In formal, deliberate psychotherapeutics the first and most important principle is the treatment of the individual patient, and not of his disease. It is much more important to know the kind of an individual who has pneumonia, as a rule, than to be able to tell the amount of pulmonary involvement. If heart, kidneys or lungs are affected when the disease declares itself, the outlook is extremely unfavorable. Similar conditions are true of the patient's mind. If he is of the worrying kind, the outlook is serious. If, on the contrary, he faces it bravely, and without after-thought except that of responding to medical treatment, he will probably get well.
Pneumonia is only one example of the part the individual plays in therapeutics. In the popular mind it is supposed that for each disease there is a definite remedy, and that when the physician gives that remedy the patient gets well. This idea of specific remedies has come to the people from the physician, but only the quack now pretends to cure disease, the physician helps the patient to overcome the affection from which he is suffering.
No Incurable Patients.—There are many incurable diseases, but there are no patients to whom a doctor should say with truth, "I can do nothing for you." We may be unable to do anything for the underlying disease. That may be absolutely incurable. In spite of this, there are practically always symptoms for which the patient can be afforded so much relief that he feels better than before. This is the most important attitude of mind for the physician who would use psychotherapy. He can always do something. Prof. Richet said not long since, "Physicians can seldom cure, but they can nearly always relieve and they can always console," and it is the physician's duty to lift up and console the mind as well as to heal the body.
Unfavorable Suggestions.—Patients often have many opinions and conclusions with regard to their ailments which are not confided to their medical attendants, and which constitute the basis of many annoying symptoms. They have mental convictions with regard to the incurableness of their ailments, the supposed progressive character of the disease, and the development of symptoms which will still further annoy them, that are often more serious and harder to bear than the symptoms from which they are actually suffering. Unless the physician has their complete confidence, these patients may suffer much in silence, though the revelation of their state of mind would {187} often be sufficient to afford a good measure of relief, and the correction of false notions would do nearly all the rest. Psychotherapy confers its benefits mainly by securing the most complete rapport between the mind of patient and physician. Good advice is often more important than any medicine. The correction of wrong notions will do more to relieve the patient, and make whatever symptoms he has bearable, than most of the anodyne drugs. The stimulation of hope means more than almost anything else in arousing the latent forces of nature and predisposing to recovery. The removal of unfavorable suggestions is but little less efficient.
Study of the Individual.—The great differences in the relations between physicians and their patients is well recognized. To some physicians a patient will present only conventional symptoms, while a follow practitioner will discover the elements of an interesting case. Above all, the painstaking physician, interested in psychology, will find mental and other personal manifestations in his patient that distinctly modify the course of the disease. We must know all that is possible about the patient's attitude of mind toward his malady, and all the ideas that he has acquired with regard to it, either from previous relations with physicians or from what he may have read or heard from others. The removal of many false notions that are thus working harm will reward the medical practitioner who gets at his patient's ideas. The old rule in therapeutics is non nocere—to be sure to do no harm. The special rule in psychotherapy is to be sure to remove all the ideas that are doing harm to the patient and making his symptoms mean more to him than they really signify.
Neutralizing Contrary Suggestion.—In the application of psychotherapy, then, the first principle is the neutralization of unfavorable mental influence. In our day men have such a smattering of knowledge about disease, especially about the worst forms of it, that they are likely to be in a frame of mind with regard to many affections that is quite unfavorable. Many patients think disease and not health. Disease means discomfort, and consequent loss of vital energy and disturbance of the resistive vitality that would enable the patient to throw off the affection. Sometimes the physician does not realize what a large part unfavorable suggestions are playing in the affection. Sometimes patients conceal their state of mind lest the doctor should confirm their worst fears. The preliminary to all successful treatment is to remove unfavorable suggestion.
Favorable Suggestion.—The next thing is to set certain favorable suggestions at work. It is possible always to do this. Even in certain of the acute diseases favorable suggestion has its place, and for all chronic cases this form of therapeutics is extremely important. The very presence of the physician, especially if he is thoroughly in control of himself, placid, imperturbed, evidently ready to use all his powers without any excitement, is of itself the strongest kind of favorable suggestion. From the very beginning of medical history the presence of the physician has in most cases meant even more than his medicines.
