Suggestive Therapeutics

Kai Tiaki : the journal of the nurses of New Zealand, Volume XVI, Issue 3, 1 July 1923, Page 99

Suggestive Therapeutics

A Lecture given before the Members of the Wellington Provincial Masseurs' Association by Dr. D. Eardley Fenwick, April 9th, 1923, Miss Hester MacLean, R.R.C., Matron-in-Chief, in the chair.

I am afraid I am going to disappoint you to-night, because — rather than attempting to describe in detail to you various methods of treatment applicable lo t'unctionable nervous disorders — I waul to help you, if I can, to a clearer understanding of the nature of these cases, and particularly to get a grasp of the main factors to the causation of these diseases. For, unless you understand what is the underlying cause of the complaint you are healing, it is highly improbable that you can treat your patient with the intelligence he is entitled to. As you know, the neuroses have in recent years — during and since the war, in fact — come very much to the fore in medical discussions and as a result a regular list of new names and diagnoses have come into existence. I see no reason why you should be bothered with these, but I do think that it is of the utmost importance that you should be able clearly to recognise three main comprehensive classes — neurasthenia, psychasthenia, and hysteria. If you will realise the essential differences both as regards symptoms and treatment of each of these disorders from the other, you will be well on your waxto having a clearer understanding of, and being as a result able to give more satisfactory treatment to, these cases when they come your way. Neurasthenia defines itself. It is an asthenic condition of the nervous system, i.e., a condition of exhaustion of the nervous system; and with exhaustion of any organ or any system an irregular, irritable action of that system manifests itself. In that lies the explanation of many of the symptoms of nervous exhaustion, the pachycardea or rapid heart action, lor instance, the headaches and the insomnia. Hysteria is a condition much more dimcult'to define. Unfortunately, the name "hysteria" has become widely used, and

its real meaning lost by many of the laity. It has come to carry a certain sense of blame with it. It has become confused with imagination, and the fact that hysteria really denotes a pathological condition — an illness for which the patient is no more responsible or blameable than for pneumonia — has been lost sight of. Now, contrary to neurasthenia, hysteria is not necessarily associated with a condition of exhaustion or asthenia. On the other hand, hysteria patients are frequently the opposite. They may be physically fit — the neurasthenic never is — and the distinctive feature of hysteria is a distortion of the natural workings of the central nervous system. Such distorted nervous action may show itself in the way of contractures of muscles, of loss of power of speech or of loss of feeling, anaesthesia. That is, there are very definite physical signs of hysteria. But these various phenomena are all brought about by a mental impression. Babinski, one of the greatest of all neurologists, has laid down as part of his definition of hysteria that all the signs and symptoms of hysteria can be produced by suggestion, and removed by suggestion. I have seen anaesthesia produced in a patient by the unwitting suggestion of a doctor during the course of a routine examination. The patient was a soldier with a hysterical forearm paralysis. This patient had before examination had no sensory changes at all. During examination the doctor said, " Tell me if you feel my touching you just as plainly in the right arm as in the left." This was putting a direct suggestion into the patient that lie should — according to the usual run of cases — have some difference of sensation in his two arms. The suggestion took effect at once. The patient said he could not feel in his right arm. And the chief point is this: not only did he say so,

but he could not feel, I. may add that, in accordance with Babinski's statements, the anaesthesia was removed by suggestion at one sitting. To leave hysteria for the time being, lel me now consider Psychasthenia. Psychasthenia is a more serious, but not less common,, affection than either neurasthenia or hysteria. It is a condition in which the mental phenomena overshadow the physical signs. Neurasthenia is a condition brought on by some outside cause — prolonged business worry, overwork, and so on. Psychasthenia, on the other hand is the outcome of a neuropathic disposition. The psychasthenic is born such. He may go through life without grave trouble; on the other hand, his psychasthenic disposition may get the better r>f him till his life becomes a misery. The chief characteristic of psychasthenia is the presence of obsessions. He becomes obsessed with a thought, usually a dread or a fear, which by no effort on Ins par) can be thrown off. He is not insane. H(i has no delusion. He knows his fear is unjustifiable, but he cannot get rid of it. lie is a prey to his thoughts. In some cases he has a vague fear. He does not know what it is lie is afraid of, but the fear is there, and he becomes miserable and de pressed. In other cases the fear is a welldefined one. He is afraid of open spaces, of closed rooms, of hills, of railway travel, of cancer, of microbic diseases. The fear goes further than this in many cases. The patient is afraid that he may give way to some uncontrollable impulse to throw him self from a height or from a car, because he has actually felt the impulse to do this thing at some time. Now 1 have spoken rather at length about psychasthenia because of the functional nervous diseases it is the commonest. It is not the most commonly recognised; but it is the commonest. Most people have a psychasthenic tendency, though it does not in most cases amount to anything in the nature of disease. Many people have some peculiar little habit, a sub-conscious habit which is bordering on a minor psychasthenic state. It is instinctive in man to step over ditches,

