_Psychotherapy in Surgery_
I. Psychotherapy in Old-Time Surgery 746
II. Mental Influence Before Operation 749
III. Mental Influence and Anesthesia 753
IV. Mental Influence After Operation 759
APPENDICES
I. Illusions 766
II. Religion and Psychotherapy 776
INDEX 781
{xiv}
{xv}
LIST OF ILLUSTRATIONS
FIG. PAGE
The Temple of Epidaurus as a health resort Facing page 9
1.--Expressions of the mouth 102
2.--Cortex of human brain illustrating complexity
of the systems and plexuses of nerve fibers 109
3.--Small and medium-sized pyramidal cells of the
visual cortex of a child twenty days old 110
4.--Series of sections showing the fine nerve
endings and branchings of the first and second
layer of the visual cortex of a child
fifteen days old. 111
5.--First, second and third layer of the anterior
central convolution of the brain of a child
one month old 112
6.--Layers of the posterior central or ascending
parietal convolution of a new-born child 112
7.--Diagram of cells of cerebral cortex 113
8.--Scheme of lower motor neuron 114
9.--Scheme of the visual conduction paths 115
10.--Schematic frontal section through the occipital
lobe illustrating manifold connections in a
single lobe 116
11.--Isolated cell from human spinal cord 117
12.--Neuron from the optic lobe of the embryo chick 118
13.--Deep layer of giant pyramidal cells of the
posterior central or ascending parietal
convolution of a child thirty days old 119
14.--Pyramidal cell of cerebral cortex of mouse 119
15.--Neuroglia cells of the fascia dentata, in the
new-born rabbit 121
16.--Neuroglia cell from the subcortical layer of
the cerebrum from which two processes go to a
blood vessel 122
17.--Neuroglia cells from the spinal cord 122
18.--An artery from the cerebral cortex 125
19.--Neuroglia cells of the superficial layers of
the brain from an infant aged two months 126
20.--Complexity of cell of the central nervous system 131
21.--Section through the cortex of the
gyrus occipitalis superior 132
22.--Motor cell of ventral horn of spinal cord from
the human fetus 133
23.--Normal diaphragm curve in normal breathing 577
24.--Curve in diaphragm before and during talking
by a stutterer 577
25.--Illusion of dual vision 615
26.--Illusion of dual vision 767
27.--Binocular vision 767
28.--Binocular vision 767
29.--The Mueller-Lyer lines 768
30.--Illusions of size 769
31.--Illusion of filled space (interrupted vision) 769
32.--Illusions of size and linear continuity 770
33.--Poggendorf's displacement of oblique lines 771
34.--Zoellner's distortion of parallel lines 772
{1}
PSYCHOTHERAPY
INTRODUCTION
To physicians who are students not alone of the manifestations of
disease but also of the workings of human nature, there are few
chapters in the history of medicine more interesting than those which
record the welcome by each generation of the supposed advances in the
treatment of disease. Each generation announced its cures for
diseases, provided its remedies to relieve symptoms, and invented
methods of treatment that seemed to put off the inevitable tendency
toward dissolution. Yet few of these inventions and discoveries
maintain their early reputations, and succeeding generations
invariably abandon most of this supposed medical progress in favor of
ideas of their own, which later suffer a like fate. Plausible theories
have not been lacking to support the successive remedies and methods
of treatment, but the general acceptance of them was always founded
far less upon theory than upon actual observation of their supposed
efficacy. Certain remedies were given and the patients began to
improve. Patients who did not have the remedies continued to suffer,
and sometimes the course of their disease led to a fatal termination.
Even with the best remedies death sometimes took place, but that was
easily accounted for on the ground that the disease had secured so
firm a hold that it could not be dislodged, even by a good remedy. The
connection of cause and effect between the administration of the
remedy and the improvement and eventual cure of the patient seemed to
be demonstrated.
The archives of old-time medicine disprove the notion that clinical
learning and teaching--that is, observation and demonstration at the
bedside--were not part of medical education until quite modern times.
The medical books of the thirteenth, fourteenth and fifteenth
centuries are full of descriptions of actual cases, while, over a
millenium before, one of Martial's epigrams tells of a patient who
dreaded the coming of his physician because he brought with him so
many students, whose cold hands gave chills to the poor victim.
Coincidence and Consequence.--In spite of the opportunities for
careful observation thus afforded and the facilities for training
clinical observers in medicine, many remedies came into vogue, were
enthusiastically applied, and then, after a time, went out of use and
were heard of no more. Sometimes they were subsequently revived and
had even a greater vogue than when originally brought out. But most of
these remedies eventually went forever into the lumber room of disused
treatments. Of the many thousands of remedies which had the approval
and the praise of past generations, two score at most hold a place in
the pharmacopeia of to-day.
There are many reasons for this initial success and eventual failure;
but the most important explanation lies not so much in reason as in
coincidence. In the majority of human ills there is a definite
tendency to get better, and almost anything that is given to the
patient will be followed by relief and {2} improvement. The recovery
is not, however, on account of the remedy, but occurs only after a
definite succession of events that would have taken place either with
or without the remedy.
Mental Influence.--What the old physicians did not, as a rule,
appreciate, or at least failed to value at its true significance, was
the effect upon the patient's mind of the taking of a remedy. Because
of the confidence with which it was given, the patient, having full
faith in the physician who gave it, became impressed with the idea
that now he must get well. The very presence of the physician and his
assurance that the illness was not serious and that many symptoms that
were sources of dread to the patient were only concomitant conditions
of the ailment, naturally to be expected under the circumstances,
relieved the patient from worry, and so gave his nervous energy a
chance to exert itself in bringing about improvement. In other words,
the suggestive elements of the presence of the physician and the
taking of his remedy were important therapeutic factors which enabled
what was an absolutely inefficient remedy, as the event proved when
closer observations of it had been made, to relieve even serious
symptoms, or helped a weak remedy to accomplish good results by
strengthening the patient's resistive vitality.
In recent years we have come to study much more closely this
suggestive element and to appreciate better its true value. Suggestion
has always been an important factor in therapeutics, but has been used
indeliberately and indirectly rather than with careful forethought.
Not that the great thinkers in medicine have not known its value and
have not used it deliberately on appropriate occasions, but that the
profession generally has been so much occupied with the merely
material means of curing that practitioners have not realized the
influence for good of the psychotherapeutic factors they were
unconsciously employing.
The history of the phases of psychotherapy brings out clearly how much
it has always meant in the curing of human ills.
Constancy of Psychotherapy in Medicine.--Though we are prone to think
of it as coming to attention in our time, psychotherapy has played an
important role in every phase of the history of medicine. It has
always been at work, though usually under other names, and has been
effectively used without conscious direction. Germs and their
pernicious activity were not recognized before our time, yet many
definite precautions against them, such as cooking of food and the
keeping of perishable goods on ice, which now seem to be the direct
result of our knowledge of bacteriology, were commonly practiced. The
influence of the mind on the body exerted itself quite apart from
man's recognition of its place or appreciation of its power. When
employed unconsciously it was in many ways even more effective than it
will be when a consciousness of the means by which it is applied
becomes more general. For most people are unwilling to confess that
their minds exercise as much influence as now proves to be the case,
and that over-solicitude means so much in inhibiting the curative
powers of nature, and that it is this which is favorably affected by
psychotherapy.
The great physicians employed psychotherapy very commonly, and on that
account many of their disciples were inclined to think that they were
neglectful of medication and other remedial measures. At all times
physicians have had to be large-minded and have had to recognize the
limitations of medicine in {3} their own time, to turn to other agents
and to appreciate how much their own influence on the patient and that
of the patient on himself meant for the relief of symptoms and the
increase of resistive vitality.
Some of the phases of indeliberate psychotherapy, however, are even
more interesting than this chapter of the history of genuine and
deliberate psycho-therapeutics. Not a few of the remedies recommended,
even by distinguished physicians, were utterly inert, yet accomplished
good through their effect upon the patient's mind. If we were to omit
all reference to certain favorite prescriptions that passed down from
generation to generation, sometimes for centuries, yet eventually
proved to be quite inefficient for the purpose for which they were
employed, what a large lacuna would be left in the history of medical
treatment! Galen's _theriac_ is a typical example of this. Still more
strikingly the role of psychotherapy is seen in the many remedies that
were recommended at various times for such self-limited diseases as
erysipelas, ordinary coughs and colds, pneumonia and typhoid fever.
Anything that was administered just before the change for the better
came in these diseases, or that was persistently taken until that
change came, was proclaimed as curative.
An even more interesting chapter in the positive history of
psychotherapy is that which shows how the value of genuine remedies
was exaggerated by suggestion, and how these remedies became
therapeutic fads, and sometimes almost seemed to be cure-alls. What a
large place antimony holds in medical history, though it is now
entirely discredited! How beneficent has venesection seemed, though it
is now frankly confessed that it has but a narrow usefulness for a
very circumscribed set of ills! Calomel in large doses has a history
very like that of antimony. Alcohol in various forms, now so
strikingly losing its hold in therapeutics, must also be placed in
this category.
Psychotherapy has perhaps had its most fruitful field of potency in
connection with discoveries in the physical sciences. Whenever a
discovery has been made in any science, an application of it to
medicine has been mooted by some fertile mind, though as a rule it
eventually proved to have no place in medicine. One might ordinarily
expect that the suggestion would be latent only when the discovery was
in one of the sciences allied to medicine, but this relation has not
been necessary. Discoveries in astronomy even, in light, in
electricity, in every department of physical science, have each been
given their opportunity to affect patients' minds favorably, and have
succeeded.
Irregular Phases of Psychotherapy.--The quack has always been a
psycho-therapeutist _par excellence_. His main stock in trade has been
his knowledge of men and his power to convince them that he was able
to do them good, so that he could tap all the sources of energy that
were in the patient, some of them quite latent, yet of great
efficiency. Often what the quack and the nostrum vender did for their
patients was calculated to do harm rather than good, yet the mental
energy aroused by the appeal to the patients' minds was sufficient not
only to neutralize the evil, but to release curative powers that
otherwise would not have been called out. The advertisements of the
nostrum maker have proved especially effective, and printer's ink,
properly administered, has been a most potent remedy.
Drug Therapeutics.--Many of the newer phases of mental healing pretend
to do away with drugs. Nothing is farther from my purpose than to
condemn drugs: I am simply pointing out how much supposed drug
efficacy has been {4} due to the mental influence on the patient of
the suggestion that went with the drugs. There has been no thought at
all of pushing drugs out of the extremely valuable place they occupy
in medicine, for I yield to no one in my thorough conviction of their
usefulness. But the efficacious element in the administration of many
drugs has been entirely the confidence of the physician in them, which
confidence was communicated to the patient's mind. Undoubtedly many
highly recommended drugs have in themselves tended to do harm rather
than good, and have been useful only because of this
psycho-therapeutic element. Dr. Oliver Wendell Holmes' famous
expression, that if all the drugs that had ever been used had been
thrown into the sea instead of put into patients' bodies the human
race might have been the better for it, should not be taken to mean
that a great many drugs are not efficacious. Above all, it leaves out
the most important consideration, that patients, while taking drugs
that are either inert or at times even slightly harmful, have had
their mental attitude towards themselves and their ills so favorably
modified by the repeated suggestion that the result has been
distinctly beneficial.
