, by 
 obsessions of fear of insanity, and by the lack of emo- 
 tional reaction to his environment, whether pleasurable 
 or painful. Throughout his life, as long as he could re- 
 member, he had always been reticent, and as a boy found 
 it difficult to associate with his playmates because of shy- 
 ness. On one occasion, when at school, he attempted to 
 give a recitation, but failed through an acute attack of 
 stage fright. He got along tolerably well until he was 
 seventeen, when he suffered an attack of typhoid fever, 
 at which time the more troublesome symptoms of which 
 he complains began. He says that he seems to lack the 
 ability to feel pleasure or pain in what he does. At the 
 theater, for example, he experiences no emotion, but sits 
 there, as he says, " equally indifferent to whatever may 
 be going on." He sees the play and hears the actors, but 
 
142 PSYCHOTHERAPEUTICS 
 
 cannot get in tune with them. In his daily w.ork of de- 
 livering letters he finds no pleasure, except that it serves 
 him as a means of occupation and a source of livelihood. 
 Constantly throughout the day, more particularly when 
 he is unoccupied, the thought flashes into his mind that 
 he is going to become insane, or that his malady will ter- 
 minate in complete despair. He used to enjoy the read- 
 ing of poetry, but complains that now poems are to him 
 merely so many words, and that while he understands 
 what the poet is trying to convey, he derives no answer- 
 ing emotion from his reading. He states his feelings 
 thus : " I seem to myself to be another person. It appears 
 to me that there is a split between my emotional and my 
 intellectual nature. I cannot get in tune with things, 
 and the greatest good fortune or the greatest misfortune 
 in the world would leave me, I believe, equally unaffected." 
 Throughout several months the attempt has been made 
 by ps ycho-analysis to uncover some source for the psychas- 
 thenic symptoms presented, but without success. His 
 seems to be one of those cases wherein the psychasthenic 
 feelings of incompleteness, insufficiency, and strangeness, 
 together with obsessions, are so interwoven with the tex- 
 ture of the mind as to render their complete removal prac- 
 tically impossible. No matter what he attempts to do, 
 there is a fundamental perversion of feeling and emotion, 
 and so long as this is present, his obsessions of anxiety^ 
 and despair arise and continue. By persuasion and fre^ 
 quent practice he has been enabled so to switch his ob- 
 sessions into a corner of his mind as to enable him to pur- 
 sue his daily work with a certain external and mechanical 
 success. This, however, requires a constant effort on his 
 part, because there is always a tendency for his psychas- 
 thenic symptoms to obtrude themselves. Hypnoidiza- 
 tion and hypnosis have been of some value in the sense 
 that after a treatment he experiences a certain relief 
 
CONDITIONS IN PSYCHASTHENIA 143 
 
 for a time, but this never lasts more than two or three 
 days, at the most. His treatment has extended over the 
 greater part of a year, but it must be said that the psy- 
 chasthenic substrata of mind continues virtually un- 
 changed. 
 
 I 
 
\ 
 
 \i CHAPTER EIGHT 
 
 PSYCHOPROPHYLAXIS IN CHILDHOOD 
 BY TOM A. WILLIAMS, M.B., CM. (eDIN.) 
 
 Lecturer on Nervous and Mental Diseases ^ Howard Univ., and 
 Neurologist to Freedmans Hospital 
 
 DEFINITION. Just as psychotherapy denotes 
 not treatment of the mind, but treatment by 
 psychic means (1), so I shall use the word 
 psychoprophylaxis, not to signify the prevention of 
 psychic disorders, but to mean the preservation of health 
 by psychic means. 
 
 The limited amount of space at my disposal will, however, 
 restrict the consideration of the subject to the psychic 
 means to be employed for the restriction of psychic dis- 
 orders, leaving aside the fascinating psychoprophylactic 
 procedures, which are one of the main elements used by 
 the physician to persuade patients whose symptoms have 
 been long absent, to regulate their life so as, for instance, 
 to prevent failure of cardiac compensation and asystole, 
 or to continue a mercurial course; or, again, in order to 
 cure an incipient tuberculosis, to persuade them to con- 
 tinue to visit him, to avoid foul air, take regular meals, 
 and avoid excesses of work and pleasure. Still more 
 largely is psychoprophylaxis employed by the sanatarian, 
 who persuades first his colleagues, later public opinion, 
 and lastly legislatures and municipalities to adopt the 
 means for the prevention of the disease. For instance, 
 the greatest obstacle to the employment of efficient means 
 to combat yellow fever lay in the psychological attitude 
 of the people of the South. Their horror of " yellow 
 jack" was so great that they could not even discuss the 
 subject. It was only when some hope was inspired that 
 
 144 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 145 
 
 the dreaded disease might be prevented that the phobia 
 could be controlled sufficiently to permit of action. 
 
 In short, the means of overcoming public and personal 
 apathy and mental inertia are the most difficult problems 
 of preventive medicine. Were this done, the tuberculosis 
 dispensary would really perform the functions it is sup- 
 posed to perform, and which I am assured it does not do 
 from a lack of this psychic motive power of persuasion. 
 The disgraceful typhoid situation in Pennsylvania will 
 terminate only when the people's feelings are aroused by 
 conviction to the pitch of real will that the abuse shall 
 cease. 
 
 Only those ignorant of psychology, and especially lay- 
 men, and more particularly ecclesiastics, who are always 
 dualists, will expect too much from psychoprophylaxis. 
 The physician is not likely to forget the state of physical 
 nerve insufficiency (10), which is at the root of so many 
 psychic perturbations, which are often mere exaggera- 
 tions of the tendencies of the character, normal and mor- 
 bid ; nor will the physician forget the role of intoxication 
 in inducing mental confusion, melancholy, acute psychas- 
 thenic symptoms, twilight states, often miscalled hys- 
 terical. The physician will take care that the exhortation, 
 advice, and instruction he brings to bear are not ob- 
 structed by the intellectual handicap of exhausted or in- 
 toxicated neurones (11), nor by the affective distress 
 caused by insufficient oxidation, intestinal irritation, and 
 so on. 
 
 In other words, he will adopt a monistic interpretation 
 of his patient, contrary to the view of Dejerine (12), 
 who has said that to be a good psychotherapeutist one 
 must not be a determinist. He has not taken into con- 
 sideration the fact that the therapeutist himself, in be- 
 coming part of the patient's environment, determines a 
 new sequence of ideas. On the contrary, as monists we 
 
1 46 PSYCHOTHERAPEUTICS 
 
 shall protect our patient from such dualistic vagaries as 
 Christian Science, for with the monistic attitude we are 
 much more apt to constantly relate mind and brain to 
 one another. 
 
 But one must be careful to avoid the pitfall into which 
 many psychiatrists at one time fell, but which we now 
 know how to avoid, thanks to the efforts of the French 
 school and of men like Adolph Meyer and Morton Prince 
 in America. I refer to the premature attempt to refer 
 every psychic perturbation to a vice of structure, as, for 
 example, is done by Swift (13) when he relates the differ- 
 ence of mental capacity between the adult and a child 
 of seven to corresponding neural changes. As a matter 
 of fact, such difference is one merely of orderliness of 
 mental reactions, as is shown by the superiority of the 
 child in acquiring unrelated facts, as, for instance, words 
 and the use of language. A man deprived of education 
 would show no greater capacity and have perhaps less 
 potentiality than a child of seven. Of course, ultimately, 
 any acquired skill must depend upon neuronic dispositions 
 of molecular kind ; but we are not even in a position to 
 perceive the nature of these, though that they depend 
 upon the functional capacity of the neurones is evident 
 from the disappearance of skill and other forms of mem- 
 ory during intoxication, as well as after destruction of 
 nerve matter. 
 
 Thus, as of all prophylaxis, an essential preliminary is 
 diagnosis, by which only an intelligent prophylaxis can 
 be guided. 
 
 The essence of psychoprophylaxis, as of psychotherapy 
 and education, is to associate useful activities with agree- / 
 able feeling-tones, and to disassociate from useless or in- / 
 jurious acts the agreeable feeling-tones that may have 
 been acquired. For instance, the kind of social obsession / 
 which eventuated in the crusades does not differ psycho- 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 147 
 
 logically from that which leads to empire building; but 
 the former was a pernicious activity, while the latter 
 may have its uses. A fixed idea may often prove an 
 incentive to useful work in individuals as well as in so- 
 cieties. 
 
 Fundamentally none of the processes we employ dif- 
 fers from those used by Pawlow (2) in " conditioning " 
 the reflexes of his experimental dogs, when he caused an 
 expectant wagging of the tail and a flow of saliva and 
 gastric juice upon ringing a bell. 
 
 Similarly, when the petted child ceases his crying upon 
 seeing his father, it is because he reflexly has associated a 
 greater discomfort with the persistency of his tears than 
 with their cessation. The eff'ect, fear, aroused by as- 
 sociation, banishes that of fretfulness. 
 
 Gradually the emotional element of the reflex fades 
 (3), and sight-of- father connotes cessation-of-weeping. 
 This leads to a respect-reflex. On the contrary, the in- 
 tellectual content of the phenomenon may be submerged 
 below the threshold of consciousness, only the eff'ect per- 
 sisting; in which case occur painful or pleasurable emo- 
 tions, the origin of which is not manifest in the subject. 
 Recollect that functional derangement may continue just 
 because it began. 
 
 The interest sentiment is an essential of all psycho- 
 therapy, as of eff^ective pedagogy ; as when a young child 
 about to cry is quickly diverted to a passing scene or 
 made to perform an act. The doing so quickly substi- 
 tutes the new interest sentiment for the disagreeable for- 
 mer one, the feelings are changed, and we have performed 
 psychotherapy by distraction and substitution. 
 
