THE PRACTICAL OSES OF SUGGESTIVE THERAPEUTICS. Read in the Section on Materia Medica, Pharmacy and Therapeutics, at the Forty-seventh Annual Meeting of the American Medical Associa- tion, at Atlanta, Ga., May 5-8,1896. BY WILLIAM LEE HOWARD, M.D. BALTIMORE, MD. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, ' JULY 18, 1896. CHICAGO: American Medical Association Press. 1896. THE PRACTICAL USES OF SUGGESTIVE THERAPEUTICS, Read in the Section on Materia Medica, Pharmacy and Therapeutics, at the Forty-seventh Annual Meeting of the American Medical Associa- tion, at Atlanta. Ga., May 5-8,1896. BY WILLIAM LEE HOWARD, M.D. BALTIMORE, MD. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL JULY 18, 1896. CHICAGO ,* American Medical Association Press. 1896. THE PRACTICAL USES OF SUGGESTIVE THERAPEUTICS. I conceive it to be your desire to have a plain state- ment of the uses and limitations of suggestion, and I shall confine myself to this conception. To those of you who desire a more comprehensive statement of the psychologic side of the subject I refer to my paper read last year before the Neurologic Section of this Association.1 In this paper I shall avoid as much as possible the misnomer hypnotism, as we shall see later on that often curative effects of sugges- tion are produced without inducing hypnosis. To anyone familiar with modern pathology the limita- tions of the therapeutic uses of suggestion will be readily understood. To those familiar with the trend of modern psychology its application for harmful effects will be fully appreciated. In treating patients by suggestion it is necessary to remember one funda- mental factor, i.e., the subjective state of the patients. Without this latter condition you will seldom succeed in effecting your object. Without doubt the reputa- tion and success of most physicians is due to sugges- tion, often unconsciously made. The great factor in the large number of cases reported by Bernheim is due to the explicit confidence in him by his patients. We all know what a difference it makes in our suc- cessful treatment of patients when they have unbounded confidence in us; how soon they will respond to our suggestion; where, with a stranger, or one in whom they have little faith, treatment has apparently but slight effect. The same medicine given the patients by the physician with whom they i Hypnotism, its Uses, Abuses and Medico legal Relations. Jour. Am. Med. Asso., Nov. 30, 1895. 4 are en rapport will have a far greater effect than if given by a stranger, provided that the former makes some simple but forcible suggestions regarding the effect of such medicine. When we start at the funda- mental facts of suggestion it all appears very simple. To illustrate the force of suggestion I will give you a simple example. Let A., B. and C. agree to meet D. at different times and places during the day. Let them be men in whom he has confidence. On his way down to his office D. meets A.; A. exclaims: “Look here, D., what’s the matter with you? You look very ill.” etc. This suggestion acts with sufficient force to cause D. to drop in to a public place and consult a mirror. He soon sees that his face is pale and begins to feel weak. He throws off the idea for a while, but it will return to him at intervals. He then meets B. whose suggestions are more forcibly made; and after- ward the third party. By this time, D. is in reality psychically ill, goes to his home and sends for his physician, who will find a rapid pulse and a generally disturbed condition. This is a fact that I have often demonstrated. Now, suggestion can act reversely. Hypnotism in all its stages is now an undisputed fact. Suggestion is a justifiable method in certain cases. In those obstinate and disagreeable cases of hysteria in all its forms; in insomnia, drug habit, and immoral practices which so often disrupt once happy homes, we here have a therapeutic remedy; and any physician, who, after he has made a correct diagnosis and failed to cure after using all his other resources, refuses to use suggestion either with, or without the aid of hypnosis, is not giving his patient that care and attention that he has a right to expect. Unfortunately, through the daily press the subject has been placed in such a light as to have caused its beneficial factors to have been forgotten, and the older practitioner, with little or no knowledge of modern physiologic psychology, has looked askance at the sub- ject. About this branch of medicine there has been foo much haste, inaccuracy, fallacious reasoning, con- 5 fused or contradictory ideas by a large number of our profession. I will now give you the practical side of the subject, leaving speculation and theory strictly alone. If