There are probably two score of drugs that are simply
invaluable--magnificent auxiliaries in times of physical and mental
distress. To realize and appreciate the place of these drugs, their
limitations, how they should be administered, and what they can do
under varying circumstances, has taken us centuries. When to these
drugs there is intelligently attached the influence that psychotherapy
has over the patient, their efficacy is probably doubled. Without that
influence nature often works against the drug and lowers its
efficiency. That is the reason why physicians, when themselves
patients, do not respond well to drugs. Familiarity has bred contempt
for some of the old-fashioned remedies, but the contempt that comes
from familiarity is often quite undeserved, and many of the things
that we thus undervalue because of accustomedness have a power that
should be respected. People in a dynamite factory become so familiar
with danger as to despise it at times, but that does not lessen the
energy of the dynamite when occasion arises. When the physician
himself is ill he is likely to remember his failures with drugs rather
than his successes. That is, however, only the tendency of human
nature to a certain pessimistic outlook where we ourselves are
concerned.
There is another class in whom familiarity with drugs has become a
serious matter. They are the patients who have made the rounds of
physicians, have learned to read prescriptions, have looked up the
significance of the various remedies that they have seen prescribed,
have heard doctors talk about them, and remember only what is
depreciatory, and who critically examine a prescription and conclude
that the remedies recommended are not likely to do them good. Every
physician knows the hopeless condition such patients are in. Mental
attitude will greatly help drugs, and it can utterly undo the effect
of all drugs except those which have certain drastic mechanical
effects. Drug failure in these cases is another illustration of how
much psychotherapy means in connection with drug treatment.
Not only is there no intent, then, to lessen respect for drugs in this
textbook of psychotherapeutics, but the one thing that the author
would like to emphasize is the necessity for giving drugs in
sufficient doses. Recommendations in text-books of medicine are often
vague in their indications as to dosage, and surprisingly small doses
are, in consequence, sometimes prescribed. {5} Practically the only
remedial element of such small doses is the mental effect on the
patient, whereas a combination of pharmaceutic and psychotherapeutic
factors would be much more efficacious. It is not unusual to find that
the patient who is supposed to be taking nux vomica as an appetizer or
a muscle tonic, or in order to produce heart equilibrium in the
cardiac neuroses, is getting five drops, two and a half minims, three
times a day, when he should be getting at least twenty drops with the
same frequency. I have known a physician to prescribe ten grains of
bromid where thirty to sixty grains should have been prescribed, and
such valuable pharmaceutic materials as bismuth and pepsin are often
given in doses so small that they preclude all possibility of benefit
except by mental influence.
With therapeutic nihilism or skepticism of the power of drugs I have
no sympathy. As a teacher of medicine I have for years emphasized the
necessity of the use not of conventional doses of drugs for every
patient, but of doses proportioned to the body weight. It seems to me
quite absurd to give the same amount of a drug to a woman who weighs a
hundred pounds and to a man who weighs two hundred and fifty pounds of
solid muscular tissue. I believe in using drugs well up to their
physiological effects if the drugs are really indicated.
With regard to other modes of treatment the same thing is true. Where
they are indicated, balneo-therapy, hydro-therapy, mechano-therapy,
electro-therapy, massage, and all the forms of external treatment,
should be used rationally and not merely conventionally. The
individual and not his affection must be treated. In all of these
methods there is a psychotherapeutic element, and for the benefit of
the patient this, too, must be recognized and used to its fullest
extent.
Supposed Novelties in Mind Healing.--We hear much of mental healing,
of absent treatment, of various phases of suggestion, and of the
marvelous therapeutic efficiency of complete denial of the existence
of evil, and sometimes we wonder whether all these things are not
offshoots of our recent growth in the knowledge of psychology. It is
possible, however, to find, masquerading under the head of the
efficacy of nostrums in the past, the equivalents for all the
activities of mental healing of the present. It all depends on what is
the scientific fad of the hour. If it is electricity, then some mode
of electrical treatment serves the purpose of suggesting cure, and
relief of symptoms follows. If drug treatment of any particular kind
is attracting much attention, then the suggestion is most effective
that is founded on this basis. Perkins' tractors or the Leyden jar are
effective at one time, radium or the X-rays at another, sarsaparilla
or dilute alcohol at another, while a generation that is much
interested in psychology may find, as ours does to a noteworthy
degree, quite sufficient favorable suggestion for the cure of many
ills in purely psychic influences, either direct or indirect,
deliberate or unconscious.
Men and women do not change, their ills are about the same, and except
for certain definite scientific remedies it is only the superficial
mode of treatment that differs very much. Psychotherapy has always
been an important element in most of the therapeutics of history. With
so much accomplished in the past by indirection, there can be no doubt
but that important advances in psychotherapeutics must result from the
extension of its deliberate use.
We have not yet reached a point in our knowledge of the mode of the
{6} influence of the mind on the body that will enable us to treat
this large subject in a scientific manner. What has been written is
set down rather as suggestive than conclusive. There is almost nothing
that the human mind cannot do, its power ranging from the ability to
delay death for hours or even days to causing sudden or unlooked for
death under strong emotional strain. But we are as yet without
definite data as to the possibilities of the immense power for good,
and also for ill, that lie unrevealed in this domain. Anything that
makes for observations by a large body of trained observers in a large
number of cases will almost surely serve to bring about a development
of this subject of valuable practical application.
Psychotherapy is open to large abuse. It will happen that men who are
not trained in diagnosis will occasionally try to use
psychotherapeutic means when what is needed is the knife, the actual
cautery, a good purge, some strong drug, or other efficient remedy
whose value has been demonstrated and which any trained physician can
use. It will also happen that men who lack tact will occasionally
disturb patients' minds still further by what they say to them in a
mistaken attempt at psychotherapy, and will sometimes suggest other
symptoms and make sufferers worse by their clumsy attempts to remove
symptoms that are already present. Every good thing, however, is open
to the same objection. Even good food is abused. The use of drugs has
been so abused that the abuse has done much to discredit medicine at
many periods. There is a Latin proverb which says: "From the abuse of
a thing no argument against its use can be drawn." We cannot prevent
liability to abuse, and psychotherapy is sure to meet that fate. It
has been abused in the past, and is abused now, and always will be
abused, but formal study of psychotherapy and its deliberate
employment will do more than anything else to limit the inevitable
abuse.
If its place in history and in medicine is definitely set forth, its
problems squarely faced and their solutions definitely suggested, it
is much less likely to be misused. At least, then, the whole subject
is open for free and frank discussion and for such additions and
subtractions as may make this department of therapeutics as important,
or at least in a measure as valuable, as climato-therapy or
balneo-therapy or mechano-therapy or electro-therapy. The development
of each of these subjects has proved helpful. It is true that each
specialist has, in the eyes of his colleagues in general practice,
exaggerated the significance of his own department. This is true in
all specialties, however, and psychotherapy deserves quite as much as
any of the subjects we have mentioned to have a place among the
text-books of medicine; and so this one is committed to the judgment
of clinical observers. Long ago Horace said:
Si quid novisti rectius his candidus imperti
Si non his utere mecum.
{7}
HISTORY OF PSYCHOTHERAPEUTICS
SECTION I
_PSYCHOTHERAPY IN THE HISTORY OP MEDICINE_
CHAPTER I
GREAT PHYSICIANS IN PSYCHOTHERAPY
"The real physician is the one who cures: the observation which does
not touch the art of healing is not that of a physician, it is that of
a naturalist."
Psychotherapy is as old as the history of medicine and may be traced
to the earliest ages. The great physicians of all time have recognized
its value, have used it themselves and commended its use to their
disciples, though realizing its mysterious side and appreciating its
limitations.
FIRST PHYSICIAN
The first physician of whom we have any record was I-em-Hetep, who
lived in the reign of King Tcsher of the third dynasty of Egypt,
probably before 4000 B. C. Among his titles, besides that of Master of
Secrets, was Bringer of Peace. He was looked up to as one who, when
not able to cure physical ailments, did succeed in consoling and
reassuring patients so as to make their condition much more bearable.
Like others of the great early physicians, he was after his death
worshiped as a god, a tribute which probably signifies that those who
had been benefited by his ministrations felt that he must have been
more than mortal.
The extent of the Egyptians' admiration for him will be appreciated
from the fact that the step pyramid at Sakkara is said to have been
built in his honor, though, as a rule, pyramids were erected only to
honor kings or the very highest nobility. The extant statue of
I-em-Hetep shows a placid-looking man with an air of beneficent
wisdom, seated with a scroll on his knees. It produces the distinct
impression, as may be seen from the illustration, that his patients
must have trusted him thoroughly, since this is the memory of his
personality that was transmitted to posterity. While he came to be
looked upon as the medical divinity of the Egyptians, he was never
represented with a beard, which is the token of the gods, or of
mortals who have been really apotheosized. Evidently his devotees felt
that it was the divine in his humanity which was the most prominent
feature that they wished to honor. Among the Greeks AEsculapius, who
had been merely a successful physician, came to be honored as a deity.
When we recall the condition of therapeutics at that {8} time, it is
evident that man's appreciation of his power to console, even though
he might not be able to heal, of his influence over men's minds in the
midst of their sufferings, and the confidence that his presence
inspired, were the real sources of their grateful recognition.
PSYCHOTHERAPY IN EGYPT
Among the Egyptians the first great development of medicine came among
the priests. The two professions, the medical and priesthood, were
one, and the temples were the hospitals of the time. We have stories
of people traveling long distances to certain temples in the early
days of Egypt and also of Greece. Often the sick slept in the temples
and dreamed of ways by which they would be cured. The stories make one
feel that somehow the sleep which came over them was not entirely
natural and spontaneous, but must have been something like hypnotic
sleep. As for the dreams, the suggestions of modern time given in the
hypnotic condition seem to be the best indication that we have of what
happened in those old days. Certain it is that the persuasion of the
patient that he would get better, the influence of the diversion of
mind consequent upon his journey and the regulation of life under new
circumstances in the temple, with the repeated suggestions of the
priests and of their various remedial measures, as well as those due
to the fact that other patients around him were improving, all plainly
show the place of psychotherapy at this time.
Much of the old-time therapy was in association with dreams supposed
to have been in some way inspired. This was true at Epidaurus, at Kos,
at Rome, at Lebene, at Athens, and at every place we know of where
cures were worked in the olden times. To the modern mind it seems
impossible that dreams should come so apropos unless they were in some
way directed. The only explanation seems to be the use of suggestion,
with the probable production of sleep resembling our modern hypnotic
trance. Apparently the patient's attention was little directed to the
origin of the suggestions received, but he remembered and benefited by
them.
The most explicit testimony that we have to the antiquity of
psychotherapeutics and to the employment of the influence of the minds
of patients over their ailments in the olden time is in Pinel's
"Nosographie philosophique" and in his "Traite medico-philosophique
sur l'alienation mentale."
Pinel himself will be remembered as the great French psychiatrist who,
confident that he could control most of them by mental influence,
first dared to strike the chains from the insane in the asylums of
Paris, at the end of the eighteenth century, when for more than a
century they had been treated more barbarously than ever before in
history. The passage makes clear that the writer himself, over a
hundred years ago, was persuaded of the significance of the patient's
mental attitude and of the value of mental treatment for many nervous
and mental diseases:
An intimate acquaintance with human nature and with the character in
general of melancholics must always point out the urgent necessity of
forcibly agitating the system, of interrupting the chain of their
gloomy ideas, and of engaging their interest by powerful and
continuous impressions on their external senses. Wise regulations of
this nature are considered as having constituted in part the
celebrity and utility of the priesthood of ancient Egypt. Efforts of
industry and of art, scenes of magnificence and of grandeur, the
varied pleasures of sense, and
{9}
the imposing influences of a pompous and mysterious superstition, were
perhaps never devoted to a more laudable purpose. At both extremities
of ancient Egypt, a country which was at that time exceedingly
populous and flourishing, were temples dedicated to Saturn, whither
melancholics resorted in crowds in quest of relief. The priests,
taking advantage of their credulous confidence, ascribed to miraculous
powers the effects of natural means exclusively. Games and recreations
of all kinds were instituted in these temples. Beautiful paintings and
images were everywhere exposed to public view. The most enchanting
songs, and sounds the most melodious "took prisoner the captive
sense." Flowery gardens and groves, disposed with taste and art,
invited them to refreshment and salubrious exercise. Gaily decorated
boats sometimes transported them to breathe, amidst rural concerts,
the pure breezes of the Nile. Sometimes they were conveyed to its
verdant Isles, where, under the symbols of some guardian deity, new
and ingeniously contrived entertainments were prepared for their
reception. Every moment was devoted to some pleasurable occupation, or
rather a system of diversified amusements, enhanced and sanctioned by
superstition. An appropriate and scrupulously observed regimen,
repeated excursions to the holy places, preconcerted fetes at
different stages to excite and keep up their interest on the road,
with every other advantage of a similar nature that the experienced
priesthood could invent or command, were, in no small degree,
calculated to suspend the influence of pain, to calm the inquietudes
of a morbid mind, and to operate salutary changes in the various
functions of the system.