holes, etc., when, he is walking. A psychasthenic burlesque of this is when he carefully, yet almost sub-consciously, avoids the cracks in a pavement and becomes irritated without reason when he steps on one. The minor obsession is instanced in the person who cannot get a catchy tune out of his head even when he tries. That does not matter much, but it is quite obvious that an irritating train of thought, equally persistent, may become a matter of very serious import to a man. Now to come a bit more to the practical bearing of all this. You must, many of you, have had patients sent to you whom you have been asked to massage or give some form of electrical treatment. You have faithfully carried out your instructions, and you have gone through that depressing experience of watching your patient make absolutely no progress. The fault does not lie with you; and yet 1 hope to be able to point out to you that you are in a position to be able to help considerably in correcting this fault. The original failing lies with us medical men. It is only in very recent years that a proper — a scientific — appreciation of the types of neuroses has come into vogue. The average medical practitioner looks. 1 am afraid, on the neuroses cases which come to him as rather a distasteful part of his practice. He has been a bit inclined to label them all neurasthenia, and to prescribe something that he optimistically calls a nerve tonic, perhaps Weir it - i'liell treatment- a course of massage or some form of e trical treatment, and if the case is one i . psychasthenia he might as well prescribe a dose of Epsom salts. You may say, "If massage and electricity are of little service in these complaints, why bother us about them 0 / What can we do " Well, 1 think you can do a great deal, and I will attempt to show you how. To do this 1 must just hark back for a moment to the cause of psychasthenic states. The emotions are at the bottom of all — fear, love, hate, anxiety — any emotion. And at some time in the lives of thevse patients they have received an emotional shock or injury, or a series of

such. Now at the time the unpleasant experience thai the patient went through had no obvious and lasting effect. But an impression, perhaps a verp deep impression, was made on the patient. He succeeded, however, in suppressing, or rather repressing, this shock. He relegated thoughts and memories of it to his subconscious mind, and there this impression lay buried, not destroyed. Some permanent damage was done at this time to the patient 's emotional equilibrium. Later in life another direct jar to his emotions, or some situation remotely resembling the original nervous shock, occurs, and a train of symptoms is set up, due in the first place to the original shock and particularly to its repression in the patient's subconscious mind. Fear, dread, and obsessions come on, absolutely without cause as far as the patient can see, because he is not aware of the emotional activities that are going on through this repressed memory in his sub-conscious mind. Now if this repressed incident, incidents, unpleasant experiences, or emotional disturbances can be discovered and brought to light, the patient is half way on the road to recovery. This is, roughly, the raison d'etre of a form of psychotherapy elaborated by Freud 's Psychoanalysis. And the essentials of it are the discovery of the repressed emotional injuries in the sub-conscious mind, and the bringing of them to the surface so that their relation to the present illness may be demonstrated to the patient, and that he may deal with this by a reasoning process of his conscious mind instead of allowing it to deal with him by an unreasoning emotional process of his conscious mind. Now please do not imagine that T am suggesting to you that you should dabble in psychoanalysis. lam not; for there may be as much harm done by clumsy methods in this respect as good by skilled methods. But here I suggest that you can quietly go far towards finding the real cause of the patient's illness. From your very circumstances I think you are in a more favourable position to do this than the medical practitioner. Personally I think the ideal of the doctor and the mas-

seur or masseuse to whom he sends his patient should be that of consultants. Outside of the special hospital for these cases at Hanmer, I know of no doctor, practising in New Zealand, who is jable to give up the time to these patients for their adequate treatment, because it means no less than an hour daily to each patient for some time. You can realise the impossibility of the busy general practitioner allowing this. Now may I outline what to me seems a reasonable attempt to treat such patients fairly and adequately? Each case would be a case unto itself, of course; but perhaps a rough general idea of routine might be attempted. The doctor at the first consultation must be prepared to listen to his patient with the utmost patience. The patient must be encouraged to relate every trouble, little or big, which he is contending against. He must not be afraid that anything is too trivia], and he must give as far as possible an outline of his previous life. The doctor arrives at a diagnosis. He is satisfied, we will say, that he is dealing with psychasthenia as distinct from neurasthenia or hysteria. But it is almost a certainty that he has not arrived at the original cause of the trouble. Nevertheless he must, for the patient's sake, start his treatment at once. He sends his patient to a masseur or masseuse. Now I know you want specified directions from your doctor. Personally my directions to you would be something like this: "Firstly I want you to gain your patient's confidence. I want you to make him realise that your doctor has explained his case to you, that you fully appreciate his troubles and that your one aim will be to remove these troubles. Above all, T want you to let him see that you have no shadow of doubt as to the certain successful outcome of his complaint. It may seem a small point, but it is an important one, that you should not let your patient believe (as they are only too anxious to believe) that theirs is an extraordinary case, something different from what has been seen before, and as such less likely to respond to treatment. You will start with general mas-