 This simple principle, then, of finding or creating the 
 interest-eff^ect, associating it with the desired conduct, 
 and training it into habit, as simply illustrated above, 
 may be found at the bottom of even the complicated ratio- 
 
148 PSYCHOTHERAPEUTICS 
 
 cinations required in the therapy of the psychasthenic, 
 and is also the outstanding indication in all paranoid 
 psychoses. 
 
 On the other hand, in the hysteric, if the tour de force 
 cannot be employed or fails, the method of repetition is 
 requisite. Those who do not depend upon reason must 
 grow into feeling by accustomedness, if the first blow 
 fails. Who does not know of communities where a doc- 
 tor's prestige is measured by the years he has spent there, 
 of the reverence derived from seniority .^^ The mentality 
 which accedes to such a criterion is, of course, irrational, 
 and it is at bottom that of the hysteric. Hence, the 
 clinical procedure of isolation to increase the speed of ac- 
 customedness, and of reiteration to force into the un- 
 reasoning aflPectivity a realization of the notions to which 
 the patient is refractory. This is not persuasion: it is 
 the method of pertinacity. 
 
 Hypnosis, hypnoidization, etc., are merely means of 
 increasing impressionability to suggestions. In principle 
 there is no difference between these and such means as 
 were empirically used in ancient times through cere- 
 monies, religious observances, ritual, etc., for the same 
 purpose. (Such methods can perform nothing morC 
 wonderful than Judge Lindsay's feat of persuading the 
 incorrigible truant boy to himself purchase a ticket and 
 travel many hours to a reform school.) 
 
 As set forth elsewhere, the distinction between sugges- 
 tion and persuasion is one of awareness by the percipient 
 (4), the acceptee. Hence, to be unaware of why one ac^ 
 cepts an opinion that so and so is the most skillful, and 
 to do so on length of acquaintance is to do so by sugges- 
 tion ; and an idea received by suggestion is a hysterical 
 one, as shown by Babinski in his definition, " A hysterical 
 symptom is one susceptible of induction by suggestion 
 and of removal by suggestion — persuasion. (5)" 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 149 
 
 In all of these procedures the preliminary sentiment of 
 respect, reverence, awe, is engendered among the people 
 by the devices of expectation, unfamiliarity, and sacred- 
 ness or mystery. This sentiment in modern democratic 
 days is less the actuating factor than that of the pseudo- 
 intellectual shibboleth, which seems to be a strongly de- 
 termining , factor in the popularity of modern move- 
 ments of all kinds. The social tropisms of the unthink- 
 ing may be graded in three categories of decreasing 
 strength, beginning in ritual and passing via shibboleth 
 to snobbery, its modern attenuated form. In all these 
 modes of conveying influence, distraction is obtained by 
 engaging the sight by the rhythm of the ceremony and 
 by engaging the hearing by the rhythm of music, to 
 which are often added the dynamic rhythms of move- 
 ments directed conformably with the desires of the priest 
 or other operator. 
 
 The distraction thereby obtained, almost tantamount 
 in some cases to a dreamy state, favors what we nowa- 
 days variously call passivity, psychological automatism, 
 mental dissociation, suggestibility. 
 
 In this state, plasticity of the desires is much facili- 
 tated, the operations of the will are in abeyance ; for the 
 critical judgment of the intelligence is no longer in 
 action. The subject does not attain to the phantas- 
 magoria of the complete dream state; for susceptibility 
 to extraneous stimuli is much stronger than in sleep, or 
 even than in somnambulism. The state resembles that 
 in the day-dream, in which, however, the meditations are 
 less systematically determined. 
 
 The moral control, the psychoprophylaxis, secured by 
 these means has in the past been incalculable ; but as the 
 sanction of these procedures has been crumbled by the 
 trenchancy of modern analysis, and we now live in a 
 scientific age, it is necessary to employ psychoprophy- 
 
150 PSYCHOTHERAPEUTICS 
 
 lactic means which accord with the intellectual' develop- 
 ment of civilized man. Thus the further we depart from 
 the methods of mental distraction, mystical appeal, and 
 pseudo-scientific shibboleths (6), the more soundly and 
 permanently shall we succeed in preventing the vagaries 
 of the neurotic, and the less shall we be a party to the 
 justification of the occult manner in which many of the 
 public, and even some doctors conceive such psychological 
 interpretations as hypnosis, sub-consciousness, divided 
 personality, subliminal phenomena, mental dissociations, 
 etc. The more we appeal to the method of common 
 sense, plain matter of fact every day conduct (which is 
 obviously the method so clearly explained and outlined 
 by Dr. Taylor) (7), the less chance shall we give for the 
 delusional interpretations of clairvoyants, medium spir- 
 itualists, and others whose sentiment of psychic imper- 
 fection leads them to seek in the occult the satisfaction 
 they cannot find in current explanations of their mental 
 life. 
 
 It is to be hoped that our labors along with other sym- 
 posia like this may eventuate in a working doctrine held 
 in common by the whole medical profession, which will 
 enable us to forestall and prevent the development of 
 misinformation concerning psychic states which have 
 been responsible for the birth and evolution of such 
 modern movements as Christian Science, Emmanuelism, 
 neo-yogiism, and other harmful misapplications of psy- 
 chotherapeutics. 
 
 A concrete illustration of what psychoprophylaxis can 
 do is afforded by a recent communication of G. Guidi 
 (8), who has shown that fifteen per cent of attacks of 
 migrain are preceded even for days by psychic symptoms 
 either of excitable or depressant type, e.g., the need to 
 move about, to talk, to tell funny or obscene stories, to 
 look out for ridiculous situations, to laugh at them, or 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 151 
 
 by a desire to go alone, irritability, sadness, anxiety, 
 even tears. I have myself noticed a feeling of unusual 
 mental clarity, of power, in certain cases. (Every one's 
 disposition is modified (9) by exercise, oxygen, food, 
 etc. ; we all have defective times. Want of exercise and 
 elimination leaves toxins which cause restlessness, irrita- 
 bility and prevent quiet intellectual work.) Now if the 
 migrainous attack can be prevented as a result of diag- 
 nosing this modified psychic state, it is evident that by 
 prescribing mental and physical, including digestive, rest, 
 we shall have performed psychoprophylaxis. 
 
 We must recollect that during the period while the 
 functions of the neurones are perverted by physical mal- 
 adies, especially the intoxicative ones which we call fevers, 
 bad habits of action may be initiated and be reinforced 
 through convalescence and become characteristics of the 
 individual. As a matter of fact more careful psychic 
 discipline is needed while neurotic activity is perverted 
 (14) than when it is healthy, and it is the family phy- 
 sician's task to guide the psychic management of his pa- 
 tients as well as the physical. 
 
 The principle of mental prepossession and inertia 
 shows the power of an idea, which may originate as the 
 result of slight physical disorder. Binet (15) has illus- 
 trated this experimentally by showing how children will 
 go on increasing the length of a line when drawing from 
 memory a series of lines shown them, though only the 
 first few of them were actually increased. Another ex- 
 ample (16) is the remarkable experience of the enumer- 
 ators of the last census in endeavoring to adapt them- 
 selves to the supposed difficulties of a new dactylograph. 
 Their work was rendered so disappointing by the " press- 
 ing " under difficulties that new clerks had to be em- 
 ployed: these quickly surpassed their more experienced 
 colleagues. To be " on edge " is not the best state for 
 
1 52 PSYCHOTHERAPEUTICS 
 
 showing high skill: as every golfer knows, it- connotes 
 divided attention. 
 
 The state of keyed-up prepossessedness is induced by 
 an excessive interference (19) with the activities of the 
 child; when every act has been regulated and controlled, 
 he will constantly be referring for approval instead of 
 confining himself to the task in hand. This principle 
 may be illustrated by the boy who instead of looking at a 
 ball he is expected to catch looks at the thrower for the 
 approval or blame he anticipates. Over-conscientiousness 
 is quickly developed by such procedure; but, again, psy- 
 cho-diagnosis will eliminate the danger, for it would be 
 a mistake, for fear of risking over-conscientiousness, to 
 have upset the entire sense of fitness of a boy of three 
 who came to his father to be thrashed, declaring he had 
 thrown a knife at the cook, an act which had been spe- 
 cifically forbidden. 
 
 The source of another danger proceeding from over- 
 conscientiousness is that of shame of eating (18), as 
 illustrated by the same boy, when conscious of wrong- 
 doing, repeating " no bananas for boy " (a dish he 
 loves). But it is very easy to prevent a perverted affect 
 in this case, while at the same time furnishing a consist- 
 ent and coherent system of conduct and morality. 
 
 In this connection one must avoid formation of bad 
 affective habits during the temporary intoxication of 
 poor oxydation due to a full stomach or too heavy a meal. 
 In this state a child while playing hard may be car- 
 ried away by excitement till he loses his temper and 
 begins to cry, just because "things are too much for 
 him." 
 
 Again, constantly interrupting him in a train of 
 thought by regulating his least little impulse promotes 
 suggestibility, and the child becomes accustomed not to 
 act until told. In not availing one's self of a moment of 
 
 I 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 153 
 
 excitement to inculcate a difficult act, one loses a chance 
 of cultivating presence of mind, even during emotional 
 states. This may even be done during pain and tears by 
 making the child do something else during them, thus 
 gaining self-control. In speaking slightingly of what 
 one wishes contemned, be sure it is not against human 
 nature. To forbid healthy acts to a boy is detrimental 
 to him, he derives a false notion of morals when he knows 
 that innocent acts are forbidden. So provide ample out- 
 let for spirit of adventure, without which a boy's whole 
 character suifers. It either is exercised illicitly, or is 
 suppressed and forms intellectual dishonesty and emo- 
 tional incompleteness, so fertile a source of psychas- 
 thenia. 
 