[Illustration: The Temple at Epidaurus as a Health Resort]
This gives some slight idea of the magnificent arrangement of this
famous health resort of the Greeks in which every possible care was
taken to influence the mind of the patient favorably and bring about
his cure. The buildings of the Hieron or medical institution of
Epidaurus were beautifully situated about six miles from the town of
Epidaurus in picturesque scenery and the most healthful
surroundings. There were a series of bathing houses for hydropathy.
The abatons, lofty and airy sleeping chambers with their southern
sides and open colonnade, are singularly like the open balconies of
our tuberculosis sanatoria. Every occupation of mind was provided.
There was a theatre that would seat over 10,000 people. Here the
great classic Greek plays were given with fullest effect. There was
a stadium seating about 12,000 people in which athletic events were
witnessed, finally there was a hippodrome for alt sorts of
amusements in which animals shared. Then there were the walks
through the country, sheltered paths around the grounds for
inclement weather, even tunnels for passage from one building to
another and all the influence of religion, of suggestion, of contact
with cultured priests thoroughly accustomed to dealing with all
manner of patients. No wonder the place was popular and many cures
effected.
A, South Propylaea; B, Gymnasium; C, Temple of Esculapius; DD, East
and West Abatons (temple enclosures); E, Pholos; F, Temple of
Artemis; G, Grove; H, Small Altar; I, Large Alter; J, South
Boundary; K, Square (building); L, Baths of Esculapius; M, Gymnasium
and Hostel; N, Four Quadrangles (for promenade and exercise); O,
Roman Building; P, Roman Bath; Q, Portico of Cotys; R, Northeastern
Colonnade; S, Northeastern Quadrangle; T, Temple of Aphrodite (?);
U, Northern Propylaea, on the Road to Epidaurus; V, Roman Building;
W, Northern Boundary; X, Stadium; Y, Goal or Starting Line; Z, Tunnel
between Temple and Stadium. (Caton.)
[End Illustration]
There are other phases of Egyptian medicine which serve to show us how
early many of the psychological ideas that we now are trying to adopt
and adapt in medicine had come to the thinkers in medicine of long
ago. There is, for instance, now in the Berlin museum an interesting
papyrus of the Middle Kingdom, the date of which is about 2500 B. C,
in which there are many modern ideas. It is a dialogue which attempts
the justification of suicide. The principal speaker, a man weary of
life, has made up his mind to suicide, but is hesitant. The others who
speak in the dialogue are his _secondary personalities_. The Egyptians
considered that there were several of these interior persons with whom
the man himself might have communication. A man could play draughts
with his _ba_ somewhat as we play solitaire. He could talk to and
exchange gifts with his _ka_. He could argue and remain at variance,
but more often come to an agreement, with his _khou_. This last was
his luminous immortal _ego_, which, according to the then generally
received Egyptian conception, formed a complete and independent
personality. The whole scene thus outlined is typically modern in
certain phases of its psychology, and presents the only known
treatment for the tendency to suicide. While we have but this
instance, there seems no doubt that the same system of persuasion must
have been employed for the cure of other mental conditions than that
which predisposes to suicide.
What is described in our quotation from Pinel as the most ancient form
of psychotherapy has all down the centuries been the rule of life for
patients at institutions similar to those of Egypt. We know more of
Greece than of other countries; there the shrines of AEsculapius were
in many ways what we now call sanatoria. They were spacious buildings
pleasantly situated, the hours of rising and of rest were definitely
regulated, the patients' minds were occupied with the details of the
cure, they met pleasant companions from distant places, they had all
the advantages of diversion of mind, simple diet, long hours in the
open air and abundance of rest away from the ordinary worries of life.
Besides, there had usually been some weeks or months of {10}
preparation during a lengthy journey and all the diversion of mind
which that implies. No wonder that these institutions acquired a
reputation for cures of symptoms which the physician had been unable
to accomplish while the patient was at home in the midst of his daily
cares and worries of life.
The temples in Egypt, in Assyria, in Greece, were much like the health
institutions--"cure houses," as the expressive German phrase calls
them--of our day. Pictures of the temple of AEsculapius at Epidaurus
show a magnificent building with beautiful grounds, ample bathing
facilities, and evidently many opportunities for a quiet, easy life
far from the worries and bustle of the world and with everything that
would suggest to the patient that he must get well. This phase of
psychotherapy in the olden time is not only interesting in itself, but
furnishes a valuable commentary on corresponding modern institutions,
since it shows that it is not so much the physical influences, which
have differed markedly at different periods, as the mental attitude so
constantly influenced at these institutions which was the real
therapeutic factor.
Now our sanatoria are nearly all founded on some special principle of
therapeutics. Some of them have dietetic fads and no food out of which
the life has been cooked is eaten. Some of them are absolutely
vegetarian. Some of them depend on wonderful springs in their
neighborhoods, others on certain forms of exercise, still others give
the rest cure. All succeed in relieving many symptoms. No one who has
analyzed the cures effected will think for a moment that it is the
special therapeutic fad of the institution that accomplishes all the
good done for patients suffering from so many different complaints.
Similar ills often are affected quite differently, and, while some are
relieved, others are not. Those who fail to be cured at one will,
however, often be relieved at another. It depends on how much
influence of mind is secured over the patient and how much diversion
from thoughts of self is provided.
MIND HEALING IN GREECE
When Greece awoke to the great literary and scientific discussion of
human thought that gave us such philosophic and scientific thinkers as
Hippocrates, Plato and Aristotle, then psychotherapy, in the formal
sense of caring for the mind of the patient as well as for his body,
came to be explicitly recognized as having therapeutic value.
Hippocrates insisted that medicine was an art rather than a science,
that personality had much to do with it, and that the patient must be
optimistically influenced in every way. The first of his aphorisms is
well known, but few realize all of its significance. Hippocrates
declares that "life is short and art long, the occasion fleeting,
experience fallacious and judgment difficult. The physician must not
only be prepared to do what is right himself, _but also to make the
patient, the attendants and externals cooperate."_ No one emphasized
more than he the necessity for differentiating the individual patient,
and to him we owe, in foundation at least, the aphorism that it is
more important to know what sort of an individual has a disease than
what sort of a disease the individual has, for the chances of cure
greatly depend on favorable individuality.
Perhaps Hippocrates' most striking direct contribution to
psychotherapy is his aphorism with regard to pain. He said: "Of two
pains occurring together in different parts of the body, the stronger
weakens the other." When {11} the attention is distracted from pain,
then it is lessened. Of two pains, then, only the one that attracts
the most attention is much felt, and, if a slight pain is succeeded by
a severe pain in another part of the body, the lesser pain will
apparently become trivial, or, indeed, not be felt at all.
In Plato we find the direct philosophic expression of the value of
psychotherapy. There had been during the preceding century a great
increase in information with regard to the facts of physical nature,
and especially the sciences relating to the human body, and so men had
come, as they are prone to at such eras--our own, for instance--to
think too much of the body and too little of the mind that rules it.
Accordingly, we have from Plato a deliberate, emphatic assertion of
this great truth under circumstances which make us realize how keenly
he appreciated its significance for the art of medicine and for
humanity.
Professor Osier, in his address, "Physic and Physicians as Depicted in
Plato," [Footnote 1] tells a story which shows clearly how much the
great Greek philosopher appreciated the place of psychotherapy.
[Footnote 1: "AEquanimitas and Other Addresses."]
Charmides had been complaining of a headache, and Critias had asked
Socrates to make believe that he could cure him of it. Socrates said
that he had a charm which he had learnt, when serving with the army,
of one of the physicians of the Thracian king. Zamolxis. This
physician had told Socrates that the cure of a part should not be
attempted without treatment of the whole, and, also, that no attempt
should be made to cure the body without the soul, "and, therefore, if
the head and body are to be well, you must begin by curing the mind;
that is the first thing. And he who taught me the cure and the charm
added a special direction. 'Let no one,' he said, 'persuade you to
cure the head until he has first given you his soul to be cured. _For
this,'_ he said, _'is the great error of our day in the treatment of
the human body, that physicians separate the soul from the body._'"
Because it anticipates so much that is thought to be recent in the
treatment of certain affections this paragraph is interesting from
many standpoints. Headache is typically one of the ills that in the
modern time has often been cured by suggestion. Critias knew how much
confidence Charmides had in Socrates, whom he looked upon as his
master, and that, therefore, Socrates' declaration of his power to
cure would probably be sufficient to relieve his disciple. Critias
shrewdly suggests, however, that Socrates possessed a charm which he
had learned from a distinguished royal physician. Cures in the modern
time of any kind are likely to be much more effective if they come
from a distance and, above all, if they have some connection with
royalty, or have been tried with favorable results upon distinguished
personages.
ALEXANDRIAN PSYCHOTHERAPY
When the center of interest in Greek medicine was transferred from
Greece itself to Egypt, and the Alexandrian school represented what
was best in medical thinking and investigation, we find evidence once
more of wise physicians realizing the influence of the mind on the
body and of what seemed to physicians of lesser experience the cure of
physical ills by mental means. One of the most distinguished
physicians of all time is Erasistratos, who, with Herophilus, made the
fame of the great medical school at Alexandria, {12} the first
university medical school in the world's history. Both practiced
dissection with assiduity, and, while it is Herophilus' name that is
associated with the _torcular_ within the skull, and it was he who
gave the name _calamus scriptorius_ to certain appearances in the
fourth ventricle, and otherwise stamped his personality on the study
of the brain, it is to Erasistratos that we have to turn for a typical
example of the mental physician. Erasistratos, about 300 B. C,
recognized the valves of the heart, gave them the names tricuspid and
sigmoid, and, like his great colleague, studied particularly the
nervous system. He seems to have distinguished the nerves of motion
from those of sensation, recognized their different functions and the
different directions in which they carried impulses, and thought the
brain the most important organ in the body.
The story is told that he was summoned in consultation to see the son
of Seleukos, surnamed Nikator, the Macedonian general of Alexander the
Great, who became ruler of Babylonia. The illness of this son,
Antiochos, had baffled the skill of the court physicians. While
Erasistratos was feeling his patient's pulse, the stepmother of the
young prince entered the room. She, the second wife of his father, was
young and handsome, and Erasistratos noted that there was great
perturbation of the pulse as soon as the stepmother came in. He
correctly surmised that the young man was in love with the lady and
that his illness had been occasioned by the feeling that his love was
hopeless. The very sharing of his secret seems to have started the
young man's cure, and Erasistratos' wisdom and medical skill became a
proverb throughout the East.