Münsterberg, in his recent book on Psychotherapy, has emphasized this in a way that deserves to be recalled:
There is one more feature of general treatment which seems almost a matter of course, and yet which is perhaps the most difficult to apply because it cannot {188} simply be prescribed: the sympathy of the psychotherapist. The feelings with which an operation is performed or drugs given do not determine success, but when we build up a mental life, the feelings are a decisive factor. To be sure, we must not forget that we have to deal here with a causal and not with a purposive point of view. Our sympathy is therefore not in question in its moral value, but only as a cause of a desired effect. It is therefore not really our sympathy which counts but the appearance of sympathy, the impression which secures the belief of the patient that sympathy for him exists. The physician who, although full of real sympathy, does not understand how to express it and make it felt will thus be less successful than his colleague who may at heart remain entirely indifferent but has a skillful routine of going through the symptoms of sympathy. The sympathetic vibration of the voice and skillful words and suggestive movements may be all that is needed, but without some power of awakening this feeling of personal relation, almost of intimacy, the wisest psychotherapeutic treatment may remain ineffective. That reaches its extreme in those frequent cases in which social conditions have brought about an emotional isolation of the patient and have filled him with an instinctive longing to break his mental loneliness, or in the still more frequent cases where the patient's psychical sufferings are misunderstood or ridiculed as mere fancies, or misjudged as merely imaginary evils. Again everything depends upon the experience and tact of the physician. His sympathy may easily overdo the intention and further reinforce the patient's feeling of misery, or make him an hypochondriac. It ought to be sympathy with authority and sympathy which always at the same time shows the way to discipline. Under special conditions, it is even advisable to group patients with similar diseases together, and to give them strength through the natural mutual sympathy; yet this too can be in question only where this community becomes a starting point for common action and common effort, not for mere common depression. In this way a certain psychical value may be acknowledged for the social classes of tuberculosis as they have recently been instituted.
Favorable Environment.—After the removal of unfavorable suggestion and the implanting of favorable suggestion, the next point must be the persistent occupation of the patient's mind with thoughts favorable to his condition. A nurse who is inclined to be pessimistic must be taken out of the sick room, and there must be only cheerful faces and cheery people around him. Hence the modern trained nurse, and especially the picked nurse, who does not allow herself to be disturbed, who is not fussy, who is not forcibly cheerful but quietly placid and confident and cheery, means much for the patient's recovery. Relatives are almost sure to exert strong unfavorable suggestions, though time was when the devoted wife or mother might be depended upon to cover up all her personal feelings and give the best possible service for the mental uplift of the patient. When she can thus conceal her own solicitude, a near relative may be the best possible auxiliary in psychotherapeutics.
Natural Relief.—The fourth step in the application of psychotherapeutics is that all the natural modes for the relief of symptoms, the making of patients comfortable in body as well as in mind, must be employed. In acute rheumatism, for instance, a number of small pillows must be at the disposition of the patient so that his limbs can be fixed in those positions in which there is the least discomfort. Every physician should frequently read Hilton's classical volume on "Rest and Pain" because of its unpretentious significance for psychotherapy, as well as its enduring value in the treatment of painful conditions. Just as soon as a patient finds that simple procedures relieve his pain and add to his comfort, his fear of the seriousness of his ailment is lessened, {189} and he begins to get bettor. Cold water in fevers, cold fresh air in pneumonia, all the natural modes of treating disease, thus become active factors in the application of psychotherapy. When fevers were treated by the administration of hot drinks the effect upon the patient's mind must have been quite serious. Freedom to use cold water, just as one wants it and whenever it is craved for, is of itself an excellent suggestion.
Neuroses in Organic Disease.—Fifth, psychotherapy, by suggestion, may alleviate or even completely eradicate neurotic symptoms that develop in connection with organic diseases. Such neurotic symptoms may prove even more bothersome to the patient than the symptoms due to his underlying affection, and may, by interfering with nutrition, hamper recovery. The appetite of a patient who is worrying about a chronic disease will be disturbed, and, as a consequence of insufficient food, constipation and a whole train of attendant evils may ensue. Headache, sleeplessness, worry at slight irritation and exaggerated complaints from slight pain may all be due to this worry and not to the underlying disease. All these, the result of over-solicitude, are attributed by the patient to his chronic ailment. They can be relieved by simple measures after he is saved from his own worry. Until the patient is made to rouse himself and look hopefully at the situation, eating more, getting out more, and relaxing his mind from its constant attention to himself, he cannot get better.
Application of Principles.—It should be pointed out to the patient that there is a constant tendency to exaggerate the significance of disease. This is true in acute as well as in chronic disease, but in acute diseases the necessity for removing unfavorable influences directly is not so urgent, since usually the presence of the physician, with his simple declaration of the meaning of symptoms, is sufficient to neutralize the effect of previous exaggerations.