 But in early childhood, and in some matters even in 
 adolescence, it is best to employ authoritative affirmation 
 rather than suggestion. A child cannot see the reasons 
 for the need for certain prohibitions ; and it is a bad 
 principle to be constantly side-stepping issues by the 
 giving of suggestions. Besides, it prevents the child ac- 
 quiring the power of immediate subordination of his own 
 desire to what after all must be done sometime. For 
 instance, a boy who cannot understand the rationale of 
 bacterial infection is forbidden to take milk unless boiled. 
 The mandate can be enforced by the suggestion that 
 boiled milk is a delicacy, and that he is privileged in be- 
 ing permitted to have it; but this procedure is quite un- 
 necessary when a mere affirmation should suffice, which, 
 moreover, will prevent the danger of his foregoing the 
 privilege, in order to drink raw milk. The advantage of 
 assured obedience to authority is most manifest during 
 such periods of emotional motor or intellectual hyper- 
 excitability as precede exhaustion. They may be com- 
 pared to the paralytic secretion of the physiologists. 
 Hence the more simple the brake used the better, for 
 
154 PSYCHOTHERAPEUTICS 
 
 complex means of arrest only increase the cerebral activ- 
 
 ity. 
 
 Another example of a misapplication of suggestion 
 consists of saying to a child, " You are not afraid," 
 when he shows timidity in some unusual situation. The 
 child knows quite well that the mere making of the re- 
 mark indicates a reason for fear; and the real effect pro- 
 duced is the suggestion of fear, which might have been 
 avoided by assuming a matter of fact manner as soon 
 as indications of hesitancy or timidity were shown by the 
 child, taking care at the same time to replace the unpleas- 
 ant affective mode by another, through substitution and 
 distraction. Of course, reliance on simple affirmation 
 must be maintained by truthfulness, and later by reason- 
 ableness. 
 
 The habits of accuracy and orderliness may be incul- 
 cated without the danger of their becoming besetments, 
 if it is done, so to speak, spontaneously as a pleasure, 
 and not as a duty Calvinically, that is, if it is made 
 kinetic rather than inhibitive. For example, a boy of 
 two and a half is asked to bring in two balls with which 
 he was playing in the garden, and later to pick out from 
 some others those he brought. This exercise not only 
 cultivates memory and accuracy, but the power of per- 
 ception of difference as well as the notion of responsibil- 
 ity and the pleasure in having it recognized. 
 
 A boy's whole world of fitness is upset when unusual 
 acts are done. A boy of three will allow no one else to 
 touch the letters placed on his father's plate. After 
 playing with his father and wanting " more fun," he 
 would not desist from his demands when told it was too 
 hard for his father, replying " not too hard," but at 
 once did so when told " Father tired." He recognized 
 this from his mother's and his own experience as a valid 
 excuse for stopping. 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 155 
 
 These habits become morally imperative (19), and are 
 very hard to eradicate in after life, for they do not de- 
 pend upon clarity of conception, as is well shown by the 
 fact that most of us do not act entirely in accord with 
 our intellectual convictions, but persist in regulating our 
 conduct by doctrines long outgrown. Hence, the im- 
 portance of preventing the feeling of dependence by en- 
 couraging the child's desire for and pride in performing 
 tasks about the house and garden. If, for instance, a 
 child is encouraged to put on his own clothes under the 
 belief that it is a clever act or to wash itself, these actions 
 will become automatic, and he will not later have to go 
 through the diflScult acquisition of the clean hand in- 
 stinct and that of self-helpfulness (20). 
 
 The ineradicability of fear when inculcated in early 
 childhood is clearly illustrated by the Southern lady, 
 who even in advanced age dared not go alone into the 
 dark, although she has long ceased to believe in the 
 stories which first made her afraid to do so. She real- 
 ized this so forcibly that she would not permit her three 
 daughters to be told any of the alarming stories which 
 most Southern children learn. Her psychoprophylaxis 
 resulted in the girls never having known what it meant 
 to be afraid in the dark. Indeed, it was the habit of 
 their schoolfellows to send them into dark and eerie 
 places to show off their powers. The tenacity of early 
 affects is again illustrated by the immovable depression 
 produced by the playing of gospel hymns on a reed or- 
 gan in the case of a lady in w^hose childhood the Calvin- 
 ical Sunday had almost caused fear. The psychoprophy- 
 laxis here is obvious (21). In another case the hearing 
 of a brass band invariably produces weeping and terror. 
 This is due to the fact that such playing occurred dur- 
 ing the horrors of the civil war. 
 
 In some children (22) care is needed to avoid the 
 
 i 
 
156 PSYCHOTHERAPEUTICS 
 
 " hesoin d'etre aime/* the craving for sympathy. This 
 may be induced by excessive petting and loving while a 
 child is tired or after injury. It is better to send the 
 child to bed when tired and to divert his attention when 
 injured. But denial of sympathy is equally bad, and is 
 the cause of the intense love hunger seen in many young 
 people whose surroundings have suppressed their natural 
 affection. 
 
 It must be remembered that the fundament of altruism 
 lies in the affect ivity (23), and this must not be sup- 
 pressed, but must be controlled and used. For instance, 
 during sympathy, interest may be aroused and turned 
 into an unrelated channel, and thus used for moral and 
 intellectual teaching instead of being roughly ignored. 
 
 These may appear small matters, but they illustrate 
 important principles, as will appear when they are ap- 
 plied to the matter of lying and the acquisition of the 
 sense of responsibility and right conduct. 
 
 The mythomanic (24) tendency, which is responsible 
 for so many medico-legal difficulties, would be much 
 diminished by a psychoprophjdaxis addressed to the 
 afore-mentioned habit of accuracy; for the conduct indi- 
 cated is merely a mode of truth in act, which to a child 
 precedes the significance of truth in speech. The latter 
 is discouraged, I believe, by mystery tales, as well as by 
 those of voodoo, though I am aware that much difference 
 of opinion on this point exists among pedagogues. I 
 cannot enlarge upon this theme, except to point out how 
 often mythomanic manifestations are miscalled hysteria 
 by medical men who have been unduly impressed by the 
 doctrines of Charcot (25); whereas, the difference has 
 been clearly pointed out by Dupre (26) and Babinski 
 (27). The newspapers of the day afford innumerable 
 examples of the dishonest point of view which eventuates 
 in mythomania. It is almost entirely preventable by a 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 157 
 
 proper psychoprophylaxis, if not on the part of the 
 parents, then later and with more difficulty on the part 
 of the schoolmaster. 
 
 In this connection, I must express the belief of the 
 need for men in the moral training of boys. The best 
 elements of moral development are inculcated, not in the 
 schoolroom, but at play, in which the masters must par- 
 ticipate more or less : and as at present trained, very few 
 women are capable of this. The revolution effected in 
 the habits or character of the English school boy by the 
 methods of Thomas Arnold of Rugby (28) afford a 
 striking illustration of this. 
 
 To attempt to manage boys by religious sentimental- 
 ism and softness, the woman-and-slave morality of 
 Neitzsche (29) is to encourage hypocrisy in the strong 
 and exaggeration of weakness in the feeble. Of course 
 sympathy must be used, but it must be a manly one, re- 
 ferring mainly to the forceful activities of the life of a 
 normal boy. In this way a self-reliant character is built 
 up by the encouragement of constant relation of itself 
 to the welfare of a society in the responsibilities of which 
 each boy has a separate niche to fill. 
 
 Than this there is no better prophylactic against de- 
 spondency, suspiciousness, and other anti-social feelings 
 of paranoid type. By this system of encouraging 
 morality to become constantly kinetic and to be thought 
 of and controlled by its relation to others while self-re- 
 spect is maintained, the hyper-suggestibility is restricted 
 and hysteria prevented. 
 
 Psychasthenic types too are not apt to develop in an 
 environment where solitariness is impossible, and where 
 the stresses are healthy and kinetic, and the emotional 
 and intellectual appeals are of a positive and clear com- 
 prehensibility. Hence the rarity of psycho-neuroses in 
 the men who have been trained in the public schools of 
 
168 PSYCHOTHERAPEUTICS 
 
 Great Britain. And their influence has not cea3ed here; 
 for the habits of conduct illustrated and brought into 
 prominence by Arnold's boys have permeated the whole 
 national life, with the result that De Fleury (30) has 
 been able to comment with admiration upon the freedom 
 of the nation from the psycho-neuroses, the study of 
 which has given such distinction to French neurolo- 
 gists. 
 
 Similar methods may be applied with success even to 
 boys perverted by faulty environment; for instance, 
 Tomlins ("37) developed a thieving jail boy into a useful 
 citizen by reversing the mawkish treatment he had been 
 receiving in the reformatory, and substituting a peremp- 
 tory and rough method of making him responsible for 
 certain duties and for other boys, and showing surprise 
 that he did not do better work than he at first showed. 
 
 On the other hand, there is the case of a girl in whom 
 intractable fits of temper were cured by one display of 
 kindly sympathy after she had torn up her books in a fit 
 of rage. The prophylaxis in each of these cases meant 
 the saving of a whole life from the misery which would 
 have arisen in a purely psychogenetic way. 
 
 The psychological insight which enabled the reflexes 
 to be " conditioned " in these two cases is responsible for 
 these two useful lives. 
 
 Many a phobia or angoisse can be prevented by psychic 
 means. Similar in principle are the means to be em- 
 ployed against the self -distrust and diffidence of the psy- 
 chasthenic form of insufficiency. The natural desire of 
 a child to play with its fellows will soon disappear if he 
 is too slow-witted to comprehend the game or too clumsy 
 to take his due part, or is constantly humiliated by his 
 failure or by the mockery of his fellows. Want of 
 capacity in some study arising from the defect of some 
 motor sensorial or associational process may produce a 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 159 
 
 self-deprecatory or anxious attitude very unfavorable to 
 healthy psychic development and most provocative of the 
 scrupulosity of psychasthenia. 
 
 The method of conditioning the reflexes is illustrated 
 most clearly by human beings in cases of sexual perver- 
 sion where some artificially introduced element becomes 
 the efficacious provoker of future sexual desire, or at 
 least satisfaction. The genesis of the felich constitutes 
 the conditioning of the sexual reflex in that person. 
 
