THE MEDICAL ASPECTS OF HYPNOTISM.

It is certain that the present interest in hypnotism depends chiefly upon its therapeutic utility, although its value for experimental psychology must not be underrated. The attention of doctors has never been directed to it so much as at present ; in spite of all differences, it becomes more and more clear in medical circles that a thorough examination of it is necessary.

We have already seen that Bernheim and Liebeault think that hypnotism means suggestion, and suggestion is truly the chief agent in it. Bernheim's definition of hypnotism makes its therapeutic value more comprehensible. He believes that hypnosis is a particular mental state, in which susceptibility to suggestion is heightened. It follows from this that suggestibility exists apart from hypnosis, and that consequently there is no contradiction between the therapeutics of suggestion in, and out of, hypnosis; one is the natural complement of the other. It is the school of Nancy which has pointed out that there are many suggestions without hypnosis, and it was the first of all to recognize the therapeutic value of purely empirical suggestion.

The therapeutics of suggestion are founded on the premiss that a number of diseases can be cured or relieved merely by making the patient believe he will soon be better, and by firmly implanting this conviction in his mind. Every able practitioner knows this suggestive treatment, which is as old as disease. Most of the miraculous cures one hears of may be referred to it; at present we may consider them the results of empirical and often unconscious suggestion. We can refer many of the results procured by the mesmerists to the same cause. It is known that when Bailly wrote his report, in 1784, he thought of the power of imagination, to which he ascribed Deslon's phenomena. From ancient times this mental influence has been used. Ancient medicine, which was partly in the hands of the priests, and in which many religious ceremonies were used, is full of this mental influence. The temple sleep of the old Greeks and Egyptians was a means to facilitate the effect of suggestion. The sick lay down to sleep in the temple, and were told by the god in dreams of something that would cure them. We find the same kind of thing again and again. The belief in some particular medicine is an important agent in healing. There is no need to recount the miraculous deeds of each century. But in later times I may mention the well-known Greatrakes, whose cures astonished all England in the seventeenth century, and Gassner, the exorcist, at the end of the last. The reports upon them make it clear that Gassner used suggestion; for though he spoke Latin, it is evident that he made his patients understand him ; nobody misunderstood his famous "Cesset"; they knew that the pain, &c, was ordered to stop. I was interested to find in Sierke that Gassner once sent a patient to sleep by command. He told her to sleep, and when to wake, and in fact induced what we should at present call a hypnosis.

Among other wonder-workers I may mention Prince Hohenlohe, at the beginning of this century; a Catholic priest, who aroused much attention by his cures in Bavaria, after 1821. The mesmerists supposed he was one of those persons who possessed a peculiar force, while on other sides religious faith was called in as an explanation. One school of mesmerists, that of Barbarin, of Ostend, took up an odd middle position. Barbarin maintained that the influence was a purely spiritual one, and that the right way to induce sleep was to pray at the patient's bedside (Perty). Even to-day many adherents of vital magnetism hold like views ; for instance, Timmler thinks religious faith valuable and necessary for obtaining the result.

I will not multiply examples of suggestive therapeutics. I will but mention the authenticated cures which have occurred at Lourdes and other holy places quite recently. Everywhere and in all times suggestion has been effectively and unconsciously used. When we see that it is exactly those people who use suggestion who are the most successful, we are justified in giving it a high place in modern therapeutics. For no one who reads the stories with unprejudiced mind can doubt that Gassner and many others were more successful than many a scientific physician ; though they are unjustly called swindlers. It may be that some of the diseases were hysterical, but there were many others. It is at least certain that nearly all of them were diseases which the usual medicinal treatment had failed to heal. As has been explained, if suggestion is to succeed the patient must firmly believe he will be cured. This belief must be impressed upon him, and the question is how this can most surely be done. Any patient who goes to Lourdes with the certain belief that he will be cured, and whose expectation has been redoubled by the reports of others and his own faith as a Catholic, will obtain quite a different result from the man who goes without faith.

It is not always possible for a doctor to implant this idea, however great his patient's faith in him may be. Hypnotism is a means of attaining this end, in spite of opposition. No patient, be he ever so intelligent, can resist the influence of hypnotic suggestion if only the hypnosis is deep enough. An idea implanted in hypnosis takes root like a dogma in a faithful Catholic. The idea of a cure should be instilled into the patient during hypnosis. If it is allowed that the idea of a cure effects a cure in many cases there can be no doubt that suggestion is an integral part of therapeutics.

We have to thank Liebeault, of Nancy, for having been the first to use suggestion methodically in therapeutics. It is true that verbal suggestion was occasionally used by the old mesmerists, Kluge, Lausanne, Jobard, and others, as Du Prel and Pick justly point out. But method was entirely wanting. It is often maintained that Braid recognized the value of suggestion in medicine, but this is an error. It is clear that Braid saw suggestion, but he did not recognize it. Whoever will take the trouble to read his works will find that he did not try to find the therapeutic value of hypnotism in suggestion. He believed rather that certain methods of inducing catalepsy, &c, influenced the distribution of blood, and he thought it likely that there were nervous changes.

I must not forget to notice that in 1880 Friedberg, and more especially Berger, concluded that hypnosis was a therapeutic agent. Berger saw a hemiplegic patient make movements in hypnosis which he could not make awake. He saw sufferers from locomotor ataxy cease to stagger during hypnosis and for a short time after. It is true that he did not use hypnosis systematically. The simplified method of Liebeault was unknown to him; he knew nothing of the Nancy methods, nor of verbal suggestion, nor of the great importance of suggestion. Many people, unknown to Liebeault, had seen that, from a medical point of view, a state in which contractures and paralyses, analgesia and pain, &c, could be induced and removed, must be of immense importance; but Liebeault was the first to find the right path, while Bernheim and Forel developed the methods and made them known to physicians. Liebeault must be regarded as the true founder of systematic suggestion.

It is not astonishing that objections have been made to the therapeutic use of suggestion. No essential progress has often been made in the science of medicine without a struggle. Every one knows how the use of quinine, and vaccination, and particularly of emetics, especially in France, was contested ; and how the cold-water cure was rejected, and how Remak was attacked in Germany before the galvanic battery was accepted in the medicine-chest. Every one knows how massage was laughed at. And all these methods have finally succeeded, in spite of opposition and childish laughter.