PSYCHOTHERAPY AT ROME
Galen.--Galen, whom we are prone to think of as a Latin because so
much of his work was done at Rome, but whose works have come to us in
Greek, and who was a disciple of the Greek school of medicine, brought
up under Greek influence in his native town of Pergamos, re-echoed
Hippocrates' expressions as to the necessity for securing the
patient's confidence and setting his mind at ease. The story in the
"Arabian Nights" of his experience with the quack, which is known to
most people, shows clearly how the place of mental influence in the
relief of human ills must have been brought home to him. For nearly
fifteen centuries his works continued to be the most read of medical
documents. Nine tenths of all the physicians of education and
influence, confidently looking to him as their master, kept copies of
his works constantly near them, and turned to them for medical
guidance as they would to the Bible for spiritual aid.
The book of Galen which is usually placed first among his collected
works shows how much more important is the mind than the body for
human happiness, and insists on mental interests as making life worth
while. In it he describes the good physician, and says that to be a
good physician a man must also be a good philosopher. When he comes to
talk of the different sects in medicine--for even in his time there
were groups of men who founded their medical practice on very
different principles--he points out that the members of the different
medical sects, while all employing practically the same remedies, do
so on quite different principles, and yet get about the same {13}
results. This concept comes as near to being a conscious reflection as
to the place that the patient's mental reaction had in therapeutics as
might well be expected at that early date.
Alexander of Tralles.--After Galen, medicine suffered an eclipse
because the Romans became too devoted to luxury to permit of its
development, and later the descent of the barbarians from the North
disturbed silence and culture. In spite of the disturbance, however,
there is evidence during the succeeding centuries of the deliberate
use of mental influence and even of direct suggestion in the cure of
disease.
Alexander of Tralles (sixth century A. D.) was not judiciously
critical in his selection of remedies. Often he has quite ridiculous
therapeutic suggestions, and yet we have at least two stories with
regard to him which clearly indicate his employment of mental
influence. One of his patients is said to have been suffering from the
delusion that his head had been cut off by order of the tyrant, but he
was cured as soon as the doctor hit on the interesting expedient of
making him wear a leaden hat, which eradicated his delusion and made
him think his head had been restored.
It is also in Alexander Trallianus, as he is sometimes called, that we
have the original of the story which has been often told, many writers
giving it as an experience of their own. A woman was sure that she had
swallowed a snake, and that it continued to exist in her stomach,
devouring much of her food and causing acute pain whenever large
quantities of food were not provided for it. All sorts of remedies had
been tried without result. At last Alexander gave her an emetic and
then slipped into the basin into which she was vomiting a snake
resembling as closely as possible that which she thought she had
swallowed. The ruse effected a complete cure. Usually in latter-day
variants of this story the cure is only temporary, for the patient
after a time has the same symptoms as before and then is sure that
during the time of its residence in the stomach the snake has given
birth to young.
Paul of AEgina.--In the seventh century Paul of AEgina collected all
that had been written on insanity by physicians of olden times, and
many of his directions and prescriptions for treatment show that he
appreciated the value of mental influence. He recommends that those
who are suffering from mental disease should be placed in a quiet
institution, should be given baths, and that an important portion of
the treatment should consist of mental recreations.
ARABIAN MENTAL MEDICINE
The Arabian physicians who succeeded to the traditions of Greek
medicine preserved also those relating to psychotherapy. Rhazes, the
first of the great Arabian physicians, has a number of aphorisms that
show his interest in and recognition of the value of mental healing.
He insisted that "doctors ought to console their patients even though
the signs of death are impending. For the bodies of men follow their
spirits." He believed that the most important function of the
physician was "to strengthen the natural vitality for, if you add to
that you will remove a great many ills, but if you lessen it by the
drugs which you employ you add to the patient's danger." "Truth in
medicine," he said, "is a goal which cannot be absolutely reached, and
the art of {14} healing, as it is described in books, is far beneath
the practical experience of a skillful, thoughtful physician."
Manifestly he realized the importance of the influence of the
physician over the individual patient.
His greatest successor among the Arab physicians, Avicenna (eleventh
century), "the Hippocrates and the Galen of the Arabians," as Whewell
called him, has some striking tributes to what he recognized as the
influence of the mind on the body. He appreciated that not only might
the mind heal or injure its own body, but that it might influence
other bodies, through their minds, for weal or woe. He says: "The
imagination of man can act not only on his own body, but even on other
and very distinct bodies. It can fascinate and modify them, make them
ill or restore them to health." In this, of course, he is yielding to
the dominant mystical belief that man can work harm to others, which
subsequently, under the name of witchcraft, came to occupy so
prominent a place for ill in European history. But at the same time it
is evident that his opinions are founded on his knowledge of the
influence of mind on body, as he had seen its action in medicine. From
him we have the expression: "At times the confidence of the patient in
the physician has more influence over the disease than the medicine
given for it."
MEDIEVAL MIND-HEALING
During the Middle Ages faith was one of the things most frequently
appealed to, and even the physicians made use of religious belief to
secure a favorable attitude of the patient's mind toward the remedies.
One of the men who particularly realized the importance of this was
Mondeville, the great French surgeon.
Pagel has called attention to Mondeville's insistence on preparing the
patient's mind properly for venesection. The patient should be made to
feel that this procedure was sure to do him good, and various reasons
should be given him why the removal of a certain amount of blood
carried with it poisons from the body, and so gave a better
opportunity to nature to conquer the disease. If the patients were
unfavorably disposed towards venesection, Mondeville thought that it
should not be performed, as it was not likely to do good. It was not
that he felt that the mental influence was the more important of the
two therapeutic factors, but that a combination of the remedial force
of blood-letting with a favorable state of the patient's mind meant so
much more than could be accomplished by venesection alone that it was
worth while to take pains to have the combination of the two. We in
modern times realize that in most cases blood-letting rather did
physical harm than good. It continued to hold a place in medicine
because patients were so much impressed by it that they were given
renewed vigor after its use.
MENTAL HEALING IN THE RENAISSANCE
What is exemplified in medieval medicine in this matter remains true
during the Renaissance. In the fifteenth century Petrus Pomponatius,
well known as a thinker and writer on borderland subjects related to
medicine, came to the conclusion that men might very well be cured of
certain ailments {15} by influence from the minds of others, and that
such treatment, undertaken by physicians appropriately endowed,
produced wonderful effects. He said:
Some men are specially endowed with eminently curative faculties;
the effects produced by their touch are wonderful: but even touch is
not always necessary; their glances, their mere intention of doing
good are efficient for the restoration of health. The results,
however, are due to natural causes.
PSYCHOTHERAPY AND MODERN MEDICINE
Paracelsus.--Paracelsus, the great physician of the first half of the
sixteenth century, who may well be considered the father of modern
pharmaceutics, had no illusions with regard to the exclusive power of
drugs over disease. He recognized that mental influence was extremely
important, and often lent a power not otherwise possessed to many
remedies. He said:
Imagination and faith can cause and remove diseases. Confidence in
the virtue of amulets is the whole secret of their efficacy. It is
from faith that imagination draws its power. Anyone who believes in
the secret resources of Nature receives from Nature according to his
own faith; let the object of your faith be real or imaginary, you
will in an equal degree obtain the same results.
Personal magnetism, in the sense in which we now use it, a
transference of the idea from the science of magnetics as related to
the phenomena of the magnet, seems to have originated with Paracelsus.
He was sure that the influence exerted over certain patients by
certain physicians was due to a force very like that exerted by the
magnet over iron. He was even inclined to think that magnets
themselves might exert a strong potency over diseased conditions, and
he found them to be useful in epilepsy. Doubtless in many cases of
supposed epilepsy successfully treated the ailment was really of an
hysterical nature. In these cases the strong suggestion which the use
of the magnets gave for many centuries acted favorably.
Agrippa.--The writings of Cornelius Agrippa, a contemporary of
Paracelsus, and, like him, a student of alchemy and of the secrets of
nature, contain corresponding passages which serve to show how much of
interest there was in mental influence during the Renaissance. All of
these men were, of course, a little outside of the ordinary medical
tradition, intent on getting to realities, not being satisfied either
with words or assumptions, refusing to accept many thing that the
physicians of their time completely credited. Agrippa in a
characteristic passage said:
Our mind doth effect divers things by faith (which is a firm
adhesion, a fixed intention, and a vehement application of the
worker or receiver) in him that cooperates in anything, and gives
power to the work which we intend to do. So that there is made in
us, as it were, the image of the virtue to be received, and the
thing to be done in us, or by us. We must, therefore, in every work
and application of things, affect vehemently, imagine, hope and
believe strongly, for that will be a great help.
Van Helmont.--At the end of the sixteenth century Van Helmont, who
carried on the work in pharmaceutics begun by Paracelsus, and to whom
we owe the discovery of a number of substances commonly used, as well
as the invention of the word "gas," was a thorough believer in the
influence of mind over body and, indeed, in the existence in human
beings of storehouses {16} of latent energy ordinarily unemployed, but
that might under special circumstances be tapped to produce wonderful
effects. Indeed, some passages remind us of Prof. James' expressions
in his discussion of the law of human energy. Van Helmont said:
All magical power lies dormant in man, and requires to be excited.
(Compare Prof. James's "Law of Mental Energy" in the chapter on
Mental Influence). This (need for excitation) is particularly the
case if the subject upon whom we wish to operate is not in the
most favorable disposition; if his internal imagination does not
abandon itself entirely to the impression we wish to make upon him;
or if he towards whom the action is directed possesses more energy
than he who operates. But when the patient is well disposed or
weak, he readily yields to the magnetic influence of him who
operates upon him through the medium of his imagination. In order to
operate powerfully, it is necessary to employ some medium; but this
medium is nothing unless accompanied by internal action.
Sydenham.--In the more modern period the deliberate use of the
influence of the mind on the body is quite as clear. Undoubtedly the
greatest of modern physicians, who well deserves the name of the
English Hippocrates, is Sydenham. How much Sydenham realized that many
of his patients' ailments could only be cured by occupying their minds
with other things is seen in his writings. There is a characteristic
story told by Dr. Paris in his "Pharmacologia" which illustrates this
well and is a striking anticipation of what we are prone to think of
as very modern views in these matters:
This great physician, Sydenham, having long attended a gentleman of
fortune with little or no advantage, frankly avowed his inability to
render him any further service, at the same time adding, that there
was a physician of the name of Robertson, at Inverness, who had
distinguished himself by the performance of many remarkable cures of
the same complaint as that under which his patient labored, and
expressing a conviction that, if he applied to him, he would come
back cured. This was too encouraging a proposal to be rejected; the
gentleman received from Sydenham a statement of his case, with the
necessary letter of introduction, and proceeded without delay to the
place in question. On arriving at Inverness, and anxiously inquiring
for the residence of Dr. Robertson, he found, to his utter dismay
and disappointment, that there was no physician of that name, nor
ever had been in the memory of any person there. The gentleman
returned, vowing eternal hostility to the peace of Sydenham, and on
his arrival, at home indignantly expressed his indignation at having
been sent on a journey of so many hundred miles for no purpose.
"Well," replied Sydenham, "are you better in health?" "Yes, I am now
quite well; but no thanks to you." "No," says Sydenham, "but you may
thank Dr. Robertson for curing you. I wished to send you on a
journey with some object of interest in view; I knew it would be of
service to you: in going, you had Dr. Robertson and his wonderful
cures in contemplation; and in returning, you were equally engaged
in thinking of scolding me."
Morgagni.--In the century following Sydenham we have a number of
examples cited by Morgagni, the father of pathology, in which his
recognition of the value of the mind as a curative agent and of the
harm that may be done by over-occupation of the mind is set forth at
its proper value. Benjamin Ward Richardson in his "Disciples of
AEsculapius" [Footnote 2] tells of two incidents in which this phase
of Morgagni's very practical application of knowledge to medical
practice is exemplified:
[Footnote 2: London, 1901]
{17}
In other examples, where the symptoms are due to mental oppression,
he pursued a course of treatment that was of soothing nature. A
distinguished professor of physic at Bologna happened to discover
that his pulse was intermittent, and being extremely anxious about
it was incessantly feeling his pulse, to discover that the evil was
daily increasing. Morgagni's advice to his patient was to take his
finger off his wrist and not to inquire too anxiously about his
condition. The advice was followed, and the result was a complete
removal of the disturbance.