Secondly, the action of unfavorable suggestions due to imperfect knowledge (everything unknown is magnified, as Cicero said), or to previous medical opinions which the case does not justify, must be stopped. The natural dread which comes to all men in the presence of symptoms of disease must be as far as possible removed.
Thirdly, the favorable elements in the case should be emphasized. This needs to be thoroughly done in order to secure the patient's co-operation, even though the serious possibilities of his ailment may be pointed out to his friends. These friends, however, must be persons who can be absolutely depended on not to reveal by word, or, what is much more important, by their looks or actions, the possible worse prognosis of the case.
Unfortunately, people expect a doctor to tell them the worst, rather than the best. Many physicians seem to have formed the habit of representing the condition of patients as grave as possible, in order, apparently, that they may have more credit when the patient recovers. Not a little of the tendency of ills to hang on in neurotic persons is due to this habit. Over-cautiousness leads some physicians to reveal a case in its worst aspect, lest, by any chance, something unexpected should happen, and the friends of the patient might think that the physician was incompetent because he had not anticipated it. Some of the serious accidents of disease are quite beyond anticipation; but they occur only rarely. For the sake of safeguarding the possible reflection on the physician because of them, it is quite unjustifiable to make bad {190} prognosis habitually, for this acts deterrently on the vital resistance and delays recovery.
Symptoms of Organic Disease.—It is usually considered that psychotherapy is beneficial only in nervous cases; yet we know that all sorts of affections with tissue changes in the skin, in the circulation, and very probably also in the internal organs, may be produced in hysterical affections—ailments dependent on loss of control over the vaso-motor nervous system. Just as ills can be produced, so they may also be cured. As a matter of fact, analysis of the statistics of disease cured by mental influence, shows that it has been more strikingly manifest in organic than in so-called nervous or functional diseases. Neurotic patients often make extremely unsuitable subjects for the exercise of mental influence, because their very nervousness is a manifestation of lack of power properly to control the mind. Cures by mental influence have oftenest been reported in non-neurotic patients. As Dr. Hack Tuke pointed out in "The Influence of the Mind on the Body" as long ago as 1884, it is in such cases as rheumatism, gout and dropsy that benefit was most frequently reported by mental means.
Tuberculosis, certain digestive and intestinal ailments that evidently are associated with tissue changes, have in recent years come particularly into this category of ailments affected by psychotherapy. Dr. Hack Tuke's declaration, made nearly thirty years ago, seems conservative even at the present day: "The only inference which we are justified in drawing from the statistics of the affections cured by mental means is that the beneficial influence of psychotherapeutics is by no means confined to nervous disorders." Many physicians are likely to hold that when cures take place the so-called organic diseases were not actual, but were only supposed to exist because of certain obscure symptoms that apparently could not otherwise be explained. But many of the cases have had external symptoms, striking and unmistakable. To assume that physicians of experience and authority were in error in diagnosing them is simply to beg the question. It is more probable that mental influence acted curatively even over tissue changes as it so often does, directly under our observation, in the production of such changes in the skin.
Tissue Changes From Nerves.—Until one recalls how many physical changes may be brought about by mental influences or emotional disturbances, it is not always clear just how mental influence can affect disease favorably or unfavorably. Prof. Forel, of Zurich, in his "Hygiene der Nerven und des Geistes im Gesunden und Kranken Zusande," Zurich, 1905, English translation 1907, brings together into a single paragraph most of these physical and physiological influences of the mind upon the central nervous system:
Through the brain and spinal cord, thoughts can lead to a paralysing or stimulation of the sympathetic ganglion nodes, and consequently to blushing or blanching of certain peripheral parts. Through disturbance of this mechanism, many nervous disorders arise, such as chilblains, sweats, bleeding of the nose, chills and congestions, various disturbances of the reproductive organs, and, if it lasts long enough, nutritional disturbances in the part of the body supplied by the blood vessels affected. In the same way there are peripheral ganglionic mechanisms which superintend glandular secretion, the action of the intestinal muscles, etc. These likewise can be influenced through the brain by ideas and emotions. Thus we can explain how constipation and a vast number of other disturbances of digestion and of menstruation can be produced through the brain, without having their cause in {191} the place in which they appear. It is for the same reason that such disturbances can be cured by hypnotic suggestion.