The difficulty of judging of the therapeutic value of hypnosis is much increased by the hazy definition of " hypnotic suggestion." Thus, some oppose suggestive treatment, and some hypnotic suggestive treatment, while others object sometimes to suggestion in general and sometimes to hypnotism, e.g., Ewald, Mendel, S. Guttmann. I think that the latter are right, in spite of their false point of view, because it is impossible to draw a sharp line between suggestion and hypnotism. I refer to the discussions in Chapters iv. and v., and again express my opinion that hypnotism and suggestion will be gradually welded into one, because spontaneous transitory hypnoses appear to be often found in ordinary life.

It has often been asked why so many authorities have pronounced against suggestive therapeutics. There are three answers—(1) Even an authority may be wrong, and generally it is the authority which believes in its own infallibility ; (2) all so-called authorities are not necessarily authoritative ; (3) many who are authorities in one field are just for that reason not so in another. The last two points are important in medicine, and we may consider them further.

In all sciences, besides the real authorities, there are men who are mistakenly supposed to be so. It is interesting to observe in the history of culture how fashion makes " authorities" out of those who have no real scientific greatness. A man is called an authority ; but when it is asked what he has done there is shrugging of shoulders, for often he has done nothing. Such pseudo-authorities are much inclined to pass judgment on questions they have not examined. There have always been such persons ; they are the drag on the wheel of science. Their position and credit is due to a faculty, which a clever writer, Karl von Thaler, a short time ago called the art of putting oneself on the stage. Their judgments are of no value.

But I do not mean to say that all who have opposed the therapeutic use of hypnotism are pseudo-authorities ; on the contrary, true authorities, such as Meynert and others, have expressed themselves decidedly against it. But as regards the third point above-mentioned, I will say that because a man is an authority on one matter it does not follow that he has a right to claim authority on another. A great historian or astronomer is not in a position to pass judgment on medicine. Now, many of those who have objected to the therapeutic use of hypnotism are authorities on matters that have nothing to do with therapeutics. Physicians as well as laymen often lose sight of this. A man may be eminent in the histology of the brain, and yet be incompetent in therapeutics. And there is nowadays no more connection between the art of healing and the histology of the brain than there is between it and astronomy. If I may call the art of healing a science, the histology of the brain is something quite apart from it—at least, in the present day. Perhaps a connection between them may be discovered later ; perhaps the histology of the brain may be of use to the science of healing ; but at present there is no such inner connection. Therefore I consider the judgment of a man who may be an authority in his own branch as of little weight here as the judgment of an astronomer would be. I would on no account have it thought that I depreciate the investigations of such men. On the contrary, investigations on the histology of the brain, for example, are necessary and immensely valuable ; but as yet they have not affected the art of healing. Whether they ever will the future will show. Feuchtersleben whom no one will accuse of dislike to medicine or anatomy, since he was their most ardent admirer, has expressed the opinion that the art of healing should not be confused with the knowledge of anatomy.

Besides, scientific opposition has always advanced science. A serious, unprejudiced opposition prepares the way for a scientific investigation of new questions ; only the investigation must be permitted, not rejected a priori, as was done in some quarters in the case of hypnotism.

Every investigator should test as a matter of course, if he wishes to judge clearly. But unluckily this is not done. When the author demanded such an examination, that the value of hypnotism might be tested, many scientific investigators protested against the demand in the most energetic way. He simply asked in several reports that the therapeutic use of hypnotism should be examined—a demand which may justifiably be made to men of science. While Virchow, &c, considered a long and thorough examination necessary, others were already prepared with an a priori judgment, for which they could not offer a shadow of reason. But, indifferent to condemnation, new observers came forward to test the healing power of hypnotism and of the suggestion and mental treatment so closely connected with it. When it became evident that the question could not be easily put aside, and it was recognized that the absolute refusal to examine was unscientific, an endeavour was made to support the original a priori decision by false assertions. Those who had first defended the therapeutic value of hypnotism were accused of having asserted the discovery of a universal panacea. It is a pity that those who, as the representatives of science, ought to seek for truth, should take such a way of justifying their original refusal. These tactics are pitiable, and deserve to be branded. Neither the serious investigators at Nancy nor those in Germany, Switzerland, and Austria, have ever wished to make a universal panacea out of hypnotism.

We will consider singly the objections made to hypnotism as a therapeutic agent.

A chief objection was made by Ewald, of Berlin, who " decidedly protested against calling suggestion medical treatment." He did this in the interest of physicians. Forel's reply to him will make it clear what he meant. It refutes his objections better than I could do.

" Ewald protested against the expression ' medical treatment by hypnotism.' He said that medical treatment meant the medical art and medical knowledge, and that every shepherd - boy, tailor, and cobbler could hypnotize ; only self-confidence would be necessary. I, for my part, think it right to protest against this way of treating a scientific question. Has not medicine drawn a countless number of its remedies from the crudest empiricism, from the traditions of the ' shepherd-boys ' ? Cannot every cobbler inject morphia, apply blisters, and give aperients if he has the material ? Yet we do not despise these remedies, nor baths, nor massage, &c. But Prof. Ewald deceives himself greatly if he believes that a delicate agent like hypnosis, which affects and modifies the highest and most refined activities of our minds, could be manipulated by a shepherd, or ought to be handed over to him. Medical science and psychological knowledge, the ability to diagnose and practise, are all necessary to its use. It is true that laymen have succeeded with it, just as charlatans have succeeded, and continue to succeed, in all provinces of medicine. Should we on that account leave the practice of medicine to them ? Long enough, much too long, science has left the important phenomena of hypnosis to ' shepherd-boys and their like'; it is high time to make up for the delay, and to devote ourselves to a thorough examination of the series of phenomena which can complete our views of psychology and of the physiology of the brain. Medical therapeutics must not remain behind when great results are to be obtained. But these results can only be obtained by a thorough study of the proper hypnotic methods."