It is a very singular truth that in describing the action of the
nervous system on the circulation Morgagni shows that he was
cognizant of the fact that the circulation may be disturbed by two
sets of nervous irritations, one inflicted through the
pneumogastrics, the other "through those nerves which are
subservient to the arteries"--the vaso-motor system which is readily
disturbed by the mind. In one patient he observed great
perturbations of the pulse in both wrists as the result of mental
anxiety. But a day or two later the pulse derangement was confined
to the left side altogether. The pulse of the right arm was quite
regular, while that of the left arm still showed the inequality.
When the mental distress was relieved, this pulse also became equal.
Morgagni cites Sydenham's contemporary, Lancisi, the great Italian
physician, as recognizing the influence of the emotions on the heart.
Examples of similar convictions as to mental influence in medicine are
also found in the works of Morgagni's great contemporaries, Boerhaave
and Van Swieten, and the great physicians of the seventeenth and
eighteenth centuries were closely imitated in their recognition of the
value of the influence of mind over body in medicine by their
successors in the profession.
John Hunter.--Wise old John Hunter recognized the influence of the
mind on the body very clearly. He said, for instance, "There is not a
natural action in the body, whether voluntary or involuntary, that may
not be influenced by the peculiar state of mind at the time." He lays
it down as a law that "every part of the body sympathizes with the
mind, for whatever affects the mind, the body is affected in
proportion." He said further, "as a state of the mind is capable of
producing a disease, another state of it may affect a cure." He called
attention to the fact that the touch of a corpse produced wonderful
effects upon the minds of patients. He said, "Even tumors have yielded
to the stroke of a dead man's hand." He observes that "while we should
naturally expect that diseases connected with the nerves--and those in
which their alteration is in the action of parts not in their
structure--would be most affected by the imagination, we find that
there are other diseases in which they appear to have little
connection that are much affected by the state of mind."
German Mind Healing.--In his monograph on "Psychotherapy in Its
Scientific Aspects" [Footnote 3] Dr. Berthold Kern calls attention to
a forgotten book of the German physician Scheidemantel, published in
1787. Its title was "The Emotions as Remedies." It seems to be very
rare since even our Surgeon General's Library has no copy of it. The
author treated psychotherapy systematically. He insisted that man was
a unit in which body and soul mutually influenced each other.
Scheidemantel blamed the moralists for considering the soul
exclusively and the physicians for thinking only of the body. He
thought that this was a serious mistake for both sides and he seems to
have anticipated much of our recent discussion on the influence of the
body and {18} of things physical generally in what is called crime and
various divagations from law. On the other hand, he thought that the
influence of the mind on the body was one of the most important
elements in therapeutics.
[Footnote 3: "Die Psychische Krankenbehandlung im Ihren
Wissenschaftlichen Grundlagen." Berlin 1910.]
Reil, after whom the Island of Reil is named, and who taught us much
with regard to brain anatomy, was also interested in the influence of
mind on body. He was the professor of anatomy at Berlin in the early
part of the nineteenth century and had great influence over the
medical science of the time. He insisted on the recognition and
development of psychotherapy and hoped to give it a place beside the
medical and surgical treatment of human ills. He did much to create a
current of thought in German medicine which culminated in Johann
Mueller's very definite expressions with regard to the power of the
mind over the body.
Very probably the most striking expression of the influence of mind
upon body is in that wonderful old book, Johann Mueller's text-book of
physiology, issued in an English edition (London, 1842) under the
title "Elements of Physiology." The subject, a favorite study, is set
forth very clearly, and evidently from personal knowledge. He
recognized that the mind might influence every organ and function of
the body. The influence of expectancy he emphasized particularly:
The influence of ideas upon the body gives rise to a very great
variety of phenomena which border on the marvelous. It may be stated
as a general fact that any state of the body, which is conceived to
be approaching and which is expected with perfect confidence and
certainty of its occurrence, will be very prone to ensue as the mere
result of that idea, if it do not lie without the bounds of
possibility. The case mentioned by Pictet, in his observations on
nitrous oxide, may be adduced as an illustration of such phenomena.
A young lady, Miss B., wished to inspire this intoxicating gas; but
in order to test the power of the imagination, common atmospheric
air was given to her, instead of the nitrous oxide. She had scarcely
taken two or three inspirations of it, when she fell into a state of
syncope, which she had never suffered previously; she soon
recovered. The influence of the ideas, when they are combined with a
state of emotion, generally extends in all directions, affecting the
senses, motions and secretions. But even simple ideas, unattended
with a disturbed state of the passions, produce most marked organic
effects in the body.
With regard to the influence of the mind over the body in the matter
of fatigue Mueller is especially emphatic. He states just as clearly
two generations ago the Law of Reserve Energy as James stated it in
recent years. Of course, Mueller was far beyond his time in everything,
but then men who really think always are, and even Mueller's accurate
expression only represents what had been in the minds of thinking men
in many previous generations. He says:
The idea of our own strength gives added strength to our movements.
A person who is confident of effecting anything by muscular efforts,
will do it more easily than one not so confident in his own power.
The idea that a change is certainly about to take place in the
actions of the nervous system, may produce such a change in the
nervous energy, that exertions hitherto impossible become possible.
This is still more likely to be the case, if the individual is at
the time in a state of mental emotion.
Even this necessarily fragmentary and rather disjointed sketch of the
main features of psychotherapeutics, as we see them recognized by the
great {19} physicians of the past, serve to show that mental influence
has always been appreciated as an important element in the care of the
individual patient.
The times when special attention has been paid to psychotherapy have
certain special characteristics. Usually the periods have come just
after a signal advance in medicine made through devotion to physical
science. Great attention is given to the advances and for a time the
individual patient is forgotten in the hope that at last physical
science is going to solve the problems of the physical man. With the
disappointment that always follows there is a reversion of feeling and
men realize once more how important is the mental state of the
patient, even in physical diseases. Then there comes an emphatic
expression of the value of psychotherapy. We are at present in the
midst of one of these periods, hence the widespread interest in the
subject.
CHAPTER II
UNCONSCIOUS PSYCHOTHERAPEUTICS
The great authorities in medicine, the men whose thought counted for
most in the development of not only the science but the art of
medicine, the men to whom we look back as having been great practicing
physicians, have always used this remedial measure deliberately and
have suggested to others that it should be so used. But the smaller
minds have been satisfied to think that their drugs, their external
remedies and applications, have been the sole sources of the benefit
that accrued to the patient. Such smaller men are prone to think that
they have specifics for disease, while the larger men hesitate and
recognize that coincidence plays a large role and that the suggestive
factors in therapeutics often deceive us as to the real efficacy of
drugs and remedies.
All physicians have at all times used, though often unconsciously, the
suggestive factor in therapeutics, and mental influence has had
everywhere a large role in the treatment of disease. Only in recent
years have we come to appreciate how many diseases are self-limited.
In the treatment of these self-limited diseases all sorts of drugs and
therapeutic methods achieved a reputation. Some of them were looked
upon by generations as specifics, though we know now that they are
almost, if not completely, useless so far as any direct influence upon
the disease is concerned. Indeed, at times they were, _per se_,
harmful rather than beneficial, and the patient literally got well in
spite of the treatment, though the repeated suggestion of betterment
often more than overcame the ill effect and helped in recovery.
REMEDIES PLUS SUGGESTION
Prof. Richet, the head of the department of physiology, University of
Paris, quotes the expression of a French critic of medicine: "Hurry up
and take the new remedy while it still cures. After a time it will
lose its power." The power that is lost as remedies grow familiar is
the suggestive element that accompanied them at the beginning. They
were announced with a flourish of trumpets as a discovery in
therapeutics, a number of cases treated with them {20} were much
benefited (because of the feeling that they must do good), and it was
only after a great many cases had been treated, many of them under
circumstances where patients knew nothing of the claims made for the
remedies, and where physicians had little or no previous confidence in
them, that their true place in therapeutics was revealed. Every
physician of experience has seen the popularity of remedies wax and
wane as a consequence of the attention called to them. We have new
therapeutic discoveries every week. Enthusiastic articles are written
about them, many of them in perfect good faith, and then after a time
no more is heard of them, or they sink back into the long list of
dubious remedies that may be tried when others have failed, but have
no special claim upon us, in spite of the fact that some physicians
continue to think them wonder-working.
"Time is short and art is long, the occasion is fleeting, experience
fallacious and judgment difficult," as Hippocrates bemoaned 2400 years
ago, and conditions in medicine continue the same. With suggestions
and coincidence ever at work, it is still practically impossible to
determine the intrinsic value of any remedy until after a prolonged
trial. In the olden time it was still more difficult because there had
been no such accumulation of experience as we have to guide us, and so
it is not surprising to find striking examples of even great
physicians recommending remedies whose main therapeutic influence must
have been the element of suggestion.
Galen's Theriac.--Perhaps the most striking instance of suggestive
therapeutics is Galen's famous _theriac_, various prescriptions for
which have come down to us, some of them much more complex than
others, so Galen is probably not responsible for all its absurdities.
This remedy contained a host of ingredients, some of which neutralized
others, and all of which taken together could have had but little
effect save by a strong suggestion to the patient that as he was
taking so many drugs he surely must be benefited.
Bernard's Theriac.--Almost in our own time another _theriac_ came
prominently before the public. In his younger years Claude Bernard,
the French physiologist, worked in a little drug store in a country
place not far from the farm on which he was born. There he found that
the most called for remedy was a _theriac_. It was good for most of
the ills that flesh is heir to and was bought in quantities by the old
women of the neighborhood, who administered it on every occasion. The
remedy was made in large quantities, but the secret of its composition
in this particular pharmacy was what interested Bernard. Whenever any
compound was for any reason spoiled in the drug store, the rule was,
"Put that aside for the _theriac_." This much sold remedy then
consisted of the most heterogeneous drugs. It was so diluted that it
could do no harm, though it had quite sufficient taste and odor to
make every one who took it realize that without doubt they were taking
a strong medicine.
The effect of the knowledge of the composition of this wonderful
remedy on Claude Bernard was the best that could have been
anticipated. He resolved to study the physiological effects of drugs
so that they could be given scientifically, and not in the hit or miss
fashion that made possible the success of the _theriac_.
The custom of Bernard's country drug store, however, was not different
from that of most country drug stores of the time. Unconscious
psychotherapeutics we may well call it, because the main therapeutic
factor was {21} suggestion, renewed as often as the mixture was taken,
that the patient ought to feel better, until finally whatever symptoms
were due to over-attention and to concentration of mind on feelings of
discomfort were diverted. Just as soon as the inhibition exercised by
this over-attention ceased its hampering effect nature completed the
cure.
Suggestion in Colds.--Many remedies acquired a reputation for breaking
up coughs and colds. It is, however, extremely doubtful whether any
one has ever aborted a cold, or any other infection, that had gained a
hold on the patient. We now know that this common affliction is not
due to cold but to absorption of infectious material. Nansen spent two
winters near the North Pole without catching any cold, and his men
were as healthy as himself. He had been back in civilization scarcely
a week before he and his men were confined to bed with a grippy cold.
In the far north, and high on mountains where the temperature is low,
colds are not as common as they are in crowded cities and especially
among those who are much in crowds. Cold weather only predisposes to
the infection, and after it has occurred it is sure to run its course.
That course may be longer or shorter. The cold is usually preceded by
chilly feelings. Every one knows it is possible to have chilly
feelings that seem to portend a cold, yet be well the next day. If in
the meantime any remedy is taken, credit will be given to the remedy.
