In spite of the important fields of application of hypnotic therapy above indicated, the principal application of hypnosis remains in the field of neurosis. To be sure, it should never be forgotten, as has been repeatedly emphasized, that hypnosis is only a technical auxiliary device in the treatment and is not a complete treatment. The general principles of the treatment of neuroses should not be lost sight of, either, in hypnotic therapy. One of the most important principles is that the patient must always be forced to act against the neurotic symptom. Thus, it is necessary to force the anxiety neurotic into the situation which is productive of anxiety for him. For instance, if there is difficulty in swallowing, the patient must be obliged to partake of precisely that food which causes such difficulties in swallowing, etc. It is almost always erroneous to avoid facing the symptom. Of course, it will not be possible to begin the use of compulsion against the symptom, as a rule, until a certain attachment to the physician has already been attained. Even in psychoanalytic treatments, the principle of active therapy requires a forcing of the patient into the anxiety-arousing situation. The psychoanalyst knows that profoundly buried repressed material will then come to light, which must thereupon be dissolved by analysis. But even in a nonanalytic "active" therapy, the same repressed material will not become tangible to the grasp of the psychotherapeutist until such treatment is begun. Even during a hypnotic treatment, the patient will under certain circumstances have to be removed from his customary environment, although we are of the view that as a rule the importance of a removal from the milieu is overestimated. In our discussion of the various specific neurotic disturbances, we are not classifying them from the point of view of a scientific system, but are rather considering their distribution according to practical requirements.

1. Actual neuroses. By actual neuroses, Freud means those neuroses which proceed from a direct sexual injury. Their chief characteristic is fear. We may even speak of acute fear neuroses. Even though lack of sexual satisfaction, conditioned by abstinence or by some unsatisfactory forms of sexual intercourse, whether it be coitus interruptus, condomatus, etc., which occupies the foreground, lack of physical satisfaction is not the sole dominant factor. Lack of physical satisfaction will have a pathological effect only if psychic factors are added. The essential point is psycho-sexual-nonsatisfaction, which may to be sure be supported by a physical aspect. This point of view is of great therapeutic importance, since the lack of physical satisfaction, on the one hand, cannot always, for external reasons, be altered, while on the other hand, the attainment of physical satisfaction will not abolish the neurosis unless such attainment has been psychically prepared and thus leads also to psychic satisfaction. Certainly the physician is by no means called upon to drive persons who live in a state of sexual restraint, against their conviction, into the many dangers of extraconjugal sexual intercourse, even disregarding the fact that such relations are for many persons unattainable in a satisfactory form, without further preparation. Even the relinquishing of precautionary measures in conjugal intercourse is very frequently impossible for a number of reasons. On the other hand, it is the physician's duty in all acute conditions of fear, to investigate thoroughly the sexual life of the patients and to discuss it with them. The giving of information, the holding of consultations, are very effective even in cases where the external form of the sexual activity is not altered. No doubt sexual injuries may in some cases be easily removed. We have frequently made the observation that married men do not pay sufficient attention to the sexual satisfaction of their wives, even when potency is adequate, which may be a cause for nervous disturbances. Appropriate instruction must be given here. In general, and particularly in such fear conditions, the constant effort must be to impart to the patient a greater inner freedom on the subject of his own sexuality. Hypnosis in such fear conditions is for the most part merely superficial. But even this superficial hypnosis is quite sufficient and precisely in such cases excellent results may often be obtained if our remaining principles of hypnotic treatment are observed, wherefore hypnosis is the indicated treatment for such cases. This is of course true only of acute cases. If the entire condition is of long duration the treatment will be more difficult, and in the case of pronounced phobia, such as bridge fear, fear of walking, etc., success may not be expected immediately.

2. Phobias. In this case again it will be necessary to operate with superficial hypnosis and success will be scored if the psychic aggregate be borne in mind, yet in the case of serious situations of long standing, psychoanalysis is the method indicated in advance. Only in exceptional cases will it be possible to apply hypnotic treatment to the severe forms. The patient must be forced again and again into the terrifying situation. If the superficial hypnosis does not suffice, it is justifiable to admit narcotic hypnosis. These principles apply to fear of walking and fear of bridges and other disturbances, as well as the fear of blushing, etc.