A second objection is the danger of hypnosis. I long ago pointed this out, and earnestly warned people not to consider hypnosis absolutely safe. Mendel and others have said the same thing later, but have somewhat exaggerated the danger. This point must be seriously weighed. But it is never asked whether a remedy might not be dangerous; we only ask if we cannot avoid the danger by careful and scientific use of it. Rust asserts, in speaking of artificial somnambulism, " the best assertion that can be made about a remedy or method of cure, is, that it might also do damage ; for what can never do positive harm can never do positive good." This assertion is to a great degree justifiable, though perhaps exaggerated; for I think I may say that there are few remedies in medicine which would not injure if carelessly and ignorantly used. There are even medicines which may injure, however carefully used, because we do not know exactly under what conditions they become hurtful I need not speak of morphia, strychnine, and belladonna, which have sometimes done injury even when the maximum dose was not surpassed, nor of the deaths from chloroform, the reason of which has not been explained. Thiem and P. Fischer, with praiseworthy scientific frankness, have quite recently published a case of the fatal after-effects of chloroform ; death followed on the fourth day. These authors say that there is at least one death for every thousand administrations of chloroform. Neither will I speak of the dangers of surgical operations ; I need only point out that an apparently harmless medicine may have very likely already done more mischief than hypnotism. Many deaths have resulted from the use of potassium chloride, and unfortunately this drug can still be bought in retail without a medical prescription. Severe collapse has been observed after the use of antipyrine. I will add to these one of the most recent medicines—sulfonal—which is supposed to be a perfectly harmless hypnotic drug. A friend and colleague has told me that he has seen sad consequences follow from its use, and that there were some patients to whom he never gave it, for fear this " harmless " drug should work great mischief. And again, as to the treatment by suspension, which has lately become almost a fashion, and from which certain enthusiasts really expect the cure of locomotor ataxy. It is now certain that it may cause great injury, or even death ; a death from it has recently been published. Many published reports show that even the presence of a doctor does not prevent evil consequences. And Billroth has lately pointed out great dangers from carbolic acid, which is constantly used. If we gave up the use of these remedies we might give up medicine altogether, as everything employed may do harm.

I need not enlarge this chapter further, for whether there are dangers in the use of drugs or not, is not the question. Rather we must ask : 1. Do we know under what conditions the danger appears ? 2. Can we remove these conditions and the consequent danger? 3. And if we cannot, does the advantage to be gained by the patient outweigh the danger he runs ? The answer to these questions is in favour of hypnotism ; we know perfectly well under what conditions it is dangerous, which we do not know about some drugs ; we are able in certain cases to exclude these conditions by using the proper and harmless methods, and thereby preventing danger; and supposing that these perfectly harmless methods fail, we can ask ourselves if we shall or shall not use the methods which are not harmless. I think the small discomforts to which the patient is exposed—a short headache, watering of the eyes, and depression, are infinitesimal compared to the advantages which may result from the hypnosis. The future will decide here also, but I will remark that nearly all the men (Gilles de la Tourette, Ewald, Mendel, Rieger, Binswanger), who have said the most about the dangers of hypnotism, and are in general against it, by no means themselves refrain from hypnotizing. By this they allow that it is not hypnotism itself, but its misuse, which is mischievous.

I will now speak of the different ways in which hypnotism might endanger health, and explain the causes of the danger, and the method of avoiding it.

In the first place, the danger has been enormously exaggerated. The inhabitants of a little town once left off eating potato soup because a woman fell downstairs and broke her neck half an hour after eating some. Conclusions have been drawn in the same way here, and this sort of reasoning is not uncommon. If a person was hypnotized, and later on had some ailment or other, straightway the ailment was ascribed to hypnotism. If we reasoned thus we should have to say that Carlsbad causes apoplexy, for Mr. X. had an attack of apoplexy a fortnight after he returned from Carlsbad, &c. Many things could be proved in this way.

I should hardly have thought it possible that such logic should be used in scientific circles. It is true I have often heard that when patients come back from a watering-place without having been cured — which must happen sometimes — they are dismissed with the comforting assurance that they will feel the effects later. Till now I thought this was a bad joke, or at best an effort to console the patient ; I never believed that such a principle was really credited in the medical world. If a patient got better or worse six months after his return from a watering-place, I should not be inclined to ascribe the effect to the baths, because in the interval other things might have affected the patient. Like Pauly, I must on these grounds reject the connection found by Binswanger, Ziemssen, and others, between hypnosis and ailments long subsequent to it. Besides, if I were to accept their sophisms, it would be easy for me to prove in the same way that modern medicine makes mankind ill ; for what medicine might not produce important results half a year after its administration ? What doctor has ever argued in this way ?

However, I by no means deny that there are certain dangers in the improper use of hypnotism.

Mendel maintains that it induces nervousness ; that nervous people grow worse, and sound people nervous through its use ; but Forel and Schrenck-Notzing think this is a mistake of Mendel's, caused by his using the method of Braid instead of suggesting hypnosis verbally. I agree that fixed attention too long continued may have unpleasant effects. It may be followed by nervous debility or nervous excitement. But I have never seen any one become "nervous" whom I hypnotized verbally, and to whom I made no exciting suggestions. This also is important (Bertrand). Whoever has seen the difference between a subject who has received an exciting suggestion and one who has received a soothing one, will agree that as much good can be done in one way as harm in the other. A man who makes absurd suggestions to amuse himself and satisfy his curiosity, without a scientific aim, need hardly be astonished if he produces ailments. Sawolshskaja is right in warning against such sports. I have observed that patients are often worse on days following bad dreams. Can we be astonished that a person who has awaked from hypnosis during an imaginary fire should feel ill after it ? Such suggestions should not be made at all, or with the greatest caution, taking care to do away with the suggestion and soothing the subject before the waking. This is the most important point. I think that even if these mistakes arc made it is of little consequence, provided the subject is thoroughly and properly wakened in the manner used at Nancy and by all who follow the prescriptions of that school. I should like to ask those who talk of the dangers of hypnotism if they have taken care that the awakening should be complete ? I know that most people are not at all aware that they should do away with the suggestion entirely. They think it enough to blow on the subject's face, and are astonished that he does not feel well after it. I am surprised that more mischief is not done in consequence of insufficient technical knowledge. It is this that is dangerous—not hypnotism. No wonder that there are sometimes unpleasant consequences. It is as necessary to know the right way in this case as in using a catheter.