When a cold was supposed to be merely a disturbance of circulation or
a congestion, one might expect to break it up. Now that we know that
it is a microbic infection, and know further that microbic diseases
are usually cured by a definite reaction on the part of the body, we
are not so likely to think of breaking them up. There are still
physicians who think they can abort a threatened pneumonia or
abbreviate typhoid fever, but they are not those who know most about
the science of medicine.
We have the story, then, of a series of remedies used with great
confidence in coughs and colds, some of them physically beneficial,
many of them, especially those containing opium, often physically
harmful, yet taken with such confidence that undoubtedly the patient
was helped through his mind if not otherwise. What is thus true for
this class of diseases can also be said of other minor affections.
Many internal remedies have been used for boils and styes and other
external infections and have often had wide vogue. The reason for
their acceptance as remedies has been that the giving of anything
produces a more hopeful attitude in the mind of the patient and this,
by bettering the general health, sometimes overcomes the tendency that
may exist to a repetition of such infectious processes.
Erysipelas.--The medical history of erysipelas is just a succession of
remedies recommended, each claimed to be almost infallible, yet
abandoned after a time for another for which like exaggerated claims
were made. The doctrine of signatures played a large role in the
treatment of erysipelas, and, strange as it may seem, still survives.
According to the doctrine of signatures, erysipelas, being a disease
involving intense redness of the skin, red things in nature would be
likely to do it good. Red pepper, for instance, was suggested for it
over and over again, both internally and externally. Various red
remedies have been favorites at different times in history. At
present, in many country places, a poultice made of cranberries is
supposed to be most efficacious. For many years I lived in a small
town where one of the grocers {22} put in a large stock of cranberries
each fall, though the people of the neighborhood used them but little
on the table, because during the winter there were many calls for them
for the making of poultices for erysipelas. People who have had
erysipelas, especially if it has occurred on unexposed portions of the
body, are supposed to be protected against its recurrence--for there
is a distinct liability to its recurrence--by the wearing of red
flannels!
There is scarcely any drug that has not at some time been recommended
as almost a specific for erysipelas. Anything that was given on the
third or fourth day, and it was only at this time as a rule that
patients came to physicians to be treated, seemed to bring about the
alleviation of symptoms that occurred on the fifth or sixth day.
Erysipelas, because of the sudden irruption of fever which accompanies
it, the intense redness which characterizes it, and the discomfort
which is often present, is an affection that disturbs patients very
much. For them, then, the presence of the physician and his assurance
that their affection is not likely to be severe, and his prompt relief
of certain conditions, all act by suggestion on the patient's mind and
strengthen the natural curative reaction.
In country places where physicians were not near, erysipelas was one
of the affections that continued almost down to our own day to be
treated by incantations. I have known in a little American country
town of a woman making a "charm," as it was called, for erysipelas.
Pneumonia.--Pneumonia is another of these sharply self-limited
diseases that give opportunity to many remedies for the acquisition of
a reputation as cures. Croupous pneumonia is so disturbing in its
onset, so rapid in its progress, yet so strictly self-limited in the
previously strong and healthy, that in the old days there were many
remedies that were supposed to bring about the crisis. The old
text-books contain so many cures that it is surprising pneumonia
should have continued to be the fatal disease it has been at all
times. Almost any remedy that is used for three or four days in
pneumonia will be followed by the crisis with, in most cases, a
favorable termination. The crisis takes place some time from the
seventh to the tenth or eleventh day, and often we do not see a
pneumonia patient until the second or third day of the disease. Just
before the crisis the patient runs into a series of acute and more or
less alarming symptoms. Often there is much restlessness, difficulty
of breathing with complaint of heaviness, and perhaps prostration. The
pulse and temperature are high, the skin hot and dry. Then in the
midst of this the patient sleeps, there is a critical sweat, the
temperature drops, the patient wakes up feeling quite well, there is
little difficulty in breathing, and he feels that recovery is sure to
come. The change is so great that it is natural that it should have
been attributed to all sorts of remedies which had been used
immediately preceding the crisis.
I once heard an old physician declare at a meeting of a large and
important medical society that calomel in divided doses was
practically a specific for pneumonia. He said he waited forty-eight
hours to be sure that the affection was pneumonia, and also that it
had reached that diffusion in the lungs beyond which it was not likely
to go, then he gave the calomel. He said that, almost as a rule,
during the next forty-eight hours the crisis came--and he attributed
it to the calomel. We have had other remedies just as curious as this
recommended and taken quite seriously. Some years ago a {23} Russian
physician, who had been treating soldiers in the Russian army for the
pneumonia which occurs so commonly after exposure on the Steppes,
announced that he had found in digitalis almost a specific. He pushed
the tincture up to twenty drops three times a day, beginning it just
as soon as the pneumonia was detected, and the rate of mortality among
his patients was about one per cent. According to his theory, it was
the failure of the heart in pneumonia that made the disease fatal.
Apparently the character of the patients in whom his pneumonias
occurred was forgotten. They were absolutely the most favorable cases
that could be selected. Most of them were young men between twenty and
twenty-five. At this age no one who is given a reasonable amount of
fresh air should die of pneumonia. If the patient had a serious heart
lesion, or a crippled kidney from nephritis after scarlet fever, or
crippled lungs because of a previous attack of tuberculosis, then the
pneumonia might be fatal--indeed, almost inevitably would be, or, in
the last-mentioned case, would end by lysis and not crisis. It really
matters little what remedy is given to young, otherwise healthy,
adults; they will get better, barring serious complications. The use
of digitalis lessened the chances of recovery by stimulating too early
in the case the heart that later had to bear one of the most serious
strains that the organ can stand. But doubtless this harm was more
than overcome by the patient's knowledge that he was taking a new and
powerful remedy, supposed to be particularly calculated to cure him.
Moreover, the special interest of the physician in these cases, and
his administration of a remedy with confidence which inspired the
patient, undoubtedly did much good. Pneumonia is one of those diseases
in which the patient is likely to be greatly depressed unless he is
surrounded by favorable mental influences, and is encouraged to
believe that he is going to get well. Every physician has probably had
cases in which patients died, not because of the severity of the
disease, but because they gave up the struggle in fright. If several
of a man's friends have died of pneumonia during the year or two
before he gets it, he is likely to conclude, especially if he is of
the worrying kind, that his doom is sealed as soon as the diagnosis of
pneumonia is made. If this thought persists hardly anything will save
him. He must be assured that pneumonia is not necessarily serious,
that there are remedies that influence it, and that his own case is
particularly likely to respond favorably to them.
We now realize that nursing is the most important element in the
treatment of pneumonia. Such attention to the patient as will treat
symptoms so as to prevent them from disturbing him, will secure him
against discouragement, will arouse his resistive vitality by assuring
him of a favorable termination. This will above all prevent the
patient from feeling that he is attacked by a fatal disease. The
presence of the doctor and his general directions make the patient
realize how thoroughly the course of the disease is understood and
therefore how likely it is that a favorable termination will be
brought about. We know how much the mind may interfere with the
breathing if allowed to dwell on it, and therefore if the patient
becomes over-solicitous about the condition of his lungs he seriously
hampers his recovery. In pneumonia the physician has always brought
relief, and he has usually attributed his success to his drugs, though
he has felt, too, that the confidence inspired {24} by him meant much
for his patient. It would have been better had he exaggerated the
mental influence rather than the drug power.
Typhoid Fever.--Typhoid fever is another affection for which we have
many therapeutic suggestions, with wide vogue, that are nevertheless
almost directly opposed to what we know about the pathology and
etiology of the disease. Typhoid fever runs its course in from between
twenty to thirty days. The majority of people who take the affection
and who give in to it early enough, so as not to wear themselves out,
come through successfully. Complications may carry them off, but we
expect uncomplicated cases to recover. The longer course of typhoid
has made the action of drugs appear less striking than in pneumonia
and erysipelas, but a number of remedies have been proclaimed to
shorten its course, to make it less dangerous, to cure, and sometimes
actually to abort it. So often have these come and gone that the
physician who knows the history of therapeutics is likely to be
suspicious of them. Even at present there are certain remedies
supposed to have this effect, but one does not find them used in
hospitals where large numbers of cases are seen and where there are
opportunities for comparative observation. They are used only by
physicians who see a few cases every year, and to whom coincidences
may mean much more than they are likely to when extensive statistics
of the disease are made.
As a rule, these remedies are founded on some real or supposed
scientific principle. The antiseptic treatment of typhoid, for
instance, was based on the supposition that if one can kill the
microbes in the intestine the disease will run a shorter course. The
principle apparently fails to note that any remedy likely to kill
microbes is still more likely to kill cells of other kinds, and above
all human cells lessened in their resistive vitality by disease. The
advocates of this remedy also forget that typhoid is now recognized as
a general disease with only a local manifestation in the intestines,
and that the treatment of this local manifestation is no more likely
to affect the course of the disease than the treatment of the symptoms
of typhoid would be likely to do. But the giving of remedies with the
thoroughgoing confidence that awakens trust is in itself an excellent
therapeutic agent, and patients thus treated are sure to be benefited
in so far as they share the physician's confidence. Just the same
effect, however, can be produced by careful nursing and by making the
patient realize that even though typhoid fever runs a definite course,
which we cannot abbreviate nor probably influence, we can by nursing
so prevent complications as to make a fatal termination almost
impossible.
Whooping Cough.--Perhaps none of the common affections illustrate the
influence of psychotherapy better than it is exemplified in the
history of the therapeutics of whooping cough. We have had all sorts
of remedies suggested for it, and most of them have been introduced by
those who had found them of great service in shortening the course of
the disease, and in making the "whoop" disappear much sooner than
would otherwise be the case. There have been internal and external
remedies, inhalations and inunctions, as well as many less likely
methods of treatment. Practically none has maintained itself. Whooping
cough is likely to run a rather long course. We know now that as a
consequence of the strain upon the lungs tuberculosis not infrequently
develops. Whenever this is true the tendency to cough is likely to be
{25} prolonged far beyond the natural period, and from habit ingrained
upon the nervous system the "whoop" is likely to continue, though
there is no necessity for it. It is this secondary period of the
affection that the remedies have succeeded in shortening either
apparently or in fact.
Practically anything that is done for children is likely to instil the
persuasion that the "whoop" should disappear. Anything impressive will
arouse this favorable attitude of mind toward the affection, and hence
the remedies have obtained a reputation. In the interior of many
countries draughts of sea water are a popular remedy for whooping
cough. Sea water, it is said, loses its efficacy if carried long
distances from the shore, so the children must be brought to the
seaside. In mining regions children are taken down into the mines. The
experience is enough of itself, especially when talked over a good
deal in the family, and when the occasion is often the first outing
that the child has had for months, to bring with it such improvement
in health as will enable it to suppress the whoop. If the exposure to
the mine air does not bring improvement, it is said to be either
because the child was not taken deep enough, or because there was no
gas in the air, or the wrong sort of mine was chosen, or some other
plausible excuse is advanced.
The development of scientific medicine, or at least what we are
pleased to think of as more scientific therapeutics than they had in
the past, has not kept us from having many and varied remedies for
whooping cough, which, after being introduced on apparently good
authority and apparently accomplishing many good results, have
eventually been allowed to drop into innocuous desuetude. Whenever the
administration of any such remedy was accompanied by strong
suggestion--when the internal remedies were particularly distasteful,
or the inhalations rather trying or at least sure to attract the
attention of the sufferers--then good results followed. But the cures
were due to the mental influences at work. In recent years various
serums, including diphtheria serum, have been tried with reported good
results. The giving of the injection is one of those little operations
that is likely to impress itself forcibly upon the child's mind, and
when given in connection with the promise, implied or explicit, of
improvement it is easy to understand that there will be a tendency to
lessening the frequency of the whoop, at least during the secondary
periods of the disease.