Health and the Central Nervous System.—Nature has so constituted and ordered the human economy that its health depends to a great extent on conditions in the central nervous system. We discuss elsewhere the return of vitalism in physiology—that is, the reassertion of a principle of life behind the chemical and physical forces of the human organism regulating it, supplying energy, occasionally enabling it to transcend the ordinary laws of osmosis, or the diffusion of gases. The main seat of this principle of life is in the central nervous system and especially in the cerebral cortex. The importance of this portion of the human anatomy can scarcely be exaggerated. In his inaugural address to the Royal Medical Society, [Footnote 23] delivered at Edinburgh in 1896, Prof. T. S. Clouston, the distinguished English psychiatrist, has a passage on this subject that deserves to be recalled:
[Footnote 23: British Medical Journal, January 18, 1896.]
I would desire this evening to lay down and to enforce a principle that is, I think, not sufficiently, and often not at all, considered in practical medicine and surgery. It is founded on a physiological basis, and it is of the highest practical importance. The principle is that the brain cortex, and especially the mental cortex, has such a position in the economy that it has to be reckoned with more or less as a factor for good or evil in all diseases of every organ, in all operations and in all injuries. Physiologically, the cortex is the great regulator of all functions, the ever active controller of every organ and the ultimate court of appeal in every organic disturbance.
Psychotherapy in Its Relation to Patient and Physician.—In spite of the present-day fad for psychotherapy, I have no illusions with regard to its popularity among patients, unless practiced with due regard to individuals and with proper tact. Psychotherapy has been most effective in the past when it was cloaked beneath the personality of the physician; when it was felt that there was in him a power to do good that must help the patient. This personal influence has to be maintained if the patient's mind is to be influenced favorably. Very few people are willing to think, and still less to welcome the thought, that they themselves are either bringing about a continuance of their symptoms or are hindering their own recovery. They are quick to conclude that this would be a confession that their ills are imaginary. "Imaginary" has no place in medicine. There are physical ills and mental ills. Mental ills are just as real as physical ills. There are no fancied ills. A person may be ailing because he persuades himself that he is ailing, but in that case his mind is so affecting his body that he is actually ailing physically, though the etiology of the trouble is mental.
It is the duty of the physician to get at these mental causes of physical ills and remove them by persuasion, by reassurance, by changing the mental attitude, by making people understand just how mind influences body, but this must be done tactfully. From the beginning of time we have written our prescriptions in such a way that ninety-nine out of one hundred patients have not been able to understand them. It has often been said that we should change this method of prescription writing, and write directions for the compounding of our medicines in plain vernacular. Besides the many {192} scientific reasons against this, it is better for patients not to know exactly the details of their treatment. Physicians, because of their real or supposed knowledge, are usually the worst patients. If, when a physician is ill, a drug is administered in which he has lost confidence, he will really oppose its action by contrary suggestion, and perhaps neutralize it. Confidence added to the action of the drug itself, makes it much more potent and much more direct. Hence the suggestive value of a prescription the ingredients of which are unknown. Every physician knows of patients who have declared that a drug has been tried on them without avail, when it has only been used in such small quantities as to be quite nugatory in its effect. Such use was enough to prejudice them against it so that when given in physiological doses it failed to work properly.
Opium given to a trusting patient, in gradually reduced doses until practically there is nothing but the flavor of the drug in the compound that he takes, will continue to have its effect. But to a patient prejudiced against the drug, even large doses of opium will prove unavailing, because the lack of confidence disturbs the mind, directs attention to whatever discomfort may be present, emphasizes the ill and prevents sleep by preoccupying the mind with the thought that neither the drug nor the dose can accomplish its purpose. In a word, medicine plus mental influence is extremely valuable. Medicine minus mental influence is valuable but sometimes ineffective. Medicine, with mental influence opposed to it, is often without effect because of the strong power the mind has over bodily functions.
Most people would rather be cured by some supposedly wonderful discovery, which presumedly made it clear that they had been suffering from a severe and quite unusual ailment, than by ordinary simple methods. The recent growth of interest in psychotherapy and psychology has, however, somewhat prepared people to accept mental influence as an important factor in therapeutics. The direct and frank use of psychotherapy will be of benefit to these people. But in most cases mental influence will have to be exerted in such a way as to conceal from patients that it is their own energy we want to tap to help them cure themselves. This would be for them quite an unsatisfactory method of being cured. In practically all cases such a combination of methods is needed that the place of mental influence is not over-emphasized. As a rule, mental influence must not be used alone. Its place is that of an adjunct, a precious auxiliary, to other methods of treatment.
Psychotherapy represents one of the important elements in therapeutics, and we must learn to use it in a way suitable to our patients. We have to learn to use our drugs in accordance with the nature and physical make-up of the patient. We have to find out by experience just how to use hydrotherapy for each individual. Varying currents of electricity and varying forms of electrical action are needed for different individuals. Just in the same way, our psychotherapy must be dosed out according to the special need of each individual, the form of the affection and the particular kind of mind that is to be dealt with. To learn the place of mental influence in healing, so that we shall not be attributing to other therapeutic factors what is really due to the mind, will be a great advance in therapeutics. This is the mistake that we have been making in the past.