To show how a suggestion should be done away with I will suppose that an exciting suggestion has been made to a subject, who is disturbed in consequence. One should say something like this : "What excited you is gone; it was only a dream, and you were mistaken to believe it. Now be quiet. You feel quiet and comfortable. It is easy to see you are perfectly comfortable." Only when this has succeeded should the subject be awakened ; and this should not be done suddenly ; there are reasons for thinking it better to prepare the patient for waking (Sallis). I generally do it by saying, " I shall count up to three. Wake when I say three." Or, " Count to three, and then wake." I add (and this is also important), " You will be very comfortable, happy, and contented when you wake."

Further on I will give some other precautionary rules which should be used before the awakening to prevent disagreeable consequences.

I have spoken of the nervousness which hypnotism is supposed to produce, and have tried to show that it is not hypnotism which causes it, but its improper use. These rules should especially be followed : I. To avoid continuous stimulation of the senses as much as possible. 2. To avoid all mentally exciting suggestions as much as possible. 3. To do away with the suggestion carefully before the awakening. The proper method will not cause nervousness. Hypnotism offers less dangers on this point when properly used than electricity, for example, which has made many people " nervous." A lady I knew became so nervous when electricity was applied to her larynx by a very competent doctor, that she was obliged to give it up.

It is asserted in particular that hypnotism causes hysteria, or hysterical convulsions (Guinon), even in people who have never had them. It is not to be denied that hystero-epileptics are sometimes thrown into hysterical convulsions in hypnosis, but I contend decidedly that the convulsions are not caused by the hypnosis. The slightest mental affection causes convulsions in such persons : electricity causes them ; they fall into them even when they hear a noise, such as a falling book, a bell, &c. But it is preposterous to say the electricity causes the convulsions ; the mental excitement of the patient about the electrization is the real cause ; timid patients sometimes faint when they are electrified (E. Remak). Besides, the main point is whether the convulsions of the hystero-epileptic are permanently aggravated or not, and experience shows that this is not the case. On the contrary, when once a complete hypnosis has been obtained we have in our hands a trustworthy means of permanently lessening the convulsions; and, in truth, an attack of hysteria is not so important that it need be regarded as one of the chief dangers of hypnotism. Hysterical attacks are sometimes artificially induced merely for the sake of experiment or demonstration.

Certain cases of Sperling and Krakauer show that hysterical attacks are of no importance, and do not indicate the necessity of stopping the hypnotic treatment ; in these cases there were attacks at first, yet cures were obtained ; and they also show that the attacks are by no means permanently aggravated, even when they take place at the first or second attempt to hypnotize. If Krakauer, in his case of hysterical deafness, had allowed himself to be thus hindered from making further experiment his patient might be as deaf to-day as she was two years ago. And I will further mention that Mesmer and Deslon even thought the hysterical convulsions (crises) necessary if the magnetizing were to do any good ; which was certainly a mistake. So far as I know, in no single case has a person hypnotized according to the above rules ever had convulsions in hypnosis, unless he had had them before.

But I should like to mention some slight accompanying ailments which are sometimes found after hypnosis, though they cannot be thought a real danger, and are often the result of auto-suggestion (Forel), or of a bad method. There may be fatigue and languor, heaviness of the limbs, &c., after waking. It is easy to prevent these by suggestion in deep hypnoses. It is different in the light ones, though I believe a clever operator can do it by post-hypnotic suggestion even here. In other cases I think it better to prevent fatigue by suggestion before the awakening ; in any case it is a good plan to get rid of it at the first sitting, as otherwise it increases by auto-suggestion at each sitting, and can finally be hardly overcome. This feeling of fatigue in the light hypnoses is the same we sometimes have after an unsound sleep. All these inconveniences are slight, and can for the most part be avoided. Drosdow made of these phenomena a particular stage of the hypnotic state, characterized by headache, pains in the limbs, faintness, &c., but he was no doubt misled in 1881 by the then want of knowledge of the methods of Nancy.

The main dangers of hypnotism are not those just mentioned, which appear relatively seldom even when improper methods are used. The real ones show themselves more easily in such a case. They are : the increased tendency to hypnosis, and heightened susceptibility to suggestion in the waking state, i.e., the possibility of a new hypnosis against the subject's will, perhaps without his suspecting it (cf. p. 45), and the danger of his accepting external suggestions even without hypnosis. It is just this too great susceptibility to hypnosis which shows us how careful we should be with the method of Braid, which is the most frequent cause of this; for accidentally fixing the eyes on some object may cause a sudden hypnosis, simply because the idea of an earlier hypnosis is thereby vividly recalled.

The last-mentioned danger can be guarded against by repeatedly making some such suggestion as follows to the subject before awaking him : " Nobody will ever be able to hypnotize you without your consent ; you will never fall into hypnosis against your wish; nobody will be able to suggest anything to you when awake; you need never fear that you will have sense delusions, &c, as you do in hypnosis, you are perfectly able to prevent them." This is the surest way to avoid the danger. Such are the dangers of hypnotism, and such the methods of meeting them Their antidote is suggestion, and they are no hindrance to hypnotic treatment. They can be avoided by a proper use of hypnotism.

But it may be objected that though a short use of hypnotism may not be hurtful, a long one, involving a repeated induction of the state, might be so. The objection is justifiable. But it might also be made against the use of various drugs, since we do not yet know whether a long use of them might not cause severe chronic poisoning. Experience is the only way to decide such questions. Now Liebeault, who has used hypnotism therapeutically in France for nearly thirty years, has watched cases for a long time, without finding bad consequences. Forel has done the same thing, though for a rather shorter time; I myself have hypnotized persons for more than a year without evil results. On the contrary, the hypnosis grew deeper, and suggestion consequently easier.

I will not enter into a purely theoretic discussion of the dangers of hypnosis. Mendel fears over-action of the cerebral cortex from it, while Ziemssen and Meynert fear just the contrary, that is, a loss of power of the same part. The contradictions in which they are involved are evident; to suppose that they meant the same thing would show a great want of reflection.

In the foregoing I have discussed and refuted two objections made to the therapeutic use of suggestion and hypnotism : first, the assertion that hypnotism should not be called medical treatment; and secondly, that it has too many dangers to allow of its practical use.