CHAPTER III
GENUINE REMEDIES AND SUGGESTIVE EXAGGERATION
The story of the suggestive use of drugs shows us many suggestions
employed even by distinguished physicians, men whose work is eminently
rational and has lived long after their time. In fact, very few, even
of the most distinguished physicians, have failed to extol remedies
which later proved to be quite ineffectual. Hippocrates felt quite
sure that an external application of snake skin was a cure for all
forms of that chronic skin manifestation, lichen. Pythagoras declared
that anise seed held in the hand was an excellent remedy for epilepsy.
These are only examples which serve to show how much suggestion has
been used unconsciously by the medical profession. The sensation {26}
produced by the touch of the viper's skin was sufficient in some
patients to bring about a change in the circulation in the skin, or
perhaps a distinct modification of the nerve impulses on which trophic
conditions in the skin depend, and this may have produced some cures
on which Hippocrates founded his recommendation. We know that the skin
can be unfavorably affected directly through the nervous system, and
there is no good reason for thinking that it may not also be affected
favorably. In our own day we have seen the suggestive influence of an
operation act as a remedy in epilepsy and have lauded it for a time.
It is, therefore, not surprising that Pythagoras saw, as he thought,
the strong scent of the anise seed act favorably. Both of these
conclusions as to the causative agency at work were wrong, because it
was suggestion and not the operation in most cases, nor the anise in
any case, which caused the improvement.
THERAPEUTIC PERSUASION
It is not only in the distant past, however, but also in quite modern
times that these therapeutic persuasions have existed among
physicians, and as a result physicians have frequently recommended and
employed remedies that we now know not only to have been quite
useless, but sometimes even harmful. A typical example of this is the
use of antimony, originally discovered and studied by Basil Valentine,
an alchemist who had busied himself much with the nature of
substances, vegetable and mineral, and with their action as remedies
for disease. Sir Michael Foster hailed him as the first of
pharmacologists, and said: "The old monk did not care for the problem
of the body; all he sought to understand was how the constituents of
the soil and of plants might be treated so as to be available for
healing the sick and how they produced their effect."
Suggestion and Antimony.--This was an eminently scientific research.
It brought the father of pharmacology to certain supposed discoveries
which continued to occupy men's minds for centuries, yet ultimately
proved to be utter misunderstandings of drug action, because
suggestion played so large a role that it vitiated all the
conclusions. The best known of Basil Valentine's books is the
"Triumphal Chariot of Antimony," which contains many interesting
scientific observations that were probably new at the time and which
show their author's investigating spirit and his interest in
scientific research.
In spite of his scientific advances, however, Valentine was wholly
mistaken with regard to antimony. He used it in various diseases, and,
of course, it always produced very definite effects on the bowels.
These effects the physician could easily foretell. It was for the
patient a proof that the physician knew much, both about his disease
and his remedies, since he could prophesy the results. After the
antimony had exerted its influence the patient was much more ready to
think that he must get better, and the influence of this suggestion
worked strongly in all cases where the affection was not serious, and
undoubtedly helped the patient's resistive vitality to throw off
disease. In weak patients its physical effect was lamentable. It still
further reduced vitality, and when used by thoughtless physicians must
have done great harm. In spite of this, however, antimony continued to
be used for centuries. Shortly {27} after the middle of the
seventeenth century, when it was beginning to be neglected, antimony
received a new lease of life as a consequence of its employment in a
lingering illness of Louis XIV. The French king was attacked by what
has since been recognized as typhoid fever. Many remedies were tried,
but all in vain; the fever continued. When the fever had nearly run
its course and the physicians were on the point of acknowledging that
they could do nothing, and when a fatal termination seemed near, it
was decided at a consultation to follow the advice of an old
practitioner and use the old-fashioned remedy, antimony. Almost
immediately the king began to get better. His improvement was quite
naturally attributed to the last drug that he had taken, and antimony
regained and held its remedial reputation for the next two centuries.
Such stories have always worked wonders in producing popular faith and
even professional confidence in drugs. When great personages seem to
be cured by certain remedies, ordinary logic ceases to act, and the
strong power of suggestion comes in to strengthen whatever remedial
influence there may be.
Calomel and Suggestion.--Such mistaken notions as to therapeutic
efficiency are not confined to centuries before our own. During much
of the nineteenth century calomel was employed as extensively as
antimony had been in preceding centuries. Calomel was often given in
doses which produced effects resembling those of antimony. Even in the
small doses we now employ, it is apt to be a thorough purgative. In
the twenty and forty grain doses, commonly administered by the country
doctors of two generations ago at the beginning of practically every
ailment, it was purgative--and worse. Its effects could, of course, be
very strikingly seen, and what patients wanted were just such visible
results of the doctor's prescription. Undoubtedly, then, the calomel
did good, but not by its effect upon the patients' bodies, but upon
their minds. Calomel is still used in ways that partake more of the
old-fashioned ideas than we care to confess. Some of its supposed
effects in stimulating the flow of bile have been placed in doubt by
modern investigation, but we still use it empirically, and undoubtedly
its effectiveness is partly due to the fact that many patients see the
results in the purgation in dark coloration of the stools and are
confident that improvement must follow--and it does. Perhaps at a
subsequent operation we find the bile ducts effectively blocked and
then learn for certain that the stool coloration observed was not
biliary but due to a chemical reaction of the calomel itself.
Venesection and Its Suggestiveness.--Between the periods of antimony
and calomel popularity venesection was the favorite remedy of
physicians. It is hard to understand now the extent to which this
practice was carried by the medical profession. People were bled for
nearly every combination of symptoms. In severe cases the amount of
bleeding practiced was almost incredible. Mirabeau, the great French
orator, suffering from angina pectoris, was bled some eighty ounces in
the course of forty-eight hours. In spite of this heroic treatment,
which his physicians thought ought to have cured him, he died. We find
it hard to understand how he lived so long. This, of course, was an
exceptional case at the very height of the venesection furor, but it
helps us to realize how convinced physicians were of the curative
power of the practice.
{28}
Thoughtful physicians like Morgagni did not accredit it, or at least
refused to allow it to be practiced on themselves, but its acceptance
was practically universal. Probably no remedial measure ever generally
used was calculated to be so effective as bleeding in producing a
strong mental influence. The rather sacrificial preparations for it,
the sight and the prick of the lancet, then the sight of the blood,
the languor that followed, the reaction on nature's part to reproduce
the lost material, all united to impress the patient's mind so deeply
that it is easy to understand that all the reserve of mental force was
now directed toward helping nature in the cure of whatever disease was
present. Venesection itself in nine out of ten cases probably did more
physical harm than good, but all the good came from its suggestion.
We are now apt to think of venesection as consisting only in the
removal of some blood from a favorably situated vein, but we must not
forget that in the olden time they bled from many veins, and that a
particular vein was picked out because it was supposed to be connected
in some way with the seat of the special trouble under treatment, and
as a result there was a particular appeal to mental influence. A vein
on the forehead was opened for the treatment of migraine and diseases
of the eyes, on the nose in case of discharge from the eyes, back of
the ears in chronic headache and in stuporous conditions, or beneath
the chin when there was pain in the eyes, or in the nose, or in the
jaws. The cephalic vein was opened for headache and for certain
affections of the eyes and ears. Altogether there were thirty
different veins opened for as many maladies. It was thought extremely
important in the drawing of blood from the arm that that arm should be
chosen which, for some anatomical or other reason, was supposed to be
the more intimately connected with the affected part of the trunk or
head. The psychotherapeutic factors at work in these cases are easy to
understand, and their beneficial effects gave the practice a firm
foothold in medicine.
Quinine and Suggestion.--Whenever any drug has secured a reputation
its use has always been extended to many other diseases besides that
for which it was definitely indicated. Quinine is a typical example.
It is a specific for malaria and, properly administered in suitable
doses, breaks up the fever--not because of any action upon the febrile
condition itself, but because it kills the _Plasmodium malariae_ whose
reproduction in the blood brings about the paroxysms of fever. It was
argued, however, that since quinine was good for one kind of fever it
would probably be good in others, and all sorts of theories were
invented and supported by supposed observations of the effect of
quinine on various organs and tissues, even on the white blood cells,
by which its efficacy in fever was supposed to be explained. Quinine
was used in all sorts and conditions of fever, and acquired a
reputation as a remedy that had the power even to abort conditions
leading to all fevers. It was used in large doses for such conditions
as cold, incipient pneumonia, or indeed any disease with a chill at
the beginning, and was supposed to be a powerful prophylactic.
Now it is settled that while quinine in small doses is an excellent
tonic, it has no effect at all upon fevers in themselves nor upon
fever-producing conditions. Yet it is still administered by many who
have not quite abandoned the old teachings as if it were a general
febrifuge. In the meantime, the use of quinine as a prophylactic of
colds and other minor febrile conditions has {29} spread so that many
people make themselves very uncomfortable by taking a large dose of
quinine and whiskey whenever they fear they are going to have a cold.
As a consequence they feel dull and heavy the next day, but assume
that they would have been much worse than they are had they not taken
the potent remedy the night before. Undoubtedly some of them are
enabled by the suggestive value of the remedy and the continued
suggestion of its unpleasant effects to throw off the lassitude that
comes from some minor infection and are encouraged to get out into the
air, when they might otherwise have stayed in the house. This enables
them to get rid of their colds sooner than would be the case if they
allowed themselves to be confined. Most of them, however, are harmed
rather than benefited, and the cold runs its course, unaffected except
that the patient is more miserable and depressed for the first day or
two than he would otherwise have been. There are physicians who still
use quinine as a febrifuge in typhoid and other essential fevers, and
doubtless its bitter taste helps their patients because of the
suggestive value of an unpleasant medicine.
St. John Long's Liniment.--An interesting exemplification of the power
of mystery in adding to the curative value of a commonplace remedy is
found in the story of the famous St. John Long liniment. St. John Long
was a well-known quack in London in the early part of the nineteenth
century. Like all quacks at all times, his specialty was chronic
diseases. He claimed to be able by means of external applications to
cure the pains and aches to which the old are so likely to be subject.
St. John soon acquired an immense reputation. He gave a liniment with
a secret formula that was literally a miracle worker. People who used
it found after a few times that they were free from, or at least
greatly relieved of, aches that had bothered them for years. It was
good for sprains and for internal pains of all kinds, as well as for
the so-called chronic rheumatisms, which have as their principal
symptom pains and aches around joints. So great a reputation, indeed,
was acquired by the remedy that an agitation was begun to have
Parliament buy the secret from its inventor in order to present it to
the British nation. The proposition was actually carried through the
legislative chambers and a considerable amount of money, still larger
in those days because of the comparatively greater value of money, was
voted to St. John Long.
His liniment had a place in the British Pharmacopeia under his name
for many years afterwards. It proved to be only a simple old-fashioned
remedy, the basis of which was turpentine, and one of the principal
ingredients was the white of egg. Just as soon as the secret was known
the power of the remedy began to decline. So long as it remained
mysterious and unknown, discovered by a man who supposedly had made a
special study for many years of these conditions, and had finally
worked out the external applications necessary for them, it
accomplished wonders. Just as soon as it was known to be a combination
of familiar turpentine and egg it lost its power. The remedy is, of
course, an excellent counter-irritant, and the gentle rubbing
undoubtedly did much good. The most important element, however, was
the mental influence, the feeling that now things must be better,
which thought distracted attention from the aches and pains and caused
the unfavorable influence of over-concentration of mind on the part to
cease, for the vaso-motor system is particularly under mental
influence. Every now and then since that time some {30} liniment or
oil containing nearly the same ingredients as that of St. John Long's
acquires a reputation as a consequence of a campaign of advertising.