In brief, the applications of the general principles of psychotherapy {193} include all means, apart from the physical, of influencing patients. Drugs will always have a large place in rational therapy. Many physical remedial measures, hydrotherapy, electrotherapy, climatotherapy and others, must be important adjuncts. To these is now added psychotherapy. It has been used before, as have most of the other forms of therapy, but in our day we are trying to systematize therapeutic modes so as to secure the greatest possible information with regard to their exact application. This is what must be done with regard to psychotherapy also. Just now its importance is being exaggerated by ardent advocates. In every department of therapy this has always been done by enthusiasts. The business of the practicing physician must be to select what is best, and above all what is sure and harmless, from the many suggestions offered, so as to build up a practical body of applied truth.
Under the head of Adjuvants and Disturbing Factors in the psychic treatment of patients come the various phases of life which make for and against such a favorable state of mind as predisposes to the continuance of good health, minimizes inhibition, and adds to favorable suggestion. By modifying the modes of life, an ever renewed set of suggestions is initiated. By definite instruction and advice with regard to exercise, position, training, habit, pain, occupation of mind and diversion of mind, patients may be profoundly influenced, and gradually made to take on an entirely new attitude of mind towards themselves. These chapters, then, while apparently much more concerned with physiotherapy than psychotherapy, are really directions for the use of such physical methods as by frequent repetition make the most valuable suggestions. There is probably nothing more valuable in the ordinary application of psychotherapy than these various auxiliaries, with their power to remove disturbing factors, while, on the other hand, nothing aids more in bringing relief for many conditions than the removal of certain disturbing factors.
There is now a general recognition of the fact that suggestion in the waking state can in most cases be as therapeutically efficient as hypnotism, and is probably even more enduring in its effects when successful, without the dangers and sequelae connected with hypnosis. Every idea tends to act itself out. When we crave something, when there are active ideas of desire, there usually are movements of our flexor muscles. These affect the hands especially. At moments of hatred, detestation or abhorrence our extensor muscles are affected, as if we would wave these things away from us. There may even be an involuntary turning of the trunk muscles, as if we would no longer face what is abhorrent, though the repulsive thing may be present only to the mind. It is not far-fetched to argue that, since the voluntary function of muscles is thus influenced, other functions are also touched by emotions, ideas, trains of thought, especially when the mind is much concentrated on them.
Bishop, the so-called mind-reader, whose exhibitions attracted much attention in London and New York some years ago, confessed that his feats were accomplished mainly through muscle reading. He would permit a committee to select a book in a library in a certain house, and even a particular page of {195} that book, and then, blindfolded, sitting with the committee in a carriage with his hand on the forehead and the arm of one of the committee, he would direct just where the carriage should be driven and would, while always continuing his contact with the member of the committee, go to the particular house and room, select the special book, and eventually find the page. There was no opportunity for collusion in some of these feats. The most startling things were often accomplished by the system of forcing a choice which prestidigitateurs use in order to compel the taking of the particular card by suggestion (though all the time they seemed to be leaving absolute liberty of selection to the person), but there was much, besides this, required to accomplish what he did. He said that there were always involuntary muscle movements, little starts and tremors that guided him in his work. Other exhibitors have been able to use this to a considerable extent, though not with Bishop's success. That our thoughts can be read in our muscle system is interesting and valuable confirmation of the unconscious tendency of ideas to affect the body.
When a single idea occupies the consciousness it will, some psychologists insist, necessarily act itself out unless some distracting thought prevents it. We know how difficult it is to stand at the edge of a height, say at the brink of a waterfall or on the cornice of a high building, or to look down a mine or elevator shaft, because the thought comes to us, how dreadful it would be to plunge over. As a consequence of this insistent idea taking possession of our consciousness, we have the sense of falling, we become tremulous and have to withdraw, or we would actually fall, or find in ourselves a tendency to throw ourselves over. There are persons who cannot even sit in the front row of a balcony because of the constant effort required to neutralize the suggestion that they may fall or throw themselves over its railing. Curious sensations become associated with this idea—a feeling of numbness and tingling in the back, sometimes a girdle feeling, sometimes a sense of suffocation. All of these are due to the concentration of attention on a single idea and its suggestions.