It is further added that its mysterious side should prevent its being used. Benedikt maintains this, and thus contradicts Mendel, who finds its healing value especially in the mysterious impression it causes. I, on the contrary, believe, as I shall explain later, that the mysterious impression plays a subordinate part, and that there is less mystery about the matter than is generally believed. Apart from this, it would be perfectly indifferent to a practitioner whether a drug took effect from the mysterious impression it made, or through suggestion, or through chemico-physical influence. The point is that it shall act, not in what manner it acts.

When Benedikt maintains that, in order to lessen the impression of mystery, hypnosis should be induced by the use of a magnet instead of the ordinary methods, he would do better if he showed how this is possible. He should prove his assertion that the magnet produces hypnosis by publishing his experiments. I have applied the magnet to hundreds of persons and never induced hypnosis.

If I believed that in some cases a mysterious agent would be useful to the patient I should not for a moment hesitate to use it; for were I to do otherwise I should be neglecting my duty as a doctor, which is of more importance than any scientific signboard. For example, I should think it right in certain cases to send patients to some miracle-working spot, e.g. Lourdes, if they expected they would be cured there; and, in fact, fifty or sixty patients are yearly sent to Lourdes from the Salpetriere (Constantin James). In any case, even if hypnosis was effectual only from its mysteriousness—which is not the case —it would none the less be well to use it.

Among the remaining objections to suggestive therapeutics the assertion that they do not produce any lasting improvement or cure may be mentioned. This may be answered as follows. The results are by no means transitory; on the contrary, a large number of lasting cures have been observed and published. The author has seen many cases where there was no relapse for years. One cannot ask for more. The objection that the improvement may be only temporary is thus not justified. But even were this so we must still rejoice to have found a way of procuring even temporary relief (Purgotti, Schuster). For instance, in difficulties of menstruation, it is a great thing if we can succeed in subduing pain for a time. If the pain returns a new hypnosis may be induced; it is always to be had, and as it generally becomes deeper the more it is used, it is less likely to lose its effect (even in relapses) than drugs, which often do so quickly (Sperling). In any case therapeutics are not yet so far advanced as to give us the right to reject a remedy merely because it only affects symptoms or has often merely a temporary value. If we were to reject remedies which suppress the phenomena of disease for a time only, we might abandon a large part of therapeutics, perhaps the whole, Besides, from some methods of treatment nothing but a temporary improvement is expected, and yet this temporary improvement is considered to prove the value of the method. How often it happens that a patient who has benefited by a stay in Carlsbad or Aix, &c, is recommended by his doctor to go back there when his ailment returns, because his health was improved the first time. Remedies should not be weighed and measured by different standards.

Another objection to the therapeutic use of hypnotism is that it cannot be generally applied because everybody is not hypnotizable. I should like to add that in many cases, even when a hypnosis is induced, it is not deep enough to be used therapeutically. I pointed out these two defects several years ago, without, however, exaggerating their importance. After all, it is the same with other remedies. For instance, under some circumstances a journey to the North Sea, or among mountains, or, perhaps, in some states of collapse, a few bottles of Madeira, are supposed to be excellent remedies. I think that many more people can be hypnotized than can be sent to bathe in the North Sea.

A further objection to treatment by hypnotic suggestion is that there may be suggestions without hypnosis. But this is exactly the standpoint which the school of Nancy and I myself have always taken up, although, as I have pointed out, it is often difficult to distinguish between hypnosis and suggestion. This is the heart of the present movement, which shows us how extensive is the empirical use of suggestion in therapeutics. It is also the real reason of the strong opposition to hypnotism. We hereby see how often suggestion occurs spontaneously in ordinary life and medical practice. Hypnotism, by means of which we can make suggestions artificially, shows us what a great mistake has been made in estimating previous therapeutics, since we have neglected to consider the mental element in the action of the various drugs. The physiological effect only was regarded ; it was quite forgotten that many remedies have only a suggestive value.

Now, when it is asserted that there is suggestion without hypnosis, and that suggestion in medicine is no novelty, let it be remembered what Ewald said a short time ago—that suggestion oversteps the bounds of medical treatment and trenches on the field of psychology. We also see that some of the opponents of suggestion generally fail to recognize mental treatment as a factor in medicine. According to them suggestion is no affair of the physician as such. I maintain, on the contrary, that a physician can only do good, only attain his aims, when he is a psychologist, and that this is at least of as much importance as what we call medical art and science.

There are, then, as the school of Nancy has shown, many suggestions without hypnosis; but, in spite of this, artificially induced hypnosis makes suggestion possible in many cases where it would otherwise fail. Therefore when any one, in objecting to hypnotic suggestive therapeutics, says that there is also sugestion without hypnosis, he is merely confirming what the school of Nancy has always maintained. This "refutation" of hypnotic therapeutics is as if one were to say that a doctor is no longer needed in confinements, because many births take place spontaneously and very well without one.

Hardly anybody thinks the temporary loss of will is an objection to hypnotic therapeutics. The main point is to choose only an experienced and trustworthy experimenter, as we should do in taking chloroform.

About the indications for suggestive treatment there is not much to be said with certainty. This is why Ewald will not concede the same rank to suggestive treatment as to other methods, e.g., electro-therapeutics, treatment by drugs, &c. Mendel decidedly opposes Ewald and thinks the indications clear ; unluckily he does not say what they are. I think that the indications are not yet clear, but that it cannot be expected they should be, when the method of treatment has been under examination for a time relatively so short. But Ewald is certainly mistaken in thinking that fixed indications are to be found in internal disease at all. Medicine consists to a great extent in trials of various treatments. Strictly speaking, there are indications in but few cases, as may be clearly seen by comparing various text-books, and from the numerous contradictions among different doctors. I think that indications for suggestive treatment are at least as exact as those for treatment by electricity, by massage, by drugs, by baths, which are all supposed to cure a great number of definite diseases, if the too favourable explanations of the text-books and essays in journals are to be believed. In any case I think that this belief is to be found hardly anywhere but in medical students, who generally greatly over-estimate the power of therapeutics (Unverricht). Any one who keeps his eyes open in practice may soon convince himself that there unluckily are not many so-called accurate indications for the treatment of internal diseases, and particularly for nervous disorders. It is by no means a contradiction to this that there are doctors who in certain cases can find the proper remedy at a glance. It rather confirms what I have said, and is a consequence of the fact that therapeutics are less a science than an art, although many representatives of " exact medicine" suppose the contrary. Though this has often been said before, it is, unfortunately, not sufficiently considered nowadays. On the whole, to exclude any misunderstanding, I should expressly declare that I recognize definite indications in certain cases of internal disease, but they are very rare when compared to the total number of diseases.