I appear dogmatic it is only because I quote the reports of the most eminent and reputable men of science; and have not gone beyond the deductions derived from experience. I shall give you only the digest of the subject as reported the last twelve months. The practical uses of suggestion are numerous. In certain forms of functional disturbances cures can be effected. The pains that often accompany organic diseases can be abolished. While suggestion will have no effect on organic disturbances per se, the relief of the accompanying pain is of vast importance, as it gives comfort and rest to the patient. The sensation of pain takes place in the cerebral cortex; it is a men- tal condition, it implies consciousness and hence, by an alteration in our state of consciousness as is induced by suggestion, pain can be abolished. Several cases have been reported of the cure of organic diseases of the cord. It is only necessary to say that either the observers were mistaken in the diagnosis, or allowed their enthusiasm to warp their judgment. The inter- nal capsule, the thalamus, the motor convolutions, the sensory tracts in the cord once destroyed are not to be restored by any form of interference. It would appear at first thought that any such self-evident fact men- tionedMiere was superfluous; but from the large num- ber of letters I receive from the profession I judge that this matter is not always understood. I find, however, that I can greatly relieve a patient suffering from organic disease. The removal of anxiety, the implantation of new ideas, the removal of the habit of introspection, are oftentimes the means of breaking those vicious circles so common in the pathologic states, and removing the unpleasant psy- chic accompaniments. In my experience, insomnia offers the practitioner his best field for the treatment by suggestion. We can here see how it acts as a cur- 6 ative agent in so many functional disturbances. I generally see the patient at my office several times before attempting to produce hypnosis. After I have gained the confidence of the patient, and am satisfied as to the functional cause of the insomnia, I begin to suggest sleep. The symptoms of sleep are readily called up, they are familiar and natural, and therefore, a patient without possessing very great confidence in the operator can, without much difficulty, be made to believe that sleep has come upon him. This much gained, the patient’s confidence in your powers are secured, and the field is ready for you to plant such suggestions as the conditions call for.2 Having your patient go to bed at the usual hour, you continually but forcibly suggest sleep. If you have suc- ceeded in your tentative efforts you will be surprised to see how readily the patient will respond to your sugges- tions. Then I suggest how long she shall sleep, and that she will awaken refreshed and hungry. Be sure you tell her to sleep until a certain hour, for a subject under your perfect control will not always awaken unless the operator tells her to do so. One of my earlier experi- ences will illustrate. I was called to treat Mrs. M. who had been suffering from insomnia for several months. She responded to suggestions readily, and soon was in a state of hypnosis. About 9 o’clock the next morning there was a f urious ringing of my door bell, an excited woman rushed in and said I had killed Mrs. M. Her family and friends had been trying for two hours to arouse her. Going immediately to the house I found family, physician and neighbors with their suggestions all there. Every method known to layman and doctor had been tried, but it was impos- sible to arouse Mrs. M. Going up to her I said firmly: “ You must wake up now, Mrs. M.; wake up, wake up!” She opened her eyes and soon arose. It was her first good sleep for eight months, and the last time I ever forgot to suggest the duration of sleep to a patient. 2 See Dr. Schofield’s Lectures, Victoria Institute, London, 1806, “ Relation of Mind and Body, or the Powers of Unconscious Mind.” 7 The suggestive sleep by the Nancy method is harm- less, and as far as my experience goes is a normal sleep produced by suggestion. The harm that comes from such a condition is due entirely to the purport of the suggestion made while in this receptive condi- tion ; evil suggestion can be given and will, to a cer- tain extent, be accepted, as well as good.3 4 Hence, we can see the importance of regulating the practice so that it can only be used by reputable and skillful men. Next to insomnia suggestion is most useful in hysteric seizures. In those troublesome hysteric contractures of the extremities, suggestion during hypnosis seldom fails to give relief. Care must be taken, however, not