Very few men, shaving themselves with an old-fashioned razor, have not, at moments of worry and nervousness, sometimes had the thought of how easy it would be to end existence by drawing the edge of the razor through the important structures in the neck. Some are so affected by this thought that they have to give up shaving themselves. It is a surprise usually to find how otherwise sensible, according to all our ordinary standards, are the individuals who confess to having had annoyance from such thoughts. This illustrates how strongly suggestive the concentration of attention may make an idea, and how much a single idea, when it alone occupies the center of consciousness, tends to work itself out in act, though there is no reason at all for willing in that direction. It is not improbable that in some inexplicable cases of suicide the tendency has actually worked itself out.
The expression, "he is a man of one idea," enshrines in popular language the conclusion of psychologists that if a single idea is present in the mind it will surely work itself out. We all know how much men of one idea accomplish. All their powers, physical and mental, are brought to bear on its development. Obstacles that deter other men, conditions that prevent others from daring even to think of doing the thing, seem as nothing to the man {196} of one idea, and in spite of discouragement, and even apparent failure, he often succeeds, notwithstanding obstacles that seemed insurmountable. What is thus true in the practical world is paralleled, for both good and ill, in the microcosm of the human body. A man who has one idea to urge him on is capable of accomplishing things in spite of pains and aches and all sorts of disturbances of function. On the other hand, if the one idea is unfavorable, then, in spite of a heritage of good physical and mental powers, his efficiency is inhibited. If a man gets an idea that there is something the matter with any organ, and concentrates attention on it, he will surely disturb the function of that organ. Just the opposite, however, will happen in case, even with physical defect, he believes that there is nothing the matter, or only something that can be overcome. This is the power of faith as illustrated in the various forms of faith healing, from mental science to Eddyism and the rest.
This is the power that the physician must learn to use. In The Lancet for November, 1905, Dr. J. W. Springthorpe, writing on the "Position, Use and Abuse of Mental Therapeutics," said:
Few indeed are the medical practitioners who daily prescribe suggestion as well as diet, hygiene and drugs. Yet the physician who makes even a minimum effort in this direction often does more for his patient than his more highly qualified confrère, who makes none. To some, and they naturally the most successful, this endeavor comes without conscious search, and improves with experience, but in some measure it may be acquired by all and no one who has become familiar with its powers will henceforward be content to remain without its constant aid.
This power is thoroughly exploited by the irregular practitioner, and the regular practitioner is bound in duty to learn to use it just as thoroughly.
What is true for the lesser faculties is eminently true for our most important faculty, the intellect. We all know how intellectual training enables us to accomplish without difficulty what at first seemed almost impossible. Not only that, but we acquire the power to devote ourselves to a subject that was at first irksome, if not actually forbidding. There are educators who insist that this discipline of mind, by which the power to devote ourselves to what we do not care for is gained, is the principal fruit of genuine education. It has been lost, or at least impaired to a great degree, by educational experiments, especially those related to the elective system which pushed interest, instead of discipline, into the foreground of education. In the same way the power of self-control, and the faculty of self-denial, so precious to the human race, have been lessened by the methods of training which omitted the consideration of these and emphasized the idea of personal comfort. Much can be done to make the unpleasant things that are inevitable in life not only tolerable, but actually to give a satisfaction surpassing selfish pleasure. It is this discipline that is needed in psychotherapy at the present time and the physician must endeavor to encourage it by every means in his power.
The one purpose of the use of suggestion in therapeutics, then, is to secure as far as possible concentration of mind on a single idea. This is what is done in hypnosis, but frequently in such a way as to leave the idea {197} to work out unfavorably associated suggestions. If there could, in the conscious state, be the same absolute concentration of mind on an idea, a great force for good, without accompaniment of ill, would be secured. Experience has shown that with patient effort and definite methods such concentration of attention on a single idea can be secured, at least to such an extent as to make it efficiently therapeutic.
Ordinarily, suggestion accompanies the material remedies that the doctor prescribes. He must emphasize just when and how the medicine is to be taken, and it is well to emphasize the effects that are expected and just about how they will come. If he is prescribing a tonic, he does not merely say before meals. He specifies from ten to twenty minutes before meals, according as he wishes it taken, with a definite amount of water, stating that the taste of it will excite appetite and that only food in reasonably liberal quantities will satisfy the craving produced by it. If he is prescribing a laxative, he states just when it should be taken and when its effects may be expected. The arousing of expectancy does much to relax inhibition and to permit the flow of nervous impulses that may be helpful. If a sleeping potion is given, the patient is directed to compose himself for sleep immediately after it is taken, or to take it just a definite time before he gets into bed, and then to expect its action in the course of twenty minutes or a half hour, designating rather definitely just when it shall have its climax of effect. Two or three things done together, as, for instance, a gentle rubbing with cool water over the body to produce a glow, a warm foot-bath, and then a sleeping potion, will combine to produce a climax of physical and psychical effect.