So far as we have hitherto been able to judge, functional neurosis is the chief field of suggestive therapeutics, i.e., nervous disorders not founded on anatomical derangements. These must not be too readily confused with hysteria or with neurasthenia. it is true that these ideas are so blended, and hysteria in particular is conceived in so many different ways, that we might almost say, " What we cannot define, that we call hysteria." "Hysteria" is used in many senses ; the term is used in one sense or another at pleasure, and thus sophisms are constructed which even many doctors fail to penetrate. I will here give two meanings of the word " hysterical."

In the first place, hysteria is a name for an illness which has no anatomical foundation, which has numerous and variable symptoms—now headache, now ovarian pain, now pain in the side, and now weakness in the legs. The patient is called "hysterical " as well as the symptoms. As such patients are sometimes obstinate and capricious, and like to make themselves interesting, this word "hysterical" has a somewhat unpleasant after-taste ; some authors so far as to say that a tendency to falsehood and hypocrisy is a chief symptom of such hysteria. This evidently an unfair generalization. At all events, the multiplicity and variability of the symptoms are the main characteristics of "hysteria" taken in this sense. Hysteria in the other sense is quite different. In many quarters any symptom is called hysterical when there is no anatomical cause for it and it is merely " nervous," e.g., headache, pains in the muscles, certain tremors, frequent vomiting, &c. ; even when the symptom is solitary and constant. Now, if in such a case the patient, as well as the symptoms, is to be called " hysterical," we have two entirely different meanings for the term " hysterical patient," from the interchange of which, at pleasure, all sorts of subtle sophisms result. The meanings of the term are changed to suit the discussion. For example, an author says in one place that any hysterical symptoms can be removed by hypnosis, i.e., such as are marked by quick spontaneous changes. That is hysteria No. 1. But as soon as some one asserts he has seen a person, without any other symptom of hysteria, freed by suggestion from a severe pain in a muscle—the biceps, for example—then, to suit the discussion, the second meaning of the word hysterical is adopted, and it is said that the symptom was hysterical. But a prudent silence is maintained with regard to the fact that the patient suffered from one merely local pain, had no other hysterical symptom, and consequently was not hysterical in the first meaning of the term. Anything can be proved or refuted if the word " hysteria " is thus treated.

To give another proof of this I return to a letter of Charcot, which has lately aroused much attention, and in which he asserts that only hysteria can be treated by hypnosis. If this means that hysteria in sense No. 2 can also be thus treated, there is nothing to say against it, and the most different authors would agree upon the point. But, in fact, Charcot, as Nonne remarks,understands much more by "hysteria" than is understood in Germany. Thus Charcot says, in contradiction to two German authors, Oppenheim and Thomsen, who think the variability of the symptoms the chief mark of hysteria, that in his view this is not a characteristic of hysteria.

To avoid error it should be mentioned that Charcot has not hitherto advocated suggestive therapeutics—at least, publicly— though he admits them conditionally in his letter. He even says that a good effect may be hoped from them in hysterical phenomena. It is true that these parts of Charcot's letter about suggestive treatment are sometimes omitted when the letter is repeated, while every impartial observer must see in this passage rather a defence of suggestive therapeutics than an attack upon them, if " hysteria " is understood in the second sense given above. Moreover, while Charcot expresses himself decidedly in favour of the hypnotic treatment of hysteria, Ziemssen, who is supposed to have the same standpoint, maintains that such treatment makes it worse.

Even though Charcot's authority is appealed to, if erroneously, against suggestion, it should not be forgotten that a short time ago Charcot was attacked and laughed at; that his hypnotic experiments were mocked at ; that Rieger, among others, energetically opposed hypnotization in the Salpetriere; that Mendel said his subjects were " prepared " ; that according to Ewald the said subjects obtained all sorts of advantages from submitting to the experiments (though he did not talk of fraud); and that Ewald expressed himself in a manner not altogether appreciative about Charcot's experiments with the magnet; that he described the antecedents of his subjects unflatteringly, &c. From all which it appears that the side which now claims him as an ally against hypnosis was attacking him vehemently hardly a year ago.

From this digression, which was intended to make clear what is meant by " hysteria," I return to the question of the indications for suggestive therapeutics. I will give them here, so far as my own experience permits, with the help of trustworthy authors, especially of Forel. Particularly suitable ones are all kinds of pains which have no anatomical cause (headaches, stomach-aches, ovarian pain, rheumatic and neuralgic pains) ; sleeplessness ; hysterical disturbances, particularly paralyses of the extremities and aphonia ;' disturbances of menstruation ; spontaneous somnambulism ; uneasy dreams ; loss of appetite ; alcoholism and morphinism; neurasthenic ailments ; stammering (Corval, Ringier, Wetterstrand, Pauly); nervous disorders of sight (Forel, Mollerup, Chiltoff) ; enuresis nocturna; pruritus cutaneus nervosus; perverted sexual feeling, when not inherited (Krafft-Ebing, Schrenck-Notzing, Ladame); singing in the ears ; prolonged cases of chorea ; railway spine and emotional neuroses (Hirt); agoraphobia (De Jong); writer's cramp (of central origin).