to attempt to correct contractures of long standing, for as Charcot has said, when con- tracture has long existed, it becomes incurable. Hys- teric amaurosis is readily relieved by suggestion dur- ing hypnosis. This is readily understood when we realize that hysteric amaurosis is not a systematic paralysis but a purely psychic amaurosis; a neutral- ization of the object perceived by the imagination. Dr. Hugh Patrick reported to this Association at its last meeting at Baltimore a case of hysteric blindness and pseudo-meningitis cured by suggestion.5 The long and tedious list of the different phases, types and isomorphic forms of hysteria are all more or less amenable to treatment by suggestion. Cephalalgia, intellectual obnubliation, pseudo-hemi- and paraple- gias are conditions that are benefited by suggestion. It is not always that the hysteria itself can be cured, but the symptoms can be removed.6 7 The treatment of dipsomania by suggestion is now being quite extensively used. At the present time we are not in the position to make any dogmatic statement regard- ing its certainty as a remedial agent. I have had 3, * See Tukey, Brit. Med. Jour. 1890, Vol. 12, 442-444. William Lee Howard, N. Y., Med. Jour., March 9, 1895, 298-800. 5 Jour. Am. Med. Asso., Feb. 8, 1896. 6 Claus. A. et F. Jacobs. Un cas chez uue fillette de huit ans; gu6rison par suggestion. Ann. Soc. de M6d. d’ Anvers. 1896. i Kochs; Phtmomenes hypnotiques ehez une hyst6rique. Allgem. Zeitsch. f. Psychiatrie, 1.1. fasc. 5, 1894. 8 excellent results with cases that have tried about every other known treatment. The fact that you can abol- ish the nervous insomnia, eliminate the anorexia, and stop the tremors and other concomitants following an alcoholic debauch, is sufficient evidence to cause one to treat these cases by suggestion. With these functional disturbances controlled I use continued suggestion regarding the use of alcohol while the pa- tient is in a state of hypnosis. The result has been very gratifying. Bushnell, Surg. U. S. A., says: “I have never failed to hypnotize a patient who sought treatment for alcoholism.”8 Dr. Am. De Jong reports very good results by this method of treatment during the last two years.9 Crothers 10 advises its employment whenever possible, and says: “ Clinical experience furnishes many facts which seem to prove that in certain cases its value is very marked, also promising from more exact studies greater results. ” Dill11 gives a list of eight cases of dipsomnia treated successfully by sug- gestion. Green12 gives a case of a man addicted to the abuse of alcohol, bromids and chloral cured by four hypnotizations. What I have said concerning the alcohol habit refers also to the drug habits. Sexual perversion as a disease has been but little studied in this country; but experience has proven to me that it is quite prevalent here. Suggestion is the only method of treatment so far known that has any effect on these cases. I refer to the acquired condi- tion, not the congenital; the latter in my hands has never been benefited. Masturbation in both sexes is generally well controlled by suggestion. It would be a work of surplusage to enter into details upon this subject when we have such classic works as those of Kraft-Ebing, Schrenck-Notzing, Moll, Ellis and many 8 Med. News, Phila., 1894, xiv, 837-343. 9 Inebriety and its Treatment by Hypnotism. 10 Jour. Am. Med. Asso., Nov. 30, 1895. 11 Dipsomania and Hypnotism, by John Gordon Dill, M.A., M.D., Quart. Jour , Inebriety, October, 1895. 12 C. Theo. Green, M.R.C.S., L.R.G.P.. Quart. Jour., Inebriety, Octo- ber, 1895. 9 others.14 Hypnotism will never supplant, in its pres- ent status, the existing anesthetics. Local and com- plete anesthesia can be produced by suggestion, but it is not available in an emergency case, unless the patient happens to be one in whom we have at prior times produced complete anesthesia by this method. In minor operations when the time for operation can be extended for a few days we can attempt to get our patient into that state of receptivity that will allow of producing a suggestive anesthesia. This can be sel- dom accomplished at the first attempt. When this anesthesia can be produced it is far superior to our present anesthetics; being devoid of any danger. Up to the present time we have had but one reported authentic case of death from suggestion, and that death was due to the purport of the suggestion, so forcibly made as to bring about the very result that was suggested, i.e.. death.15 A case was reported last year from Paris as a death due to hypnotism. Prof. Bernheim gives the following explanation. “ A man aged 37 years whom he had hypnotized to relieve the pain due to phlebitis