sage. In this case your chief aim in giving general massage is to induce a sense of comfort and well-being, and you will endeavour to teach your patient the meaning of relaxation. When you have once taught him how to truly relax himself , you will find that you can get him to relax his mind, and when you have once got him to that stage, you have igot him to a stage when he is particularly susceptible to good suggestions. I want you to pay particular attention to this point. I want, you to allow T your patient to talk freely to you all the time you are treating him. I don't want you to ask questions — questions are always dangerous to the psychoneurotic. Unless they are very guarded, you do not know what unmeant suggestion they may convey to his ill-regulated mind; but I want you to encourage him to confide in you, to tell you any little trouble, however trivial it may seem, and to tell you anything he likes about his history or his family history. And each day you should make a note of anything which, knowing how the neuroses occur, you think mav have any bearing on his condition. After three or four treatments we shall meet and discuss the patient. T shall have a further talk with the -patient, and I should by that time be able to arrive at a fairlv reasonable iitd^ment as to the origin of his trouble. Up to this point I do not want you to attempt anviTimar at all in the way of explanation to tho patient, because nothing can be more fatal to the success of treatment than for you to explain matters to a patient in one wav and for me to do in another wav. We shall discuss the manner in which this trouble is to be explained to him, and then you can repeat these explanations to him daily, or as often as he brings up a point about which he is troubled. Once he accepts these explanations the success of his treatment is assured. As regards treatment by suggestion, be guarded in w r hat you do in this respect. The host sue^estioii you can make is just a quiet, deliberate expression of your conviction that he has started on the road to recovery, and that each day will see an improvement in some respect. The matter of detailed suggestion is a difficult one, and unless

you have your patient in a condition particularly receptive to suggestion — a condition, in fact, in which his conscious reasoning power is almost in abeyance — any detailed suggestion you may make (e.g., the prophesying of a good night to the insomnia patient, or the loss of his phobias to the phobia patient) is more than likely to act by direct contrary, in the manner explained by Coue." Now this brief outline is just my idea as to how a physician and a masseur or masseuse might start in their combined, attempt to cope with the difficulties of such a patient. I cannot go more into detail, for, as I said, the details of no two cases are the same. But I want to impress on you how great can be your service to these unfortunate people. They are trying patients — extraordinarily trying — but if you will remember that they are ill, ajid that their troubles, far from being imaginary, are terribly real to them, you will give them of your sympathy and help, I know. I would like to say just a few words about the other *typ es I mentioned — the neurasthenic and the hysteric. There is little to be said of the neurasthenic proper. He is a straight-out case of exhaustion of the nervous system. And rest is his chief indication. Because he must be deprived of exercise, massage is indicated to keep up muscular tone. And almost daily every neurasthenic is constipated. In my opinion, a portion of the daily massage given to the neurasthenic should be abdominal massage, for tliis reason. The other most important part of the masseur's duty to the neurasthenic is his education in relaxation. Nothing can be more valuable than this. One word of warning I may perhaps be permitted to give here. The neurasthenic is a tired person. Start gently with your massage, and never leave him more tired than when you started, and in every case insist on an hour's absolute rest after massage. And another point. The neurasthenic, in contradistinction to the last class of patient, should not talk during his treatment. Talking is not going to help him

to reach the stage which is more valuable to him than anything else — relaxation. Hysteria is too wide a subject to do more than touch upon. It is in hysteria that the therapy of suggestion comes in more than in anything else. The hysteric is a person .susceptible to suggestion. That is how he developed hysteria. And you must remember this point: Suggestion, to be efficacious, must be made to the subconscious mind. Now that is a vague, impossible kind of statement. I expect most of you appreciate the meaning of the 'subconscious mind. But as briefly as 1 can put it, the meaning of the term is this: We all have two separate and distinctly acting parts of our mind: (1) our conscious mind, with which we deliberately initiate thoughts and actions, with which we reason — our reasoning mind; and (2) our sub-conscious mind, which plays its part in all sorts of automatic actions which we perform. We say that we do these things by instinct; that is the same thing as saying that our sub-conscious mind impels us to do them. In the same way our sub-conscious mind often brings certain thoughts into being. You have surely all often found yourself thinking things you had no intention of thinking, that occurred through your sub-conscious mind. Dreams also are very obviously activities of the sub-conscious mind. Now in the normal person there is a definite balance between the two minds, and the conscious mind is in the ascendancy. The position is reversed in hysteria. A single example of the production of hysteria is hysterical aphasia. This occurred often during the war as a symptom of shell shock, but it is a fairly common occurrence in civil life. Here the sequence is: the patient has an attack of laryngitis. He is particularly impressed by the fact that he has lost his voice as a result of this inflammatory condition, and after the laryngitis has cleared up, he still is unable to speak because of the emotional impression made on his mind that his voice was igone. Nothing is easier to cure than this condition. The shellshocked patient could be immediately cured by hypnotic suggestion, or by suggestion to the bub-conscious mind under light anaesthesia. I used this latter