In many conditions that come for treatment to the modern physician, the physical remedies are much less important than the psychical. This is particularly true for the affections known as psychoneuroses, in which some slight nervous disturbance is exaggerated into an extremely painful condition or a disturbing paralytic state; in the so-called hysteria of the older times; in the drug habits; in the sex habits; in the over-eating and under-eating habits, and then with regard to dreads and other psychic disturbances connected with dreams, premonitions and the like. In all these cases it is important to secure concentration of the patient's mind on a neutralizing suggestion. This must be done deliberately and in such a way as to secure thorough concentration of attention. It is often a time-taking process, but nearly everything worth while requires time, and the results justify the expenditure. Methods mean much in the attainment of this. They must be impressive, the patient must be convinced of the power of the physician to help him, and he must have trust in the efficacy of the mode of treatment.
The patient should be put into a comfortable position, preferably in a large, easy arm-chair, should be asked to compose himself in such a way as to bring about thorough relaxation of muscles, and then to give his whole attention to the subjects in hand. Occasionally the arms should be lifted and allowed to fall, to see whether relaxation is complete, and the knee jerks may be tested, to show the patient that he is not yet allowing himself fully to relax. There should be no lines in the face: the muscles around the mouth, and especially those in the forehead, should relax. It is surprising how {198} much can be done, sometimes by slight touches on the forehead, to secure this. The patient should then be made to feel that the tension in which he has been holding himself, and which makes it so difficult for him to relax, has really been consuming energy that he can use to overcome the tendencies to sensory or motor disturbance, or to supply the lack of will which makes him a victim of a drug or other habit, or takes away from him that mental control that would enable him to at once throw off dreads and doubts and questionings and bothersome premonitions which now, because of the short circuiting on himself through worry and nervousness, he cannot do.
Two or three séances usually show a patient how much better control over himself even a short period of relaxation will give. He comes out of a ten-minute session of relaxation, during which he has been talked to quietly, soothingly, encouragingly, with a new sense of power. Often he feels that there will be no difficulty in overcoming his habit. This may pass, of course, but he has received a new idea of his own resources of energy and self-control.
In most cases it is well, after securing relaxation, to ask the patient to close his eyes gently and to keep them closed till all his muscles are relaxed. Then suggestions may be made to him with regard to his power to control cravings, and to put away doubts and questionings, because, after all, as he sees them himself, they are quite irrational and entirely due to habitual tendencies that he has allowed to grow on him. A concentration of attention on the idea, not only of conquering but of being able to conquer, will be secured. Unless this complete attention can be had, suggestion in the waking state may not prove efficient. There are nervous, excitable people for whom, at the beginning, it will be quite impossible to secure such relaxation and peaceful quiet as will be helpful to them. For these a number of séances may be necessary, but on each occasion a little more of quieting influence is secured.
In recent years, this quiet, peaceful condition, with eyes closed, thorough relaxation and absolute attention, has sometimes been spoken of as the hypnoidal state. If it be recalled that hypnos in Greek means sleep, and that this is a state resembling sleep with the restfulness that sleep gives, the term is valuable in its suggestions. If, however, the word is connected with hypnotism, then there may be an unfortunate connotation. This state is entirely free from the dangers of hypnotism, and instead of making a patient dependent on his physician, teaches him to depend on his own will. It is not a new invention as this term hypnoidal might seem to indicate, but is as old as our history at least.
In recent years a great change has come over the popular mind regarding exercise, especially in the open air. It is well to emphasize at the very beginning the subject of too much exercise, because there is no doubt in the minds of many who study the question, that many Americans, and indeed people of the northern nations generally, take a certain amount of voluntary {199} exercise that is not good for them, though they take it at the cost of considerable effort and sacrifice of time and are firmly persuaded that it is of great benefit.
Sufficient Exercise.—There is a much larger number of persons who do not take sufficient exercise. The amount to be taken is eminently an individual matter. Neurotic patients exaggerate everything in either direction, so that perhaps the state of affairs that exists is not so surprising as it might otherwise seem. Instead of the uncertainty that prompts now to too much exercise, and again to too little, for health's sake there must, as far as possible, be a definite settlement of the needs.