 The whole element of the sexual element in the causa- 
 tion of the psycho-neuroses is too long to discuss here. 
 I must, however, deplore the difficulties thrown in the way 
 of the study of these very important problems of psycho- 
 prophylaxis by the unwillingness of some observers to 
 investigate the sexual life of their patients. To estab- 
 lish a solid psychoprophylactic doctrine we need accurate 
 information, and the scientific search for such informa- 
 tion must not allow itself to be hampered by national 
 prudishness. It is this noli me tangere perversion of 
 morality which arrogates to itself the exclusive title of 
 morality which is responsible for much of the prurient 
 attitude of the young towards sexual relationship. 
 
 What shall we think of a civilization which permitted 
 a highly respected woman physician of twenty years' 
 standing to be placed in jail for having written a book 
 instructing young women upon sexual hygiene? This 
 actually happened less than five years ago in Chicago. 
 Such an attitude fosters ashamedness in the young; and 
 shame of the bodily functions as we know frequently 
 dominates the field of consciousness of a psychasthenic. 
 An adolescent who has been discouraged from discussing 
 or understanding the phenomena even of his own sexual 
 life and taught to regard them as diff*erent in kind from 
 other facts of personal function and hygiene is sadly 
 handicapped in the difficult process of somato-psychic or. 
 
160 PSYCHOTHERAPEUTICS 
 
 allo-psychic adjustment in that difficult period of his 
 life. 
 
 Similar animadversion may be made against what is 
 now less common — the state of apprehension and terror 
 induced by religious teachings founded upon the doctrine 
 of man's inherent evil nature and damnableness. A re- 
 search by Coe showed that less than ten years ago a 
 very large percentage of college students had suffered 
 severely from the spiritual agonies of the attempt to 
 reconcile their dawning knowledge of the universe with 
 the inadaptive and injurious doctrines they had been 
 taught in the name of religion and morality. 
 
 Now it is very simple to forestall such morbid reaction 
 by directing the activity of such children into channels 
 for which they show aptitude. From the feeling of ac- 
 complishment and triumph thus engendered the child will 
 gradually learn to adjust himself to difficulties which 
 mental prepossessions and inertia would have rendered 
 impossible to overcome. A delusion of persecution so 
 often fertile in dangerous reactions has really its source 
 in a mistrust and suspiciousness which might have been 
 prevented or removed by the self-satisfaction coming 
 from the fulfilled desire of productive activity. The de- 
 lusion is essentially a defense reaction against the feeling 
 of self-distrust. Such feeling is powerfully conduced 
 to by cultivating in children a pride not consonant with 
 their true relatien to others ; for the social activities of 
 such children will be contaminated by an exaggerated 
 self-respect which will necessarily be constantly wounded, 
 whence an inevitable withdrawal from social activities 
 which do not minister to their pride, and therefore an 
 ever-increasing seclusion which is more and more domi- 
 nated by suspicious inferences from innocent words and 
 acts of others and brooding thereupon until this idea- 
 tional-emotional complex dominates and becomes the 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 161 
 
 character of the person and refractory to intervention; 
 but the psychoprophylaxis would have been simple, and 
 is obvious. 
 
 The gastric neuroses are a striking example of the 
 non-use of psychoprophylactic power by medical men: 
 for the great majority of these cases occur as the result 
 of the suggestions of medical men while prescribing for 
 patients suffering from temporary indigestion (33) or 
 by the indirectly gained notions of medical origin with 
 regard to eating and diet. Again, recent work has 
 shown the difference between tic and true chorea, and 
 also that the latter, now clearly shown to be an organic 
 disease (37) may begin by intellectual and emotional 
 perturbations long before the motor areas are affec- 
 ted. 
 
 The only practical way of detecting these early condi- 
 tions is through medical inspection of school children by 
 trained neurologists whose knowledge of physical and 
 mental test signs will anticipate many a breakdown, be- 
 sides removing from the other children the contagion 
 which habit-spasm and choreiform movements are known 
 to exercise on their plastic minds. As a matter of fact 
 the co-operation which should be sought is much less 
 that of the priest than that of the teacher of the young. 
 We can hope to influence him to a scientific attitude to- 
 ward the biological phenomena with which he deals; be- 
 sides which the help in managing difficult and neurotic 
 children which he gains from neurological advice makes 
 him very ready to welcome it, as my experience shows. 
 
 And indeed pedagogues themselves have noticed the 
 need of medical psychoprophylaxis. Thus Swift (loc, 
 cit.) says, " Half an hour's observation of pupils at their 
 school work will convince one skilled in interpreting nerve 
 signs that nervous disorders have become so common as 
 to menace our national health, and the significance of 
 
162 PSYCHOTHERAPEUTICS 
 
 this for education has been too generally ignored." 
 And again further, " It is unfortunate that instincts are 
 so frequently the child's only defense against the peda- 
 gogical enlightenment (sic) medical supervision cannot 
 fully meet the need unless a nervous affection is detected 
 in its incipiency; so the teacher must be taught about 
 the early signs, so as to call in a physician to prevent 
 aggravation by the continued irritation of test and ex- 
 amination." 
 
 As desirable would be the teaching of the mothers to 
 form healthy emotional habits in their children. The 
 happy-go-lucky absolutism which so often assorts itself 
 as capacity is sadly defective as such a guide for hesi- 
 tating childhood. The management of the mind and the 
 emotions into a morality constitutes the most difficult 
 study and art. But it can hardly be expected that 
 fortitude can be inculcated by a mother who has not 
 herself shown it sufficiently to even attempt to under- 
 stand the biological laws upon which depend the reac- 
 tions of the nervous system which we call conduct, for 
 the ethics taught to most children is a vestige of 
 medievalism conspicuous for its poverty in such criteria 
 of modern civilization as justice, liberty, courtesy, altru- 
 istic sympathy. The child's natural good impulses are 
 checked and twisted; when his reasoning from cause to 
 effect is not neglected or obstructed, he is thus confused 
 and finally often discouraged into sadness or indifference, 
 becoming as a man either despondent or happy-go-lucky, 
 with either no morality or one of words only, which has 
 no efficacy in preventing maladjustment. 
 
 But a morality which is really active instead of being 
 merely received on faith becomes a part of a boy's char- 
 acter and is carried out in his conduct. It intertwines 
 with his every thought often quite unconsciously. Sug- 
 gestions contrary to this trend are then automatically 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 163 
 
 repulsed, and we secure reliability of conduct; and so- 
 cially speaking that power of prediction which gives 
 security in man's relationship with man. 
 
 Now this may appear hardly a medical but more a 
 sociological matter; but there is no difference of kind 
 between a perversion of conduct which we call criminal, 
 that is, anti-social, and an aberration proceeding from 
 ideas which we call hysterical. The false belief that 
 one's limbs are incapable of locomotion or the comfort- 
 able and cherished feeling that one is an invalid and un- 
 able to support one's self are both anti-social attitudes, 
 in whatever good faith they are assumed. 
 
 Now their prevention as well as their cure is the pre- 
 rogative and duty of medical science, which is called 
 upon to distinguish from the aberrations of conduct due 
 to the change in the secretions, and the nervous system 
 those due to aberrant notions. And, nowadays, as this 
 symposium shows, we have to apply the remedy, not only 
 to the former, but the latter in supplementing the activi- 
 ties of the pedagogue and priest with the special means 
 the psychiatrist's training permits ; that is to say, when 
 a pathological type of reaction has been constituted by 
 the hurtful suggestions of a faulty environment, it is 
 the doctor's province to eradicate the hurtful sugges- 
 tions and to emplant a habit of mind tending for the 
 good of society and refractory to suggestions contrary 
 to that object. For a close analysis shows that the real 
 cause of most so-called " nervous prostration " is failure 
 of adjustment to environment, and is psychogenetic. A 
 rest cure in itself is inefficacious, but gives the doctor 
 the opportunity to re-educate the perverted trends of 
 the patient's disposition. Before reaching the neurolo- 
 gist, a patient has been " suggestioned " ad nauseam: 
 and such empirical therapy has failed, as has the inju- 
 dicious appeal to his will power already exhausted by the 
 
1645 PSYCHOTHERAPEUTICS 
 
 complexities, social and professional, which have con- 
 tributed to his failure of adjustment. 
 
 To arrest a morbid train of thought and set a mind at 
 rest is an art requiring knowledge and skill. Its at- 
 tempt by untrained men has been even more disastrous 
 than the work of the tyro in gynaecology; for it is the 
 direct cause of the rise of Christian Science, Emmanuel- 
 ism, and such cults. Happily, a body of experts in psy- 
 chopathology is now counteracting their injurious influ- 
 ence: for an affectation of knowledge will not supply the 
 public's demand for real psychic treatment. But we re- 
 quire greater facilities for instructing medical men in 
 the principles of psychopathology and therapeutics ; and 
 proper wards and out-patient clinics under competent 
 teachers should be provided, at least in every large city. 
 
 REFERENCES 
 
 1. Grasset. Therapeutique des Maladies du Systeme Nerveux. 
 
 Paris, 1907. 
 
 2. The Huxley Lecture, Brit. Med. Jour., 1906. 
 
 3. See Morton Prince. The Unconscious, Joue. Abnor. Pst., 1909, 
 
 Dec. Friedmann and Gierlich Studies in Paranoia. Trans. 
 Nervous and Mental Series, N. Y., 1908. 
 
 4. Suggestion and Persuasion. Alienist and Neurologist, 1909, 
 
 May. 
 
 5. Rev. Neurologique. 1907. 
 
 6. Camus et Pagniez. Isolement et Psychotherapie. Paris, 1904. 
 
 7. The Relation of the Med. Prof, to the Psychotherapeutic Move- 
 
 ment. Boston Med. Jour., 1908. 
 