3. In compulsion neuroses, psychoanalysis wherever feasible under external circumstances, is the indicated method. Success is attained by hypnotic treatment only in very mild cases, and this success is not always permanent. Comparatively favorable for hypnotic treatment are those nonchronic cases of neurosis in which the compulsion neurosis appears in the form of a single symptom, more or less isolated from the remaining psychic contents, and without any pronounced presence of the total picture of compulsive neurotic traits. In a number of such cases of compulsion neurosis in female patients, in whom the absent sexual intercourse had been replaced by the substitute—corresponding to the fundamental sadistic character of the compulsion neurosis—for their inhibited sexual desire of a tendency, manifesting itself as a compulsion, to choke persons in their environment,—we have applied hypnotic treatment with good results and with cures of long duration. Here also, of course, a discussion of the symptoms, according to the regular analytic practice, a retracing of the symptoms to the displaced sexual adjustment, must precede the treatment.

4. Occupational neuroses and tic. For the treatment of tic it is desirable first to recall the method of Brissaud, Meige and Feindel. This method consists in telling the patient to learn to suppress his tic before the mirror. First he is made to suppress the tic before the mirror for a short period only. Such exercises are carried out several times a day and it must be insisted that they be performed successfully, at first only in the short period prescribed.

The period of suppression of the tic before the mirror is thereupon systematically increased. It is particularly important, in this connection, to have the twitching area touched by the fingers of the tiqueur. Only this stimulus to the senses makes possible a perfect concentration of attention on the twitching region. In many mild cases this method is sufficient. In more serious cases hypnosis is the royal remedy; profound hypnosis is absolutely required; particularly effective is narcotic hypnosis. It is desirable to have the tiqueur sleep long and soundly right after the hypnosis, whether it be a narcotic hypnosis or a hypnosis without narcotics. Even in cases which can be reduced to profound hypnosis without the use of narcotics we occasionally employ the latter in order to strengthen the sleep effect. The treatment must of course be continued for some time. Kauders has recorded great improvements even in the tics of post-encephalitics,(*) and temporarily complete cures. We have already stated that in the treatment of organic and neurotic tics, a hypnotic long sleep treatment (combination of hypnosis supported by occasional administering of small doses of narcotics), often permitted to continue for several days, gives good results. A few general remarks are now in place. The view is of course now accepted that the border line between psychogenic and organic Tics is hard to draw (compare on this point Gerstmann and Schilder), and we are justified in assuming a relation between the psychogenic tics (**) and the striopallidal system. The latter appears quite susceptible to psychic approaches. The question therefore arises whether other striopallidal systems may not also be hypnotically susceptible. Thus Reinhold has influenced hypnotically the micrography of post-encephalitic Parkinsonisms, and it is well known that akinesias are also easily influenced by the psychic method. Unfortunately, however, the effect of the psychic treatment in such cases is of but short duration. Obviously the psychic influence is not able to combat the organic disturbance for long. In a case of hypnotic treatment of a post-encephalitic tic observed by Kauders, the complicated tic of the facial muscles first resolved itself into a simple blepharospasm, which finally gave way to a complete cure after further treatment. In a relapse of the tic, only the blepharospasm returned, and even the latter quickly yielded to hypnosis, but never more than temporarily. At any rate, these observations at least suggest that even organic symptoms may be influenced in hypnosis, and that the accessibility to influence in hypnosis may not always be made use of in setting up a differential diagnosis between a functional and an organic disturbance.

(*) Many cases of tic and myoclonic contraction of voluntary muscles, during the encephalitic epidemics, were relieved of these affections by hypnotic suggestion.—Trans.

(**) An unusually severe case of generalized tic in girl of nineteen treated a number of years ago with relaxation exercises and mild hypnosis, was so well affected by the treatment that she was subsequently able to perform in an act on the vaudeville stage and earn a very substantial salary. The tic, however, continued as before immediately after leaving the stage.—Trans.