National Customs.—There is a curious difference in the attitude of mind of the various nations towards exercise. Most of the southern nations of Europe do not as a rule take any violent exercise. As is well known, however, they are not for this reason any less healthy than their northern contemporaries, though perhaps they are less strong and muscular. But muscularity and health are not convertible terms, though many people seem to think they are. An excess of any tissue is not good. Our economy should be taxed to maintain only what is useful to it. Nature evidently intended, in cold climates at least, that men should maintain a certain blanket of fat to help them retain their natural heat, but any excess of fat lessens their resistive vitality by lowering oxidation processes. Fat in cold climates can be used to advantage as a retainer of heat. In the warmer climate it would be a decided disadvantage. Muscular tissue is a manufacturer of heat and this is a decided advantage in the colder climates, but in the temperate zone, where the summers are very warm, muscle in over-abundance, unless its energy is consumed by actual physical exercise, may be quite as much of a burden as fat. Muscular people do not stand heat well. They demand exercise to keep muscle energy from being converted into heat, and they require frequent cold baths, and other forms of heat dissipation, in order to be reasonably comfortable.
Exercise in Early Years.—The question of the amount of exercise that is to be taken must be decided at an early age for individuals. Most of the young people of the Celtic and Anglo-Saxon races are tempted by traditions and by social usage to develop considerable muscle during their growing years. In this respect, the difference between the German and the English schoolboy is very striking. The English schoolboy is likely to be as "hard as nails," as the expression is, as a consequence of violent exercise in his various sports, taken often to the uttermost limit of fatigue. The German schoolboy has his walk to and from school, and some other simple methodical exercises, with some mild amusements that make little demand on muscle, but of games in the open he has very few, and of the violent sports he has none at all. A comparison of the health of the two nations will not show that the English boy, who receives a public school and a university education, with all their temptations to exercise, enjoys any better health, and, above all, reaches an average longer life than the German youth, who has gone through a similar educational career in his own country, but without the athletic training that the English schoolboy has had.
As a consequence of the absence of athletics and its diverting interest, the German is apt to have learned more than his English colleague, but a {200} comparison of mortality and morbidity tables would show that his resistive vitality, his power to overcome disease and recover from accident is not lower than that of his colleague from across the North Sea. The German is less strong muscularly, and in a contest of physical effort would as a rule come out second best, but then we have gotten beyond the period when it is important for a man to be able to defend himself by physical force, except in emergencies that may never come. Surely the English time and effort devoted to athletics is not justified by this.
Preparation for a Sedentary Life.—Certainly if a young man is going to live a sedentary life in his after years, it does not seem advisable for him deliberately to devote much time to muscular exercise during his growing years. This only provides him with a set of muscles for which he has no use. Ordinarily it is assumed that muscles are organs for the single purpose of evolving energy. This is not true, since they are important organs for the disposition of certain food materials and for the manufacture of heat for the body. Nature in her economy probably never makes an organ for one function alone, but usually arranges so that each set of organs accomplishes two or three functions, thus saving space and utilizing nutrition to the full. The man with a well-developed muscular system, which he is not using, will have to feed it, and besides will have constantly to exert a controlling power over the heat that it manufactures whenever it is not dissipated by actual exercise. For these reasons he will be constantly nagged by it into taking more exercise than his occupation in life demands, and if he does not do this, his developed musculature is likely to deteriorate so as to be a serious impediment, or to degenerate by fatty metamorphosis into a lower order of tissue that is a clog and not a help to life.
The Germans are more sensible. As students, they live quite sedentary lives, develop their muscles just enough to keep them in reasonably good health, and then, when it comes to living an indoor life, as will be almost inevitable in their chosen professions or occupations, they do not meet with the difficulties that confront the Anglo-Saxon with his burdensome, over-developed muscular system. German professors, as a class, do not find themselves under the necessity of taking systematic daily exercise. They are quite content and quite healthy with an hour or two of sitting in the open air, and a quiet walk from the home to the university or the school. With the ideas that some people have with regard to the value of exercise for health, it might be expected that the German professors would be less healthy than their Anglo-Saxon colleagues. This is notoriously untrue, for the Germans live longer lives on the average, and most of them accomplish much more, and above all are much more content in the accomplishment, than their physically strenuous Anglo-Saxon colleagues. They are not oppressed by the demands of a muscular system that insists on having its functions exercised, since it has been called into being in the formative period. These German professors live to a magnificent old age, requiring very little sleep and often doing a really enormous amount of work. The man with a developed muscular system generally requires prolonged sleep, particularly after exercise, but even without it very seldom is it possible for him to do with less than seven hours, while the Germans often are content and healthy with five hours, or less.