Hysteria (in the sense of definition No. 1) is not easily curable. Consequently we try as much as possible to obtain an improvement in the symptoms. As far as our experience goes, this is at least as easily done by hypnotism and suggestion as by any other method. Much depends upon the depth of the hypnosis, and upon the degree of susceptibility to suggestion, &c. But I am decidedly of opinion that hysterical patients are less susceptible to suggestion than others. Forel thinks that a sound brain is above all things necessary for hypnosis ; the sounder it is, the sooner we may hope for results. In hysterical patients the brain is often by no means sound. For the same reason it is difficult to treat insane persons by hypnotism. However, improvements have been obtained in the lighter forms of mental disease, e.g., of melancholia and mania (Forel, Burckhardt, A. Voisin, Seglas, Dufour). But generally the effect is less than in the neuroses. This is partly because insane persons are not good subjects for hypnosis. Even when the hypnosis is deep, insane ideas and delusions of the senses are much more difficult to remove than nervous troubles, such as sleeplessness and headache, which are often found to accompany psychoses (Forel). Although there may sometimes be organic changes which cause the mental disturbance, and which explain the resistance to suggestion, yet the chief reason is to be found in the tenacity of the patient's diseased ideas. These might often be rightly called auto-suggestions. A. Voisin and Repoud say, however, that they have seen good effects produced in cases of severe mental disorder ; but Forel is unable to confirm this.

The therapeutic successes which hypnotism has had in neuroses have been confirmed in so many quarters that a doubt of the trustworthiness of their source is hardly possible. I will only name Forel, Krafft-Ebing, Obersteiner, Hirt, Bernheim. Those who dispute the successes do so generally a priori, without having scientifically and patiently tested the matter. It is a mistaken assertion that only such cases of illness can be benefited which could easily be benefited in other ways. At least I must contend that this was not so in a number of cases in my own experience, where the cold-water cure, massage, electricity, surgical operations, or drugs had been tried in vain, while suggestion, and hypnotic suggestion in particular, was successful.

Besides, even when one of the above methods is successful, we should be careful how we draw the conclusion that suggestion had nothing to do with it ; for numerous remedies appear to be effectual only through suggestion ; they succeed because the patient believes in them, as even Mendel, one of the most decided opponents of suggestion, has admitted. It is in the nature of things that drugs, even when they only act by suggestion, should sometimes succeed better than verbal suggestion, because many people are more easily influenced by something tangible than by words only. Some very practical investigators (Krafft-Ebing and others) even attribute a merely suggestive value to drugs in certain diseases, e.g., in neurasthenia and hysteria.

With regard to organic diseases, in which we find anatomical changes in the organs, as opposed to functional derangements, we have before us a number of accredited observations, from which it follows that important functional improvements were made possible, i.e., the consequences of the disease could be partly removed by hypnosis. Thus in a case of tabes dorsalis, though the disease continued, the severe pains were subdued (Lloyd Tuckey). It may, no doubt, be objected that the diagnosis was mistaken, and that a functional derangement was mistaken for an anatomicallesion. But the examination of sections of the spinal cord contradicted this in one such case. Bernheim saw an apoplectic paralysis rapidly improved by suggestion. The patient died later of disease of the lungs, and the seat of the original disease was discovered on dissection. Besides this confirmation by anatomy there is another method by which we can sometimes decide a doubtful diagnosis. For example, in chronic rheumatism of the joints, with clearly visible and tangible swellings, there can be no doubt about the diagnosis. If suggestion removes the pain, we have obtained an important improvement in an organic complaint. But many such cases have been published. I can confirm it from my own experience in a case of articular rheumatism.

Among other diseases accompanied by organic injury I have seen a very painful eczema of the ear, in a child of eight, made painless by post-hypnotic suggestion. I observed this case in the company of my friend and colleague Friedemann, of Copenick, whom I have to thank for a number of interesting experiences in hypnotism. The child in question could not bear the slightest touch. An order given in his first hypnosis had such an effect that he could after wards endure even strong pressure on the spot. What are the counter-indications against hypnotic treatment, i.e., what conditions forbid the use of hypnotism ? I do not know of one. But it may be that when certain phenomena produced by autosuggestion cannot be avoided the use of hypnotism is counter-indicated. However, the therapeutic effect we wish to obtain is of so much more importance than a chance attack of hysteria, &c, that in general we should not allow ourselves to be restrained by it. In any case there are no more counter-indications against this treatment than against any other.

How can the effects of hypnotism be explained ? Some think that it is in itself healing and beneficial (Beaunis). The general view is that suggestion is the healing agent. I believe it to be the essential point. To make this somewhat clearer I will take an example. Suppose we wish to cure a headache by arousing in the subject the idea that the headache is gone. Spontaneous reflection would prevent this in most waking people, but in hypnosis ideas are more easily established. If the subject accepts the suggestion we may be sure that in the hypnotic state he does not feel the pain. But now we have to prevent the return of the pain after waking. Either external post-hypnotic suggestion or auto-suggestion will do this. We can make the patient continue to think the pain is gone after he wakes. He need not be conscious of this idea in the sense of remembering it. On the contrary, the less conscious the idea is, the more effect it will have, because reflexion will not struggle against it (Forel). Auto-suggestion is the second plan. The patient, finding himself without pain in hypnosis, may convince himself that pain is not a necessary consequence of his state, and this idea may under some circumstances be strong enough to prevent the return of the pain.

The more easily an idea can be established in the subject, the quicker a therapeutic result can be induced. And the deeper the hypnosis, the more easily ideas can be established. Consequently, the deeper the hypnosis, the better the cure. I cannot agree with Schrenck-Notzing when he says the deep stage is in general unnecessary ; on the contrary, the deeper it is the better. It does not follow, of course, that the light stages are of no value. Apart from the fact that they often become deeper, they are often useful in therapeutics, especially when we have to do with motor disturbances. Much depends upon the subject's character. For example, A. may be as susceptible to suggestion in the light stage as B. is in the deep one. However, it is not to be contested that suggestibility increases in some persons with the depth of the hypnosis.

This methodical suggestion is the key to suggestive therapeutics. When the hypnotized subject refuses the suggestion, which sometimes happens, the mysterious impression may be ever so great, and yet no therapeutic result will be obtained. I have successfully treated people who certainly had no mystical ideas about the matter. People can be influenced hypnotically or suggestively though they do not believe they are hypnotized ; they are often much astonished when they wake to find they have been hypnotized. But I do not contest that in certain cases the mystical impression may not have some effect, though it is by no means the rule.