Vocational neuroses may be treated according to the same principles that apply to tics. Of course, in the case of writer's cramp we are dealing with a very stubborn complaint, whose successful treatment by means of hypnotic therapy may not be; predicated with certainty in advance.

5. Stammering is probably to be regarded as belonging, on the whole, to the same category as the tics. Of course, hysterical stammerers must be regarded as a separate class. The latter are easy to influence, while the cases with the typical serious phenomenon of stammering are after all more serious. The phenomena here extend at least in part beyond the striopallidary system. Kronfeld prefers hypnotic therapy to drill exercises. Our own experiences on this point, which are not very numerous, have not been so favorable.

6. Hysteria in all its phases is one of the most grateful objects of hypnotic therapy. This is true in the first place of crude motor phenomena whether they be paralysis, astasia, abasia, mutism, aphonia,(*) hysterical contractures. Also, stimulus phenomena such as trembling, convulsions, are usually easy to influence hypnotically. It may perhaps be proper to remark that the general run of war hysterias and traumatic hysterias are as a rule quite primitive and accordingly easily treated with success. But we may not evolve a theory of hysteria in general from these experiences, as has often been done, and make a stereotyped outline for therapeutic procedure. Precisely in the treatment of hysteria it is particularly important to occupy oneself closely with the psychic life of the patients, in the sense described above, and to obtain at least a superficial understanding of the psychic structure of the symptom. Precisely here it is very necessary to demand that the therapy be thoroughly individualized. If the physician will observe the guiding lines laid down in our general therapeutic section, he may count not only on excellent temporary successes, but on good permanent cures. A profound hypnosis is by no means necessary for the treatment of hysteria, and it is also not desirable that the profound hypnosis be forced. We have records of cases of hysteria treated in accordance with these principles which have not shown relapses in spite of unfavorable external circumstances. It is self-evident that even in the hypnotic treatment of astasia-abasia, exercises and encouragement must be constantly applied. In difficulties in swallowing, even in such as are combined with cardiospasm,(*) the patient must be obliged to swallow during hypnosis. Once the first success has been attained, improvement will usually proceed rapidly. The procedure with hysterical vomiting is similar. Patients with attacks of hysteria must not only always be forced into the anxiety arousing situation, but must be made to pass through the situation producing this emotion again and again in hypnosis, a procedure which we have also found very useful in other psychogenic disturbances. As we make use of hypnosis for securing modifications in the character, we do not depend entirely on suggestions, which the patient has amnesized, and we consider a treatment, in general, to be terminated only when all the amnesic lacunae have been filled. We rigidly avoid permitting any sections of the treatment to remain amnesic.

(*)Aphonias are frequently not recognized as of hysterical character and are often severely treated when a mere suggestion or mild hypnosis might instantaneously cure the patient. Recently a physician was so treated by me with immediate recovery of his voice.—Trans.

During a pathological state, hypnosis is frequently hard to obtain. Sometimes it is possible to cut short pathological states by means of hypnosis. In general, there is no objection to a hypnotic treatment of hysterias with exceptional states. Cases with serious alterations in the character should be treated from the very start by means of the regular technique of analysis. In general, we have had fewer successful results from the use of the cathartic method than from the method of direct influencing.

There are cases in which hypnotic therapy fails and in which psychoanalysis also is not feasible without further effort. These are predominantly cases in which serious paralyses have long been present. Here either violent exercise or the Faradic current will be of assistance. In such treatments, to be sure, we apply pain rather in the form of a threat than as an actual application of pain. We permit the latter to operate for a short time only, promising improvement, make the patient exercise at once, and add the remark that if improvement does not result upon this exercise, a further application of pain will be necessary. We do not by any means attempt to force a disappearance of the symptom in a single session, but very frequently administer suggestions referring to the following day, hoping that a favorable further manipulation of this suggestion will take place during sleep. This slight modification is occasionally of value also in the case of suggestion given in hypnosis. Once the symptom has been made to disappear in this somewhat high-handed manner, a rational psychotherapy, the attempt to remold the character, must be applied in full strength. Of course, this method can be used only in the case of crude, externally visible symptoms. Stubborn-organ neurotic symptoms based on hysterical conditions are not so easy to remove, as Kronfeld also points out.