It is the printers ink that counts, however, and just as soon as the
advertising ceases to attract attention the remedy fails in
efficiency.
Alcohol Plus Suggestion.--Alcohol has been employed in medicine with
the persuasion that it is a remedy for many states of exhaustion,
though we have gradually gotten away from its use to a great extent,
because we realize that subsequent physical ill consequences outweigh,
in most cases, the physical good it may do. Its use was undoubtedly
due to the confidence of physicians communicated to patients, and the
sense of good feeling which it gives and which proves a further strong
suggestion to the patient. This sense of well-being is illusory, for
it is sure to be followed by a longer period of dejection, which more
than counteracts it unless the dose of alcohol can be maintained for
some time.
A generation ago few physicians would have cared to treat exhausting
diseases, the continued fevers for instance, without liberal doses of
alcohol. Practically the only treatment for pyemia and septicemia on
which any stress was laid, and in which there was any general
confidence, was the administration of alcohol in large quantities. In
the septicemia consequent upon puerperal infection it was the common
teaching to give alcohol by the tablespoonful or more every hour, or
oftener, until its effects began to be noticed, and ordinarily large
quantities were required, so that sometimes nearly a quart was taken
in the twenty-four hours. Undoubtedly these septic conditions were
accompanied by great mental prostration, and this was emphasized by
the knowledge that they are often fatal. So patients were usually
depressed into a state of mind in which their resistive vitality was
much lowered. Alcohol, then, by producing a sense of well-being as
well as by stimulating hope in other ways and suggesting possibilities
of recovery, undoubtedly exerted a powerful and favorable influence on
the mind. Its use in these cases nearly always did good, in spite of
its inevitable depressive reaction, for the course of these infections
was rapid and the dosage of alcohol could be maintained until there
was a change for the better or the fatal termination was in sight.
Alcohol was frequently used in many other conditions of a similar
nature, and above all in the septic conditions so common in hospitals
before the days of antisepsis and asepsis. When it is recalled that
amputations yielded a mortality from sepsis of at least one in four,
the extensive use of alcohol in hospital practice two generations ago
will be readily understood. We have changed that, however, and Sir
Frederick Treves, at a meeting of the British Medical Association at
Toronto, five years ago, called particular attention to the statistics
of the use of alcohol in British hospitals. During the last forty
years milk and alcohol have exactly changed places in the London
hospitals. Between 1860 and 1870 about four times as much was spent
for alcohol as for milk in these hospitals; during the last decade
about four times as much was spent for milk as for alcohol.
A corresponding change has taken place in many other phases of
treatment in which alcohol was commonly used. The physician of fifty
years ago would have thought that one of his most efficient remedies
had been taken from him if he could not use alcohol freely in
tuberculosis. There are practically no well-known specialists in
tuberculosis now who recommend the use {31} of alcohol. On the
contrary, most of them point out the dangers from its use and consider
that the depression which follows even a moderate dose is likely to do
much more harm than the temporary and fleeting stimulation which it
gives can do good. In the treatment of phthisis in recent years milk
has done much more than take the place of alcohol: it has displaced it
entirely. The medical profession realizes now that what the
consumptive needs is not more stimulation--for more of that than is
good for him is forced upon him by the toxins of the disease--but more
nutrition to enable him to resist the progress of the disease and
raise his resistive vitality against its toxemia. The one stimulant
that is of service in the affection is oxygen, and even that should be
given in nature's dosage rather than by artificial means.
_Alcohol in Pneumonia_.--A corresponding change has taken place in the
professional attitude towards the use of alcohol in pneumonia. There
was a time not so very long ago when alcohol was considered the sheet
anchor of our therapeutics for pneumonic conditions, especially those
in which from the beginning a fatal termination seemed inevitable,
because of the age of the patient or some complication. There were
physicians who said that if they had to choose between all the drugs
of the pharmacopeia on the one hand without whiskey and whiskey
without all drugs whatsoever, for the treatment of pneumonia, they
would make the latter choice. We are not as yet entirely away from the
point of view that attributes a certain value to alcohol in pneumonia,
though even those who still employ alcohol are less emphatic in their
advocacy of it. Any one who has seen the result of the fresh air for
pneumonia patients will think less and less of alcohol. One well-known
clinical authority declares that the very best place to treat
pneumonia in our cities would be beneath the trees in the parks. Our
patients are being treated at the ends of wards with the windows up,
on the balconies, and on the roofs, and the death rate is much reduced
and the necessity for any other than oxygen stimulation seems much
less.
_Alcohol in Vague Affections_.--The suggestive influence of the effect
of alcohol is unconsciously obtained in a number of vague and rather
chronic affections. Among these the most noteworthy are women's
diseases. Various alcoholic home remedies, gin and whiskey, usually
disguised by some bitter, used to be popular. But the known presence
of alcohol in these discredited them. Then the nostrum vendors
proceeded to supply something just as good. They were, in fact, the
same things under another name. Many of the much-advertised remedies
that are supposed to cure the ills the weaker sex is liable to, have
been found to be little more than dilute whiskey, for in alcoholic
strength they were about equal to whiskey diluted once with water, and
the other substances were added only to disguise the taste and the
odor of this principal ingredient. Many of these remedies have
elicited innumerable flattering testimonials and not all of these were
fraudulent or obtained by questionable means, but many of them were
given because of results secured through the remedies. The alcohol
gave the well-known sense of well-being, and the suggestive influence
of this increased the appetite, tempted the patient to move around
more, and to get more into the air than before, and the consequence
was an improvement in the general health, in the midst of which many
symptoms that seemed to the excited imaginations of run-down
individuals to be serious were relieved. In a great many cases,
however, the result was the {32} formation of a whiskey habit; hence
the crusade which has discredited these remedies.
Other patent medicines, and, indeed, some of the proprietary
preparations, commonly recommended as nutrients and the like, and
supposed to be ethical, are found to owe whatever efficiency they have
to their alcoholic content. Here once more the suggestive elements
were the more important, and enabled substances of little physical
efficiency to produce effects that seemed to indicate the presence of
powerful energizing materials.
_Whiskey in Snake-Bites_.--A typical example of a remedy which owes
its efficacy to mental influence over the patient is the use of
whiskey for snake-bites. It is generally recognized that whiskey is
not only of no special beneficial effect for snake-bite, but that when
taken in the large quantities usual in such cases it probably produces
an ill effect by disturbing the patient's general condition and
lowering his resistive vitality. I have no doubt, however, that its
use in considerable quantities has in these cases proved of value
because of the mental effect upon the patient. Ordinarily a snake-bite
is followed by a sense of extreme terror and prostration that lowers
the resistive vitality. This is overcome by the temporary stimulation
of the alcohol. The generally accepted idea that whiskey is almost a
specific remedy for snake-bite takes away from most people this dread
and consequent depression, and does this especially at a time when the
acuter symptoms of the venom are making themselves felt. Only about
one in six even of those bitten by large rattlesnakes are likely to
die. Many circumstances are in their favor. The bite is not likely to
be fatal unless the full contents of the poison sac is injected--which
will not be done if the sac has been emptied in the preceding
twenty-four hours--and if there are any obstacles, such as clothing or
even hair, on the part struck by the snake. Most people, however,
would almost die from fright, and such a thing is quite possible, if
they thought there was no remedy. The fact that they understand that
alcohol is an almost infallible remedy gives them courage, and as soon
as they receive some whiskey and it begins to take effect this intense
depression is relieved.
It would be better if the knowledge we now have as to snake-bites were
more generally used, and if people understood that only rarely is such
an accident fatal. In this way there would be no necessity for an
appeal to mental influence through whiskey. It is probable, however,
that alcohol will still be used for many years, at least in the
country districts, because the supposed knowledge is too widely
diffused for a correction to come soon, and then other modes of
treatment have not that persuasive mental influence which whiskey has
as the result of the long tradition. There are many other popular
remedies for snake-bite not quite so inefficient as whiskey, but that
will continue to enjoy a reputation and really have a certain
efficacious result as a consequence of the expectant attitude evoked
by the fact that for as long as the patient has heard anything about
these things this particular remedy has been mentioned always as the
one thing sure to do good.
Other Cures.--Fontana, toward the end of the eighteenth century, was
sure that he had discovered in caustic potash an absolute specific for
snake poisoning. He had had a series of cases, and felt that he had
actually observed this substance following the snake poison into the
system and neutralizing it. Its active effect on the external tissues
proved eminently suggestive for {33} the patient and good results
followed. We have had many specifics since, and yet we are not quite
sure how much any of them avail unless recent biological remedies
prove lasting in their effects and are really of therapeutic
efficiency.
Antidotes and Suggestion.--For many other poisons beside snake venom
there have been announced supposed antidotes of all kinds. The
literature of the antidotes used for opium is extremely interesting
and even in recent times contains many disillusions. Twenty years ago
our medical journals contained any number of cases in which a solution
of potassium permanganate seemed to have proved effective in
neutralizing not only opium itself but its alkaloids and derivatives.
Not only was it efficacious, then, if taken while the opium was still
in the stomach but, just as with Fontana's caustic potash and the
snake venom, it followed the opium into the tissues and at least
blunted its action. Numbers of cases were reported in which potassium
permanganate was supposed to have had this desirable effect. The
effect of alcohol in neutralizing carbolic acid attracted as much
attention as did potassium permanganate for opium. Here there was no
doubt that alcohol immediately after the external application of
carbolic acid did prevent its corrosive action. It was supposed to do
the same thing in the stomach and even, as some enthusiastic observers
thought, followed the carbolic acid into the tissues. Here once more
the claim is not proven and it is evident that the influence on
patients' minds when small doses of carbolic acid were taken, was the
real therapeutic factor at work.
Poultices in Suggestive Therapeutics.--Poultices represent another
phase of the value of suggestion in medicine and surgery, though for
many centuries those who used them were sure that the reasons for
their employment were entirely physical and not psychic. All sorts of
poultices have been used and each was supposed to do specific curative
work. New forms of poultice material have been introduced, and
physicians and patients have been certain that each worked wonders of
its own. The drawing power of the poultice was extolled until patients
dwelt on the idea that this external application was literally engaged
in extracting from them, even from distant portions of their anatomy,
virulent material that would do harm if allowed to remain in them.
Poultices in suitable cases, because they represent moist heat, do
good by counter irritation, by bringing about the expulsion of gas, by
diverting internal hyperemia to external tissues, but most of their
supposed efficacy has been really due to the bother required to
prepare and apply them, the discomfort of having them on, and the
feeling that now something had been done and the aches and pains must
get better. They are still used, but to a much less degree than
before. Now the ordinary teaching is that a hot water bag wrapped in
dry flannel, if dry heat is the agent desired, and in moist flannel,
if moist heat is the desideratum, is much more efficient. It takes but
a few minutes for a poultice, no matter how hot when applied--and
occasionally in the olden time they were applied so warm as to burn or
scald--to decrease in temperature to that of the body. After that they
represent only a moist compress.
It is easy to understand that the suggestive influence of poultices
might serve for an age that knew less about the realities of the
efficacy of external applications than ours. As a matter of fact, we
have, nevertheless, shown ourselves to be quite as credulous and ready
to receive analogous remedies as the past generation. With the waning
of the popularity of the poultice, not {34} only among the profession,
but also among the people generally, there came into use various
plasters which were supposed to have even more wonderful efficacy than
the poultice of the olden time. These required a good deal of trouble
to apply and once applied remained on for hours, and so continued to
produce a definite curative effect on patients' minds. When first
introduced, exaggerated claims were made for their therapeutic value
and a regular crusade to diffuse correct information regarding them
had to be made, in order to set them in their proper place as mere wet
compresses, without any therapeutic efficiency beyond that of cloths
wrung out in water and kept in touch with the skin.