Neither is the effect to be attributed to the patient's confidence in itself, though it plays a large part. Misrepresentation has aroused so much distrust of hypnotic treatment that in some cases there is no confidence at all. But the immense power of hypnotic suggestion is shown by the fact that it succeeds in a large number of cases in spite of mistrust; for mistrust is a powerful auto-suggestion, and auto-suggestion is the greatest foe of external suggestion. The success of hypnotic suggestion will be greater the more distrust disappears, and when it has been recognized that hypnotism properly used is as harmless as electricity properly used. Then only will the power of hypnotic therapeutics be practically estimated. I have little doubt what that estimation will be. Hypnotism and suggestion will outlive many remedies whose praises fill the columns of medical journals at present.

To avoid misunderstanding, I will briefly state in what way the improvement of organic diseases by hypnotic suggestion is to be explained (according to Bernheim). I only mention this because Binswanger and Seeligmuller mistakenly represent Bernheim as having maintained that the original organic injury is done away with by suggestion (Corval). Apoplexy hi example. If a part of the brain, a, is injured, then the functions of the nerves served by a are interfered with. Now it is a well-known experience that when a is injured the functions of another part of the brain, b, are often influenced. Then the function of the nerves served by b; are also interfered with; b itself is not organically injured, only its functions are inhibited. Now suggestion can restore these functions. It can sometimes also produce a functional amelioration in an organic disease. In any case it need not be supposed that suggestion has an immediate influence on the organic lesion, in order to explain the functional improvement in organic diseases. Bernheim's explanation may, mutatis mutandis, be called in for other cases. Sperling believes that electricity only does good in apoplexy by restoring the inhibited functions of parts which are anatomically sound. He is known to have experience and ability in the field of hypnotism and electrotherapeutics, such as are possessed by few, but does not believe that the part of the brain injured in apoplexy has ever been restored by electricity.

It would take too long to give all the rules for hypnotic treatment, and Baierlacher, Bernheim, and Forel have already done so. I will merely mention that there is a difference between preparatory and therapeutic experiments. Practice will enable us to decide whether the hypnosis in particular cases is deep enough to be used therapeutically, or whether further trials are needed to increase susceptibility to suggestion. In most cases preparatory experiments are necessary. The first trials should only be continued for a few minutes. If they are unsuccessful the stronger methods should be tried, e.g., fixed attention. As violent pain often prevents hypnosis it is better to choose a time when the subject is free from it for the first attempt. Hypnosis will be easily induced later, even in the midst of violent pain. It is generally necessary to repeat the suggestion occasionally, after improvement or cure has been obtained, to prevent relapse.

Hypnotism does not necessarily succeed at once. If the hypnosis is deep a result may be very quickly obtained ; in other cases patience and method are wanted, and the time the illness has lasted must be taken into consideration. The more the idea of pain has taken root, the more difficult is it to overcome.

Why hypnotism should be measured by a different standard than other methods of treatment is inexplicable to me. A doctor is often satisfied to obtain a result after weeks or months of electro-therapeutic treatment, and how often, after months of perseverance, it fails to appear. Why, then, should we expect suggestive therapeutics to succeed in one day? Patience on the side of both doctor and patient is often required.

I likewise deny that hypnotism should be regarded as a sort of last hope in the treatment of diseases. The longer they have lasted the more difficult they arc to cure, because the idea of the disease has established itself firmly. It is the duty of every one who believes that hypnotism is harmless when properly applied to use it where he thinks it will be of service, and before it is too late. For some diseases become incurable simply because they were not rightly treated at first. The illness develops into an auto-suggestion, more and more difficult to overcome. The more a patient thinks of his pain at first, the less his attention is turned from it, the less possible it is to remove it later. We might hesitate to make long preparatory experiments with people difficult to hypnotize (Grasset). But it is to be wished thathypnosis should be used when the hypnosis can easily he induced, and when the method is indicated, rather than that a hundred other methods, all disagreeable to the patient, should first be tried in vain.

It has been asked whether hypnotism and suggestion arc of real value to the art of healing. To. answer this we must consider whether a larger number of patients are cured or improved by this means than by exclusively physical and chemical treatment. It is difficult to decide. If we suppose that 50 per cent, are cured or improved by the usual treatment—which is by no means the case—and that 2 per cent, are cured or improved by suggestion, these figures would not mean much, as the percentage would only be raised from 50 to 52. But if we suppose that by the ordinary methods only 1 per cent, of functional neuroses arc cured or improved—which is nearer the truth—and that 2 per cent, arc cured or improved by suggestion, this would be a great progress, since the percentage would be raised from 1 to 3 per cent., i.e., the number of successfully-treated patients would be tripled. I have chosen two extreme cases, to show how difficult it is to settle the question. I think that very few neuroses—I will consider only these in the first place—are cured or improved by any treatment not mental ; perhaps one per cent, is too high a figure.

Such questions are hard to decide, since we are not dealing with fixed quantities. I have spoken on purpose of improvement as well as cure, because cure is understood in different ways. Mendel calls a disappearance of the symptoms a cure, without regard to the time during which they have disappeared. He said that a person who was periodically deaf-mute had been cured by hypnotic treatment, because he spoke and heard for several days, though a few days later there was a relapse. I should make the idea of cure depend upon the disappearance of the tendency to return of the disease. But this is a scientific theoretical notion, while the other springs from practical need.

But I certainly believe, with Krafft-Ebing, F.

Muller, and others, that no important effect can be obtained in most functional neuroses without suggestion. Therefore I consider suggestion an immense step in advance in this direction ; suggestion without, as well as with, artificially induced hypnosis, which, however often materially helps its effect. I think that hardly any of the newest discoveries are so important to the art of healing, apart from surgery, as the study of suggestion. This will be specially pointed out in a later work. In any case, the conclusion that neither hypnotism nor suggestion will again disappear from the foreground in medicine is justified. This hope is grounded on the fact that there are in Germany a number of practical doctors, not carried away by enthusiasm, who study suggestion, and do not look for hasty successes and " miraculous " cures. They are all the more careful inasmuch as many opponents of suggestion watch their cases in the hope of forming an opinion of their failure. This is the only proper and scientific way, which the most decided opponents have not always followed.

Naturally, care must be taken to examine character as in all therapeutics. Men are no more alike mentally than physically, and I believe that their mental differences are greater than their bodily ones. Therefore it is not astonishing that doctors who have psychological knowledge should succeed, while others, who treat by hard and fast rule, fail. The