 8. Riv. Sper. di Phren. et Psy., 1908. 
 
 9. Janet, Les Oscillations du Niveaux Mentale Congrfes de Rome, 
 
 1904. 
 
 10. Williams, The DiflFerential Diagnosis between Neurasthenia and 
 
 Some Affections of the Nervous System, for which it is often 
 mistaken. Archives of Diagnosis, 1909, Jan. 
 
 11. Williams. Hints on Psychotheraphy. Monthly Cyclopedia, 
 
 1908. 
 
 12. Lemons Cliniques. 1907. (Unpublished.) 
 
 13. Mind in the Making. New York, 1908. 
 
 14. Williams, Discussion on Responsibility of Hysteria. Contes 
 
 rendues Congr^s de Lille, 1906. 
 
PSYCHOPROPHYLAXIS IN CHILDHOOD 165 
 
 15. La Suggestibility. Paris, 1897. 
 
 16. Jastrow. Fact and Fable in Psychology. N. Y. and London, 
 
 1907. 
 
 17. See O'Shea, The Dynamic Factor in Education, 1904. N. Y. 
 
 Archibald, The Power of Play. London, 1908. 
 
 18. Raymond et Janet, Les Obsessions et la Psychasthenic. Paris, 
 
 1903. 
 
 19. Leuba. The Nature of the Moral Imperative, Amer. Jour. 
 
 Psy., 1897. 
 
 20. See Williams, The Psychological Bases of Inebriety. New 
 
 York Med. Jour., 1909, April. Also Pedag. Seminary, 1909, 
 
 21. See White, Theory of the Complex, Interstate Med. Jour., 1908, 
 
 April. Morton Prince, loc. cit. Chap. II. 
 
 22. Raymond et Janet, loc. cit. 
 
 23. Spencer, The Data of Ethics. 
 
 24. Dupr6, La Mythomanie. Paris, 1906. 
 
 25. See such current text books as SaviUe, Church, and Petersen. 
 
 26. Loc. cit, 
 
 27. Ma Conception de THysterie. Paris, 1906. La Demembrement 
 
 de I'Hysterie. Semaine M6dicale. 1909. 
 27a, The Trend of the Clinician's Concept of Hysteria. Boston 
 Med. and Surg. Jour., 1909. March 25. 
 
 28. Sec Tom Brown's School Days and Numerous Lives. 
 
 29. Mancken, The Philosophy of Neitzsche. New York, 1908. 
 
 30. Le Figaro. Paris, 1906. 
 
 31. Communicated verbally. 
 
 32. See Williams. The Most Frequent Cause of Nervous Indiges- 
 
 tion, Jour. Abnor. Psy., 1909, Feb. Also Amer. Med., 1909, 
 April. Old Dom. Jour., 1908, Nov. D6g6rine Les Fausse 
 Gastropaths, Presse Med., 1906. 
 
 33. Le R61e du Medecin en errant ou en maintainant par ses Sug- 
 
 gestions Maladroites les Maladies produites par I'lmagina- 
 tion. Congrfes des Neurologists k Lille, 1906. Trans. Amer. 
 Med., 1908, Aug. 
 
 34. Steherback, Arch, de Neur., 1709. 
 
 35. The Psychology of the Spirtiual Life, Chicago & New York, 
 
 1904, 
 
 36. Meige et Feindehl, Les Tics et leurs Traitements. Paris, 1901. 
 
 Williams, Differential Diagnosis of Tics & Spasms Via 
 Semi-Monthly, 1908. 
 
 37. Payne et Poynton, The Etiology of Chorea, Brit. Med. Jour., 
 
 1906. 
 
 38. Burr, President's Address, Jour. Nery. et Ment Disease, 1908. 
 
CHAPTER NINE 
 
 The Relation op Character Formation to 
 Psychotherapy 
 
 by james j. putnam, m.d. 
 Processor Emeritus^ Harvard Medical School 
 
 MY object in this paper is, first, to indicate the 
 place of a study of character in a scheme of 
 psychotherapy ; next, to delfine what we mean by 
 character; and lastly, to point out how far it is reason- 
 able to expect to modify character and under what prin- 
 ciples this is to be attempted. 
 
 The word character will be here employed in its usual 
 double sense; first, as in describing the prevailing ten- 
 dencies of a man's life without reference to their value 
 as regards the securing of results; next, as a sort of 
 estimate of value — intellectual, esthetic, moral, voli- 
 tional, — of these various tendencies. 
 
 In accordance with the former of these two meanings 
 we might speak of a person as being sanguine or volatile, 
 stolid or visionary, dependent or independent, etc. In 
 accordance with the second meaning we might speak of 
 him as being a man " of character," meaning thereby 
 that he was of " fine " or ** strong " character. It is 
 needless to say that these terms " fine " and " strong " 
 have a relative significance, but into this consideration 
 we need not enter here. The antithesis between these 
 two meanings of the word character is best shown when 
 we say of a person, as we clearly may, that his character 
 is to be defined as consisting in an absence of character. 
 It will be seen that the various terms hitherto used for 
 
 16^ 
 
 
CHARACTER FORMATION 167 
 
 the designation of character will have to give place to 
 others of more exact scientific meaning, or else to get 
 themselves reclothed with the connotations of a new sort, 
 but the word character is likely, none the less, to preserve 
 its double signification. 
 
 It must be evident to every one who looks closely at 
 the facts, that the therapeutic efforts of those physicians 
 who concern themselves especially with the study of the 
 functional psychoses have been rapidly developing on 
 new and interesting lines. The neurologists of the pres- 
 ent day tend less and less to treat the nervous invalids 
 entrusted to their care in accordance with the principles 
 of a narrow militarism or as subjects for cajoling, and 
 more and more as reasonable beings possessed of con- 
 sciences and independent wills and capable of intelligent 
 co-operation. In proportion as our knowledge of the 
 mental life has become deeper and more accurate there ^ 
 has been a growing tendency to seek further and further 
 for the causes of distressing mental symptoms, whether 
 these causes lie in the environment of the patients or in 
 the habits and instincts and experiences dating back to: - 
 the years of childhood or expressed in inherited physical 
 traits. Hand in hand with these tendencies towards a 
 more searching analysis of symptoms with reference to 
 this origin there has come a willingness to undertake a 
 modification of the mental mechanism such as was not 
 characteristic of the therapeutic efforts of earlier days. 
 Success in these efforts constitutes the triumphs of mod- 
 ern neurological practice. The more complex of these 
 methods might be described as constituting the major - 
 surgery of this form of therapeutics, since to utilize them 
 at their best requires both skill and insight and willing- 
 ness to expend a vast amount of time for the accomplish- 
 ment of the results. The modern practice has come more 
 and more to deserve the name of education. Less effort 
 
1^ PSYCHOTHERAPEUTICS 
 
 is now made to shunt out the critical powers and instincts 
 of our patients ; greater effort to lead them into paths 
 of intelligent insight. Hypnosis is less often used for 
 the purposes of pure suggestion, while the induction of 
 hypnoid states, for the purposes of analysis, and through 
 analysis, of treatment, has become more common, and 
 even this method is giving place to kinds of mental prob- 
 ing in which the patient takes a conscious and a willing 
 part. " Isolation cures " and " work cures," valuable 
 as they are, are found to yield their best results when 
 made parts of a broad system of education. The final 
 aim of the isolation should be social life, in its best sense, 
 and work done by the invalid should lead to work done 
 for the social welfare. In the same sense, rules of living 
 are found to yield their best results when made sub- 
 servient to principles of living, and success in treatment j,- 
 is estimated, not so much by the disappearance of symp- 
 toms as by the appearance of a thoughtful individual, 
 liable to fail, but competent to use his failures in the 
 interests of progress. 
 
 It is on the basis of a firm belief in the value of these 
 new forms of inquiry into the mental life that the fol-<^ 
 lowing remarks on character are offered. The object of 
 these new and searching inquiries is to make us intimately ^ 
 acquainted with the nature of the man with whom we ' 
 have to deal. But it is precisely in attempting to define 
 his character that we put this knowledge to the best test. 
 JiFoT the character is the epitome of the man. It is no 
 longer enough to characterize a man as " self-centered," 
 " irresolute," " dominated by envy, suspicion, jealousy "; 
 or, on the other hand, as a person of " fine " or " strong " 
 character,' as if we had the right to assume that we had 
 thereby added something material to our knowledge of 
 him, in a scientific sense. If the person in question is 
 not unified, in respect to his mental states, but " disso- 
 
 I 
 
CHARACTER FORMATION 169 
 
 ciated," as through strong emotional strain or through 
 even moderate emotional strain acting on tendencies al- 
 ready physiologically unstable; in other words, if he is 
 a " hysteric," with contracted field of mental vision, then 
 of course he is self-centered, and the physician's duty is, 
 not to blame him but to recognize him, to see that he is 
 not misjudged, and if possible to cure hini. 
 
 The truth is that ever since the day when medical 
 observation first began to intrude itself definitely into 
 the field of psychology, a new vocabulary and new syn- 
 onyms have been more and more demanding recognition. 
 
 It is as true in the mental as it is in the physical field 
 that " disease is but health under altered conditions " {^ 
 and that many a moral ban of the conventional social 
 judge will have to give way before a truer re-statement 
 of the facts than our ignorance had known. So far as 
 we can, then, let us in the future strive to infuse new 
 meaning into our conceptions of the terms character 
 and characters. Let us be more chary of roughly group- 
 ing men as bad, selfish, or weak in character, and more 1/ 
 ready to search diligently for the exact influences that 
 made them what they are. Nothing happens by pure 
 chance. 
 