of the leg, and whose death fol- lowed two hours afterward, was only an unfortunate coincident; as the postmortem showed death to be due to embolism of the pulmonary artery.”16 I have often operated in minor cases after putting the patient in a state of suggestive anesthesia. A large number of authentic cases have been reported. Wagner17 gives twenty-one cases of minor surgical operations done under suggestive anesthesia, and three obstetric cases. Major operations have also been done under the same conditions. It is very useful in obstetric cases. Here to be of any value you must have frequently hypnotized your patient, and have become certain that ii Psychopathia Sexualis von Kraft-Ebing; Suggestive Therapeutics in Psycho natkia Sexualis, von Schrenck-Notzing. Sexual Perversion, Albert Moll; Sexual Perversion, William Lee Howard, Alienist and Neu- rologist, January, 1896. A Case of Heredity. W. L. Howard, Md. Med. Jour., April 26, 1896. is See Author’s paper in Jour. Am. Med. Asso., Nov, 30, 1895, 16 Revue M6dicale de l’Est., Feb. 1, 1895. ii N. Y. Med. Jour., xlix. 10 she will respond to your suggestions at any time. The advantages of suggestion in parturition are the removal of consciousness of pain, regulation of posi- tion of limbs, body and attitude, and increase of uter- ine contraction of voluntary muscles. In dentistry, for the extraction of teeth, it is a most satisfactory method of painlessly operating. What percentage of persons can be controlled by suggestion? Authorities differ. The resuh will depend upon the individual operator, as in any other branch of medicine and surgery. A conservative estimate would be about 25 per cent. I succeed in about 30 per cent. What class of patients is most susceptible to suggestion? Phthisical patients; children between the ages of 5 and 15 years of age; those of a neurotic temperament; last and most difficult is the hypochon- driac and the melancholic. The insane, imbecile and idiots seldom, if ever, respond to suggestion in any form. A. certain class of normal intellect can not be controlled by suggestion. To use a hibernianism, they will insist on keeping awake to see how you will put them to sleep. What are the requirements to be successful in using suggestion? The tact, judgment, diagnostic ability and confidence in one’s self and all that makes the successful physician. Suggestive ther- apeutics is no “ royal road” to success. It involves the same application, severe attention and experience that is necessary in all branches of medicine and surgery. Until you have had some experience you will not have that full confidence that is necessary to impress your patient. There is no such thing as “ will power,” “ animal magnetism,” or any other so-called occult force employed. Get your patient in a state of men- tal receptivity by having him look at some small bright object distant about six inches from the pupils and a little above them. When the eyelids begin to close, or a fibrillary motion commences, close them gently, and in a low but emphatic tone of voice sug- gest sleep. Once in this state the therapeutic sugges- tion should be made. In a large number of cases it 11 is not necessary to produce complete hypnosis to get satisfactory therapeutic results. If the patient is only in a state of lucid lethargy he will often accept a suggestion with good results. A new idea of the explanation of the phenomena of hypnotism has just appeared.18 This is no place for psychologic discussion or polemics, but as this idea has only been put before the profession the last few days I will call your atten- tion to it. Dr. Henry Stark of Boston says: “ Hyp- notism is a pathologic process depending for its origin on contagium, probably specific in character, although unrecognizable by any of the five senses.” Suggestion as a therapeutic method of treatment is oidy an adjuvant, often a powerful one, to go hand in hand with other rational means of hygienic and med- icinal treatment, and is not to be understood as by any means being a certain cure for all ills and complaints that man is heir to. It is not a catholicon, a philos- opher's stone, as many enthusiasts would have us believe. Psycho-physiology10 has placed suggestion on a sound scientific basis, and those who step from this basis and make claims that have no psychologic foun- dation, are those seized with the vertigo of the super- natural and condescend to serve as vouchers for the most absurd aberrations. is Psychic Iafection; Remarks upon the Probability of a Mental Contagium. N. Y. Med. Record, April 18, 1896. 11 Crocq fils:L' liypnotisme Scientifique. Rapport a M. le ministre de l’Interieur, a de i’iustruction Publique. Introduction de M. le Prof. Pitres, 1896.