(*) Two cases of esophageal stricture of hysterical character in a man and a woman respectively, were only temporarily relieved by superficial hypnosis but their nutrition was decidedly enhanced during the period of treatment.—Trans.

7. Hypnosis is as a rule of slight value for purposes of altering and influencing the character. It might at most serve as a transition to the first suggestions, and must not last too long. Here it is necessary to apply psychoanalysis or Adler's " individual psychology." In thus recognizing the practical utility of the " individual psychology " in a number of cases, we are for the present pronouncing no judgment on the content of truth in Adler's doctrine. We cannot investigate this problem here. The above remarks are also equivalent to a statement to the effect that hypnosis may very rarely be applied for pedagogical purposes. Here again, it is very important to secure a swift solution of the attachment to the hypnotizer and to suggest in such manner that the suggestion will not localize externally, but will be woven organically into the general personality.

It is often required of the hypnotizer that he liberate persons from their love-passion, etc. Such an attempt may be justified in advance only on the express desire of the person concerned. But in general it is necessary to guard against any crude interference with the psychic life of the hypnotized. Here again it will be necessary to study the individual psychic life of the person concerned, to seek to uncover the connections of excessive fixation to a person, and very frequently hypnosis as such will turn out to be superfluous. Let us again emphasize the fact that hypnosis remains always a technical auxiliary device of psychotherapy, an auxiliary device of convenient and effective application, but one capable of replacement in many cases by other technical auxiliary devices.

8. Morbid addiction. Forel reports favorable results from hypnosis in the case of alcoholism. So does Haupt. We have had no such experiences. In general, we consider it desirable to secure a liberation from alcoholism by means of external remedies.

We do not consider the attempt to withhold morphine from morphine addicts or cocaine from cocaine addicts by hypnosis alone to be very promising, though it may be successful in individual cases. In general, we consider it necessary to intern the morphine and cocaine addicts for breaking their habit; without attempting an exhaustive treatment of the subject we recommend that the morphine be not withheld suddenly, but in the course of five or six days. Should dangerous symptoms appear, the breaking of the habit must be further retarded. Large doses of veronal during the deprivation, beginning perhaps with the third day, have shown themselves useful. The difficulties due to abstaining from morphine very often react very favorably to hypnosis. The deprivation should always be made easier by means of hypnosis. In general, the addicts are particularly easy to hypnotize after being deprived of the drug, a fact which is theoretically of interest, for recent investigations (Wuth) make it seem probable that a condition of stimulation in the sympathetic-parasympathetic system calls forth the difficulties due to abstinence. The particular accessibility to hypnosis during the abstinence phase fits in very well with our general theoretical views. If hypnosis has been begun within the abstinence phase, it is advisable to continue the hypnotic treatment in order to strengthen the will of the patient to abstinence. An individual study of the causes of the addiction is here also desirable. Of course, according to our experiences, even this procedure by no means assures the addict against recidivity.

We do not consider it desirable to keep the patient in the hospital too long after deprivation, in general three or four weeks appear sufficient, provided the patient can sleep without the aid of narcotics. Deprivation of cocaine in the form of snuff usually results in but slight abstinence pains, yet the danger of relapse is exceedingly great. We have no experience of our own in the breaking of the nicotine habit, but no doubt hypnosis would facilitate such a process. The curing of addicts unquestionably requires a profound hypnosis.

9. For the treatment of perversions, hypnosis is not sufficient in most cases. In so far as psychic treatment may give promise of success at all, psychoanalysis should be used. This holds particularly true of homosexuality. Only Schrenck-Notzing declares that he has had success with hypnosis. We again state that the hypnotherapeutist should never make it his task to graft any nonorganic conditions on the psychic life of the patient. Under certain circumstances, he will rather renounce possible successes where there is no prospect of securing a balanced psychic life in the patient.