 The most fruitful work in the way of mental analysis,*? 
 and therefore incidentally, of character analysis, has I 
 been that which has centered round the observations of 
 Janet, of Bergson, and of Freud — to mention only a 
 few of the foremost names — and the main object of 
 their researches has been to discover the influence of the 
 unseen mental life. Most people feel as if they could 
 point distinctly to the influences that have shaped their 
 characters and conduct. But, in fact, the necessity of 
 action, the necessity of social conformity, force our 
 choices, narrow our vision, and compel mental conflicts / 
 which take a silent part in shaping the habits and tenden- 
 
170 PSYCHOTHERAPEUTICS 
 
 cies of response that we call our characters. Thus the^ 
 lives even of the best men are compromises, adaptations 
 for more or less special ends. It has often been pointed 
 out of late years what an important part emotion and 
 emotional interests play in determining the current of 
 our thought and actions, and that when a painful emo- 
 tion is suppressed it is apt to carry with it a cluster of '^ 
 memories into a species of oblivion. But this grouping 
 of mental processes around emotions, which gives a tend- 
 ency to our thoughts to recur in " constellations " rather 
 than isolated, one by one, typifies the construction of our 
 mental lives in general. It is therefore theoreticallyV-^ 
 explicable that the tendency to the formation of double 
 or multiple lives, or to what has been called dissociation 
 and reassociation on new lines, should occur to a certain 
 extent not only in hysteria, but under conditions com-t ' 
 monly called normal. It can be understood on the same 
 principle how a person's character may be double, and 
 inasmuch as our subconscious mental lives, those por- 
 tions of ourselves which we exclude from the focus of 
 our immediate interest, are far more comprehensive than 
 our lives of self-conscious awareness, it is also comprehen- 
 sible that large tendencies and even personalities, each 
 expressible in condensed form as character, should exist 
 side by side and affect our conduct without being readily 
 observable in and for themselves. 
 
 Equally important with this principle of dissociation 
 and reassociation is the principle of the persistence into 
 later years, of mental twists and habits formed in child- 
 hood, not in their own form, but strangely altered and 
 concealed. The principle itself is familiar enough, but 
 it is to the keenness and genius of Freud that we owe its 
 working out in ways which must indeed be tested further, 
 but which are certain to be of great utility, both in help- 
 ing us to understand character and to treat its morbid 
 
CHARACTER FORMATION 171 
 
 modifications. Underneath the cloak of fears and ter- 
 rors we are taught by this writer to seek for the hidden ^^ 
 element of desire, and are given directions for the search 
 which demand our thoughtful consideration. 
 
 It might appear from these remarks that I regard the 
 psychological method as the only one likely to help us 
 in this study of character and its treatment, and like- 
 wise that the sole use of the tendencies to reaction that 
 deserve the name of character is to secure an adaptation 
 to a given environment. But this is by no means true. 
 In the first place our knowledge has not yet reached so 
 far but that our instinctive judgment outstrips it still 
 at many points. Try as we may to explain character by 
 studying its genesis, it has still a meaning which is cer- 
 tain to elude our critical inquiry, yet which we strongly 
 feel. In the next place, the explanation of the progress 
 of vital processes as here hinted at, does not supply the 
 meaning of life nor the motives for living. It is one of 
 the great mistakes of modern science to assume that we 
 can get on without interesting ourselves in these matters. 
 It is widely thought that a man need not speculate about 
 his origin and his destiny, or upon the obligations of 
 loyalty furnished by considerations of these sorts. 
 These sentiments I by no means share. I think, on the 
 contrary, that physicians are as much bound to study 
 philosophy as psychology and to carry their patients 
 with them so far as it is practicable to do so, through 
 this path. Then, as regards the matter of adaptation, 
 I believe it is only just to speak of character as stand- 
 ing for adjustments to the environment if we are ready 
 to define our environment in a broader way than it is 
 usually defined. We are surrounded by a world of spirit 
 just as obvious as the world of matter to any one who 
 has the knowledge and willingness to probe beneath the 
 surface, and possessed of a reality more basal than any 
 
 I 
 
172 PSYCHOTHERAPEUTICS 
 
 reality that it is possible to assign to the material world, 
 considered in and for itself. 
 
 Excellence of character, then, is definable with refer- 
 ence to the degree to which it represents all the different 
 portions of a person's history and nature, and may be 
 defined as of a better sort the more completely it implies 
 a unification of the powers, physical, and mental, of 
 which he is composed, and the more it indicates that he 
 is capable of adapting himself to a variety of environ- 
 ments. But these environments must not be purely of 
 a material sort. The individual possessed of the best 
 form of character must be suited not alone to the en- 
 vironment which he sees but to an environment which he 
 imagines with the vision of an intelligent and critical 
 idealist. 
 
 The treatment of patients from the point of view of 
 character is then identical with the treatment of them as 
 partial neurasthenics, hysterics, or psychasthenics, etc., 
 on the one hand, and as individuals standing in need of 
 a broader vision, on the other. 
 
 A man's character is not something superadded to his 
 other qualities, something capable of existing independ- 
 ently and to be recognized in and for itself. It is only 
 picturesquely and for convenience' sake that we speak of 
 character as of a sort of seal stamped on the record of a 
 person's life, a diploma of success or failure, granted 
 from without. Each one of a man's acts is the outcome 
 ^ of all the acts that have preceded it in the past, plus a 
 quality derived from free choice. This free choice is 
 based partly on a divination of the future, or — to speak 
 more accurately — on a half-conscious recasting of the 
 present in terms of a wider order than that which is rep- 
 resented by experience alone. We outside observers com- 
 pare and contrast a series of such acts and when we find 
 that there are features common to them all or to large 
 
CHARACTER FORMATION 173 
 
 groups of them, we collect and name these common fea- 
 tures, and thus assume for them by implication a sepa- 
 rateness of existence which in fact they cannot claim. 
 In reality every act represents an indivisible effort of 
 the actor's mind, and it is only by abstraction that we 
 assign a definite portion of a given result to the man's^ 
 character. 
 
 From a single base an infinite number of triangles can 
 be drawn, and all will have something in common though 
 each may be conceived of as independent of the rest. 
 And so may the same basal elements of character per- 
 meate an infinite number of single acts, each of which 
 has an autonomy of its own. 
 
 When we state, then, in respect to a person's intellec- 
 tual, emotional, or volitional life, that it has this or that 
 character, we render, primarily, a judgment based on 
 observation of his conduct under various conditions. 
 But this judgment contains also an implied belief that 
 his conduct owed its existence to the influence of certain 
 sets of causes. Thus when we speak of a person as being 
 of " good " character or as being " able," or " courage- 
 ous," or the reverse, we instinctively think of him as hav- 
 ing inherited certain traits or as having been exposed to 
 influences which helped to make him habitually act in 
 certain ways. 
 
 Both these elements in our judgments of a person's 
 character are subject to considerable error, but this ap- 
 plies especially to the second element, that which deals 
 with the genesis of character. 
 
 The statement of a person's character thus assumes to 
 give an epitome of his past and a forecast of his future. 
 A forecast of his future, because in the acts and atti-i 
 tudes of every individual something of his own divination 
 of his future is contained and actually exerts an effective 
 force, and thus communicates a portion of the tendenciea 
 
i ; i PSYCHOTHERAPEUTICS 
 
 that make up his character. It is just this power to 
 penetrate the future that measures and constitutes a 
 man's free will. 
 
 J, ^ It follows from what has just been said that it is only 
 as a figure of speech that it is justifiable to speak of at- 
 tempts to form character as in the sense of seeking to 
 reach a clearly defined goal. If a valid character is the 
 outcome of valid acts done in the past, modified at every 
 turn by free choices made in the interests of a higher 
 order, then we can gain character only in one way, 
 namely, through our acts. It would be an ignoble effort, 
 and one certain to defeat itself, to attempt to gain the 
 favorable judgment of others as a species of personal 
 asset, in any other mode than this. The habit or tend- 
 ency to react in a desirable manner is formed as the re- 
 sult of a long series of thoughts, purposes, and senti- 
 ments genuinely entertained and efforts effectively car- 
 ried out. A person who would reach the same result, 
 and who would be recognized as having reached it, should 
 seek it by following a similar road in the same genuine 
 spirit. But this road is not one mapped out in advance. 
 Each person builds it as he goes, through acting out his 
 own nature. Neither can the goal be foreseen except in 
 very general terms. As the needs change so do our acts 
 and purposes shift and become modified, and so likewise 
 our character. For a man's character is a sort of com- 
 posite photograph of his life. The portrait is bound to 
 be genuine, whether the elements to be portrayed repre- 
 sent genuineness and consistency in the ordinary moral 
 or intellectual sense, or lack of genuineness and incon- 
 
 "i sistency, effectiveness or ineffectiveness. 
 
 / The more symmetrical, unified, and adequate a man's 
 development has been, the more consistent is his conduct. 
 On the other hand, not only the best in each person but 
 also the worst and the indifferent elements in him neces- 
 
CHARACTER FORMATION 176 
 
 sarily play a hand in this game. Fortunately, in the con- 
 tinual melting up and remelting that goes on within the 
 crucible of progress, the worst may be made eventually 
 an element of the best, but, for the time being, if it be- 
 comes a fixed habit to be trivial that habit will be faith- 
 fully represented in a person's character, for this repre- 
 sents the master habit of his habits, the master tendency 
 of his tendencies. There is no room for deception in the 
 judgments of that court. 
 
 A person's character is, however, not always just the 
 same. It presents itself under different forms, corre- 
 sponding to the changing aspects of his personality and 
 his moods, though shifting less than they, just as the 
 trunk of a tree moves less than the branches. Each 
 phase of a multiple personality has its own character, 
 and these phases reappear as quasi normal moods. The 
 severe test of illness sometimes develops forms of charac- 
 ter that otherwise might have remained undeveloped. 
 Within the orbit of the invalid, which includes the doctor 
 and the nurse, selfishness sometimes reigns and narrow 
 egotism, together with sentimentality, ignorance, and 
 weakness of the will, and these tendencies may remain 
 active long enough to make themselves felt through modi- 
 fications of the character. But, — what is more impor- 
 tant for our purposes, — unselfishness, devotion, willing 
 sacrifice of ambitions and desires, thoughtfulness, per- 
 sistent effort, loyalty, the sense of service, may likewise 
 be manifested here, in their best form. The invalid may 
 make excursions into certain realms which are rarely 
 open to the well and strong. 
 