10. The treatment of disturbances of potency is an important subdivision of hypnotic therapy. Vaginal anesthesia in women may in some cases be very favorably influenced by hypnotic treatment; no doubt a number of cases nevertheless resisted such treatment. An investigation of the psychic causes for the vaginal anesthesia should not be neglected. The same applies also to vaginismus. Physical examination is very important, as it frequently reveals anatomical anomalies which render cohabitation difficult or impossible.

Physical examination should also be resorted to in the case of impotence of the male, but in the great majority of cases no local symptoms will be found. Accordingly, local treatment may be applied only as a suggestive remedy. Nor is it advisable to overestimate the importance of organic complaints, in disturbances of potency. No doubt dystrophia adiposogenitalis, serious diabetes, serious tabes, or an advanced senium will cause impotence, but even a serious organic complaint very frequently merely results in lower potency, and the symptoms of disturbed potency very frequently depend only on psychic factors. This is particularly true of the disturbed potency of the senile, even in cases of apparently organic disturbances of potency, psychotherapy will frequently yield results. A rational psychotherapy of impotence must of course investigate the psychic causes conditioning the impotence; these may be of very varied nature. Very often a perversion is hidden behind impotence. A primitive infantile sexuality will renounce the normal sexual goal. The disturbances are at times to be sought in the domain of the Oedipus complex, often in more primitive strata. Exhaustive, analytically guided preliminary conversations are necessary in all cases; psychoanalysis is required by serious cases. Mild and medium cases are excellently treated by hypnosis, which need not be very profound. In general, a favorable prognosis is followed by cases in which normal sexual activity has once been present, if only for a short time. More difficult are the cases in which the patient has passed into the thirties without normal sexual activity. If a perversion or a neurosis (fear neurosis!) is at the bottom of the thing, the success of the treatment will depend on influencing the fundamental complaint. In mild cases, such as cases, for instance, which record failures only in the presence of specific objects, let us say, esteemed love-objects, a rational psychotherapy will usually lead to swift recovery. Recourse to medicaments may offer useful assistance. The fear may be subdued by bromides, but it must be remembered that this remedy, like that of eliminating restrictions by the use of alcohol, is indicated only in mild cases. It is better not to try such means in more serious cases. It is not only permissible, but even desirable, to enhance the psychotherapy by means of hormonal preparations. Yohimbin is sometimes also useful. But it should not be forgotten that all these drugs merely improve the preliminary conditions for the sexual act, but that the main emphasis in the treatment must always be devoted to securing a proper adjustment on the part of the patient, within and without the hypnosis, toward his sexuality. Sexual inhibitions have very often caused male patients to have very erroneous conceptions as to the anatomy of the female genital organs. Object instruction is here often absolutely required. Little technical hints are often of great use to the patient. In many cases the sufferer from ejaculatio precox is recommended to abstain from sexual intercourse. But on the whole it should not be forgotten that abstinence for too long a period is not to be recommended from the point of view of the treatment of impotence. The patient should be forbidden to have sexual intercourse only when it is expected that he will violate the injunction. The conditions for the patient are then favorable in the sense that he is not laboring under the impression of a specific task, a condition always to be avoided. In general, an impotent man is only too much inclined to be dissuaded from attempts at sexual activity. He must then be forced to make such attempts. But we must always bear in mind the fact that a physician may not recommend extraconjugal sexual intercourse to a man unless serious reasons are present, and unless the patient is familiar with the possible consequences. It is inadmissible to permit the patient to marry before his potency has been fully restored. In making these commonplace observations with regard to the treatment of impotence, we have merely desired to point out the insufficiency of a mere mechanical communication of a suggestion in the treatment of impotence. We must again particularly emphasize that hypnosis is only a technical device within the frame of the psychic treatment.

11. Enuresis nocturna may very often be favorably treated by hypnosis. The suggestion may either be formulated in such manner as to train the patient by hypnosis to wake up at regular intervals, or he may be adjusted in such a way as to wake up on feeling the slightest pressure of urine. Not all cases react to hypnotic treatment.