 ^ There are forms of character in which patience is 
 unified with clear intelligence and strong will, with in- 
 stincts which have found natural expression and ideals 
 which have grown broader with experience. The pos- 
 sessor of such a character as this has at his command a 
 
176 PSYCHOTHERAPEUTICS 
 
 means of combating illness, a compensation for illness, 
 and a safeguard against certain forms of illness, which 
 are of inestimable value. These aids are needed, for the 
 tests to which the invalid is exposed are serious tests. 
 Pain , disappointment, the necessity of sacrificing cher- 
 ished hopes ; the necessity of ceaseless struggles with the 
 sense of weakness, of exhaustion, of isolaiien; the neces- 
 sity of living in almost perpetual companionship with 
 some parasite or demon or phantom of the fancy, hardly 
 less hard to bear for being recognized as fictitious; 
 harder still, the tearing asunder of strong ties of family 
 and friendship; trials such as these may mar, but often 
 make a fine character, and many examples of the latter 
 result are known to all. Such persons are " unified " to 
 a remarkable degree. The syntheses that represent each 
 one, even of their more trivial acts are enriched and ani- 
 mated by similar memories and motives. The emotional 
 " core " of each harmonizes readily with all the rest. 
 
 ^ ^ But, it might be urged, to what purpose cite the ex- 
 amples of eminent heroes of invalidism if it is an impos- 
 sible task for most of us to follow where they have led.^^ 
 If our characters depend so much on our inherited traits 
 and on instincts arising at the very threshold of infancy 
 that our very carriage and gestures, our voices, and the 
 expressions of our faces reveal our natures and stamp us 
 to the casual observer for what we are, why should we 
 fret ourselves with vain attempts at change.? We can- 
 
 } not change our bodies, how, then, can we hope to alter 
 our characters, some elements of which are almost as 
 fixed as our spinal reflexes themselves.? The most trivial 
 habits, even if recently acquired, obstinately resist dis- 
 missal, and the same is still more true of our obsessions. 
 >The causes of many of our abnormal traits lie out of 
 reach, it is said, buried in the form of bodily mechan- 
 isms and forgotten experiences of the past. Timidity, 
 
CHARACTER FORMATION 177 
 
 vanity, selfishness, may be graven so deeply into our lives 
 that although we can conceal them for a certain period 
 it is often claimed that we cannot eradicate them alto- 
 gether. 
 
 So strongly do many persons feel that a man's charac- 
 ter is in many ways outside of his control, that the very 
 knowledge that he belongs to a certain family, even to a 
 certain race, is enough to make them doubt his capacity 
 for any considerable change. Various students of hered- 
 ity rate the influence of education very low * as compared 
 with that of hereditary tendencies. Even admitting that 
 a real changing of the character is possible, the invalid 
 — many men would say — is heavily handicapped for 
 such a struggle. His inheritance may be dark, his in- 
 terests narrow, his opportunities for mingling actively 
 in the stimulating game of life and feeling the warm 
 breath of others' zeal are relatively few. He must often 
 stand by and " look on with cold hands while they join 
 in the whirling game." He is tempted, pushed and 
 drawn towards a life of selfishness, discouragement, and 
 inertness. But, fortunately, there is another and very 
 different side to this picture, and one which both science 
 and observation contribute the materials for painting. 
 The argument for the inalterability of the fundamental 
 tendencies to conduct is unsound; the motives and oppor- 
 tunities present to the invalid are inaccurately stated. 
 Character is to be measured in terms, not of quantity, 
 but of quality. What a person needs in order to fulfill 
 his destiny, to reach his goal, whether in a personal sense 
 or with reference to his obligations towards the world, is 
 a power of insight and a sense of progress and freedom, 
 rather than any special form of external accomplish- 
 ment. There are many kinds of insight and many doors 
 and avenues to the realms of freedom. It is only neces- 
 
 iCf. Heredity in Royalty. Woods. 
 
178 PSYCHOTHERAPEUTICS 
 
 sary to look at the invalids who have accepted their 
 conditions cheerfully and taken their lot at its best, to 
 realize what possibilities are open to those who can es- 
 cape from estimating the pleasure and value of their 
 lives in too conventional terms. 
 
 We see daily, to be sure, persons who refuse to regard 
 sickness in any light except as an obstacle and a misfor- 
 tune of a wholly different class from those of a more 
 familiar sort, and in whom it excites no note of response 
 other than that of terror or indignation. Overwhelmed 
 by a sense of isolation and of personal grievance, they 
 can do nothing but repine. But very different is the pic- 
 ture presented by those persons whose characters are so 
 made that they move forward in spite of the handicap 
 of illness, so steadily that like a stream of water poured 
 upon the ground, which finds itself met by one obstacle 
 after another only to turn in a new direction and pass 
 on, while the idea of being conquered or permanently 
 checked seems not to present itself before their minds. 
 The characters of such persons may vary greatly in de- 
 tail, but they resemble each other in the respect that they 
 all point to more or less effectively unified personalities, 
 to a fairly concurrent action of the multifold tendencies 
 through which their actions are determined. 
 
 Even faults, failures, and defects have no prescriptive 
 right to bar one's way to a larger view of illness or of 
 trouble, and should not be allowed to do so. Morbid 
 self-consciousness, egotism, the tendency to follow aims 
 less desirable than the best, unwelcome as they are, should 
 nevertheless be actually welcomed, if, as so often hap- 
 pens, they mean movement and progress. The outlook 
 for the invalid is also for another reason much better 
 than it is frequently pictured. The dead hand of an 
 inheritance, assumed (usually on very insufficient 
 grounds) to be "morbid," of habits supposed to be un- 
 
CHARACTER FORMATION 179 
 
 alterably fixed, often owes its baleful power to the fact 
 that its workings are concealed from us. 
 > It is the skeleton in the closet, the tug of an evil 
 spirit residing in the mysterious depths of our subcon- 
 scious life, the misunderstood twists and tendencies de- 
 rived from unfortunate experiences in childhood, experi- 
 ences which at the time may have seemed innocent and 
 trivial enough — that contribute many of the specters 
 which terrify us and seem to block our paths. It is 
 among the best contributions of modern psychiatry and 
 psychotherapy that it has been shown to be possible, in 
 a remarkable degree, to reverse these hidden influences, 
 which are due to old environments, to misinterpreted 
 emotions, — in brief, to ignorance. The discovery that 
 even patients with dementia precox can be measurably, 
 helped through application of this principle is one of the 
 encouraging developments of modern medicine. 
 
 The invalid who finds himself in face of difficulties 
 which seem so hard to overcome is drawn forward and 
 held back by strong and varied groups of impulses in 
 which good and evil, basal instincts and fresh ideals, 
 traditions of courage and traditions of cowardice, confi- 
 dence, and terror, love of his fellowmen and fear of his 
 fcllowmen, freedom and prejudice, seem to be joined in 
 combat for the formation of his character. The phy- 
 sician's duty is to aid him in discovering his best birth- 
 right, in helping his best instincts, the best fruits of his 
 intelligence, the best conquests of his will, to gain the 
 mastery. 
 
 The habits that we seek to alter, after all, are habits 
 only. They reside in the physiological mechanism of 
 our bodies, and these, just because they live, are more 
 or less susceptible of change. I recall an interesting con- 
 versation with an able student of these subjects with 
 relation to the bodily signs of neurasthenic states, and 
 
180 PSYCHOTHERAPEUTICS 
 
 remember well his agreement with my view that' many of 
 them, deep-seated though they seem to be, are susceptible 
 of modification in the direction of more normal nutritive 
 development^ provided only that their mental accompani- 
 ments can be improved. The bare fact, indeed, that the 
 nutrition of the body can be modified, even in its most 
 intimate forms, through the action of mental states, is 
 too well acknowledged to need further emphasis. 
 ^ Every one has seen individuals whose characters have 
 been so changed through development that for all prac- 
 tical purposes they have become fundamentally different 
 from what they had been before. In many of these cases 
 the influence of illness has been one means through which 
 this change was brought about. The mode in which the 
 change takes place seems usually to be one of either of 
 ^ two sorts. First, the former traits of character are, 
 as it were, side-tracked by the formation of new habits, 
 a new personality, dependent on new interests and devel- 
 '^oped in practical substitution for the old. Next , the 
 new character may absorb the old ; as when a person 
 utilizes, more or less consciously, all the influences, pain- 
 ful as well as pleasurable, which have been brought to 
 bear upon him, and makes his faults as well as his virtues, 
 his weakness as well as his strength, materials for the 
 formation of a new character which without these influ- 
 ences could not have been formed. Intensely self-con- 
 scious persons of the type of Bunyan are among those 
 who adopt this latter plan, and there are various other 
 types of invalids whose development follows similar lines. 
 Whichever of these two modes of effecting a change 
 in the fundamental movements of one's life is chosen, 
 three great influences, sanctioned alike by the experience 
 of educators and the observation of physicians who have 
 dealt with morbid minds, must be mainly relied upon in 
 the accomplishment of the task, y These are, on the one 
 
CHARACTER FORMATION 181 
 
 hand, the utilization of emotions, desires, strong inter-*- 
 ests, enthusiasm, even the enthusiasm attending intellec- 
 tual convictions of a high order; on the other hand, per-4^ 
 sistent, arduous, and thorough training, carried out un- 
 der a clear conception of the difficulties in the way; and, 
 finally, the eradicating of hidden obstacles to success ^ 
 residing in the form of motor habits and memories not 
 clearly present before the waking consciousness. The 
 principles underlying these three methods need to be sep- 
 arately considered. '^ 
 
 To speak, first, of the " side-tracking " plan, it is ob- 
 vious that if the invalid is to be led to adopt new inter- 
 ests, to gain new enthusiasms of sufficient strength and 
 enduring power to modify his character, these interests 
 and enthusiasms must be in harmony with his own nature ; 
 he cannot be expected to form a wholly artificial self. 
 And yet by assumption he is cut off from many of the 
 special interests and pleasures prominent in other per- 
 sons' lives and perhaps previously in his own. If success 
 is to be obtained it must be because every person's nature 
 is in reality far broader than at first appears. There 
 are persons who appear able, — not merely as a matter 
 of hypocritical pretense, but actually — to feel their in- 
 terests merged in the interests of the community, taken 
 in a larger or a narrower sense. Parents usually care 
 intensely for the happiness of their children, and do not 
 feel aggrieved and depressed if they are obliged to sac- 
 rifice lesser personal interests for interests of this greater 
 sort. Citizens, and even races, in whom the sentiment 
 of patriotism has been strongly developed, work and die, 
 cheerfully and loyally, for national successes that they 
 will never see. These community sentiments, which are 
 thus so strong, may take a definitely personal or a rela- 
 tively impersonal form. If, now, some persons are so 
 powerfully moved by these feelings, it must be that all 
 
182 PSYCHOTHERAPEUTICS 
 
 persons are capable of responding to them, and that the 
 physician's problem is to find means of rousing these sen- 
 timents into flame. I believe that the diflSculty in the 
 way of this result consists less in overcoming an essential 
 resistance than in overcoming conventional habits of 
 thought and feeling. 
 
 The fear of others' criticisms makes us cold. Our 
 conventional views of success, misfortune, death, are too 
 often irrational and even positively low, and it is custom 
 more than nature that makes them so. The very fact 
 
 >> that the habit of esteeming the community success or the 
 success of a cause as preferable to personal success may 
 become, within certain limits, a national habit, is a sort 
 of warrant for the possibility of exciting it in a given 
 case. Invalids should learn to regard themselves as mem- 
 bers of an imaginary band of persons, inspired by loy- 
 alty to sentiments of health and courage, although, like 
 themselves, obliged to carry burdens of a certain sort. 
 The numerous individuals who suffer from ideas of 
 morbid self-consciousness carry about with them a band 
 of imaginary critics and enemies, and can often substi- 
 tute for them without great difficulty this ideal band of 
 
 ;?» allies. It is a question of gaining new ideals of living 
 and making these ideals actually count as standards. 
 " I have tried to live so that my smallest act would cor- 
 respond to my highest ideal," wrote an intelligent pa- 
 tient with whom this sentiment had become the prevailing 
 motive of her thoughts and conduct. 
 
 Every invalid has also many capacities for genuine 
 interest and pleasure of the lighter sorts, which are 
 capable of exciting enthusiasm if only they are followed 
 without the reserve induced by conventional restraints 
 
 /" and by the habit of comparison of one's self with others. 
 
 ^In the way of this result stands the instinctive longing 
 
 for individual success, misunderstood and taken in an 
 
CHARACTER FORMATION 183 
 
 exclusive and personal sense, as if one man's success must 
 mean another's failure. Personal courage and personal 
 energy and enterprise do indeed seem to stand at the 
 very center of all progress, but they connote much that 
 is barbarous and need the counter-balancing note of the 
 " courage to let the courage sink." ^ We continually 
 underrate or wholly fail to recognize the deeper motives 
 by which we might be impelled. We like too well to im- 
 agine that our lives and impulses are clear before us, 
 and to gain this seeming clearness we close our eyes to 
 great masses of influences which it would cost us much 
 pains and perhaps pain to analyze. 
 
 ^ It is obvious from what has been said that character 
 serves as a stimulus to action. It is likewise known that 
 through experimental methods, as in the case of a hyp- 
 notized patient, it is possible to secure impulses to action 
 which, primarily at least, do not deserve the name of 
 character or even of emotional interest. In other words, 
 it has been found that any positive suggestion made 
 when the mind is in a receptive state is likely to be car- 
 ried into execution. In fact, the attempt has been made 
 to form character through " suggestion," especially 
 with children, and it is indeed possible that cettain steps 
 in this progress can be thus accomplished. It is, how-< 
 ever, instructive to note that there is a striking differ- 
 ence between the impulses to action formed through sug- 
 gestion and those gained through experience and strug- 
 gle, even though the apparent result and form of the 
 action might seem, now and then, to be the same in the 
 two cases. This difference resides in the fact that al- 
 though an impulse to action secured through suggestion 
 may fit us to carry out a certain result, and thus make 
 us adapted for a definite environment, the position of 
 character — assuming, of course, that it is character of 
 2 Arthur H. Clough. 
 
184 PSYCHOTHERAPEUTICS 
 
 a desirable sort — adapts us for environments of many 
 sorts. The memories of the experiences through which 
 a person has passed, under these circumstances, come 
 to his aid in the way of enriching his perceptions and his 
 thoughts, to an extent which it would be otherwise im- 
 
 y possible. 
 
 ^The second of the two methods of character modifica- 
 tion consists in the systematic study of one's personal 
 experiences and traits in the interest of an outcome bet- 
 ter than the present. Much has been said of the evils 
 of introspection, and this would seem to imply introspec- 
 tion on a large scale. But there are two sorts of intro- 
 
 ^spection. One of them is simply emotional, morbid, and 
 depressing, and ends in nothing that is useful, while the 
 other is a thoughtful study of one's self, made desirable 
 either for the sake of increasing the general sum of 
 knowledge, or for the sake of the correction of tenden- 
 cies which absolutely need correction. This self -Investi- 
 gation, which is much better conducted with the aid of 
 the skilled physician, may take either one of two forms. 
 The patient may scrutinize the obstacles consisting in his 
 own peculiarities of disposition and of habits, and learn 
 to estimate them at their true value, regarding them, so 
 far as practicable, in a matter of fact way and without 
 undue emotion, especially without self-reproach, and may 
 utilize the information that he gains in the interests of 
 progress. Or, he may make a very thorough scrutiny 
 of the origin of his symptoms, be they what they may, — 
 morbid self-consciousness, fears, undesirable feelings to- 
 ward those around him, dissociations of the hysterical 
 type. Every thoughtful person is aware that many of 
 these symptoms have their roots in experiences and hab- 
 its formed in childhood, but there are few persons, even 
 though thoughtful, who have as yet learned to appreci- 
 ate the full bearing of this principle. Mental conflicts 
 
I CHARACTER FORMATION 186 
 
 may begin almost in the cradle, and are often attended 
 or soon followed by desires, aspirations, and fears, which 
 too often are given no outlet, but are ostensibly sup- 
 pressed. In reality this suppression means frequently 
 conversion into some other form and the establishment 
 of an undesirable tendency to morbid growth. The 
 chapter by Dr. Ernest Jones describes this principle with 
 far better justice than I can render it in these few lines. 
 I will only say that the longer I have studied the matters 
 of which his chapter treats, the more fully I am con- 
 vinced of their significance. I have already discussed 
 them somewhat in the earlier portion of this chapter. 
 
 Besides these two great methods of character forma- 
 tion, that which operates through the operation of new 
 interests and that which operates through the scrutiny 
 of past experiences and present peculiarities, — there is 
 a large field for efforts toward character-formation 
 ^ through the systematic training of the will and the as- 
 sumption of duties and obligations toward individuals 
 and the community. ' 
 
 Back of them all, however, lie the question and the 
 doubt, " Do we mean to substantiate our principles with 
 acts".? "Are we prepared to pay the price, in labor, 
 of freedom and self-control .? " If these questions can 
 be honestly answered in the affirmative, the battle is 
 half won. For the development of character in harmony 
 with new ideals and needs it is not necessary or desirable 
 to eradicate the past, but only to make it lend some ele- 
 ment of value to the present. The oriental philosophy 
 would see virtue reached through the obliteration not 
 only of sensuality but of the senses. A typical reductio 
 ad ahsurdum of this principle is furnished by the con- 
 duct of those devotees who have themselves immured in 
 narrow cells to be thereafter kept alive for varying pe- 
 riods through food thrust in by narrow apertures. 
 
186 PSYCHOTHERAPEUTICS 
 
 The Western philosophy adopts sense pleasures as ele- 
 ments to be utilized; adopts the seeming paradox that 
 sins and pains, even if apparently useless, are not incom- 
 patible with the theory of a moral universe. The man^ 
 of finest character has long ceased to be sensual; yet he 
 does not, for that, shut his eyes upon his natural in- 
 stincts, but remains sense free and sense active, and rec- I 
 ognizes the splendid working out of sense instincts in 
 civilization and community life. Neither do the tempta- 
 tions and trials of illness and misfortune fetter his 
 thought any more than the temptations of sensuality. 
 
 The development of character in a desired direction is 
 then to be secured through free choice, but, as a rule,u. 
 slowly, perhaps painfully, and under constant vigilance ^^ 
 and effort.^ Most of all, the principle should be recog'i_ 
 nized that in the conscious attempt to modify character 
 and to escape from the bondage of hampering habits, 
 what we really seek is not the destruction of order, in 
 the supposed interests of freedom, but acceptance of aw, 
 more comprehensive order as the highest choice of free-<- 
 dom. It is the conception, under the form of an ideal 
 vision, of this higher order, combined with the power 
 which the vision furnishes of seeing one's self as part of 
 a larger whole, one member of a great company of per- 
 sons not wholly describable in terms of bodily forms, a 
 company whose pleasures and progress each one may 
 enjoy, regardless of his individual lot; it is this concep- 
 tion that makes illness not only bearable, but sometimes 
 the road to a more satisfactory sort of health. 
 
 3 It is interesting to note that Dante, in his Purgatorio, while 
 asserting the possibility of progress, symbolizes, by the lengths of 
 time which he assumes to be required for his modifications of char- 
 acter, the practical difficulty in the way of the result. 
 
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