method at No. 1 N.Z.G.H. during the war with excellent results. The same result can be attained at once in civil practice by the application of a Faradic current to the throat. And you know perfectly well that Faradism in such a case can do nothing except by acting 1 as a convenient and striking vehicle for suggestion. It is in hysteria then, that the practice of suggestion has its greatest applicability and usefulness. And suggestion is a means of therapy which I consider you masseurs should certainly carry with you. T advise you to read a little of this, and you will get no better insight into the elements of suggestion therapy, its practical application and its possibilities, than by reading Baudouin's book, " Suggestion and Auto-Suggestion/' which is an exposition of Coue's methods and theories at the Nancy clinique. Just a word of caution here, however. In reading a book like this, do not take everything it says as incontestable fact. Criticise it yourself, remember that it is written by an enthusiast, who is possibly a little blinded by his enthusiasm. Cone's theories are not accepted wholeheartedly by the English psychologists. His point is that suggestion, to be efficacious, must be autosuggestion — i.e., the suggestion must be made by the patient to himself. Now this, T think, is too dogmatic. Suggestions made by the physician or by the masseur may and do become converted into autosuggestions later on, but the original suggestion must be made by the person treating, and the wisdom of leaving any patient to develop his own suggestions is very doubtful. T had an interesting example last week of the possibilities of suggestion therapy as applied by a masseuse. My patient is a case of combined spinal sclerosis, to which is added a mild hysteria element, which has interfered greatly with the patient's sleep. I saw her the other morning, and she said to me entirely voluntarily, "Do you know, doctor, T had the best night last night that T have had for months, and the funny part of it is that T remember Miss So-and-So (her masseuse) saying yesterday afternoon that I would

sleep well, though I didn't pay any attention to it at the time." Now it was because she did not pay any attention thai that suggestion was efficient. Let me explain this by another example. Let us suppose you are treating a stiff arm — an arm stiff originally from some injury, bu'r remaining stiff purely from hysteria, and this is the 'Commonest form of hysterical manifestations. An injury or origanic disease produces a disability, a very definite emotional impression is made on the patient, and the disability remains lone: after the original cause has been removed. The remaining disability is functional: it is what is called conversion hysteria. "Well. supposing during your treatment of that arm you say to your patient: "Now you can move that arm more than vou think. You must make up your mind that you are going to do so. You must say to yourself, 'I'll move this arm a bit more every day/ " Well, if you go about it that way you will inevitably fail. Why? Because you are appealing to the patient's reason ing conscious mind, and the disability is one produced by an emotional impression in his sub-conscious mind. You will sim ply fix his mind more firmly on the fad that his arm is disabled. Tt is what Ooue describes as the Law of Reversed Effect But if during your treatment, possibly by means of Faradic stimulation of certain muscles, you demonstrate to the patient the fact that a certain range of movement is possible, and you say to him that "Youl muscles work all right. There is no essential difference in the working of a muscle stimulated by electric current and a muscle stimulated by a nerve stimulus or iginating in your brain. Certainly you! muscles may be a little weakened by Ion*? disuse, but that part is being remedied They are being toned up by the massa^l and electrical treatment you are having Don't worry about it, and, above all, don'l concentrate your mind on trying to get il better yourself. You w T ill find that to-mor-

row there will be a definite increase in the movement of your arm." If you speak to him like this you arc leaving a definite impression in his mind, and that impression wall develop into an auto-sug-gestion which will surely take effect. At subsequent treatments there should be no more explanations, but there should be made repeated confident statements that a further improvement will be manifest each day. Now these are just rough examples of the working of suggestion therapy. You wil, T am sure, realise the enormous number of cases in which this therapy is applicable. I do not want you to go away with the idea that suggestion therapy is a simple matter. I warn you it is full of pitfalls, but I hope I may have interested you sufficiently to induce you to study this matter a little on your own account. You will never regret it if you do. My main object to-night has been to enb'st your support and to stimulate your interest in these unfortunate patients, and to uris^e you never to be satisfied to accept a patient under that faulty comprehensive term — wihich is really a cloak for ignorance — functional nervous disease. Distrust, also the diagnosis of neurasthenia. Fifty per cent, of cases diagnosed neurasthenia are hvsteria or psychasthenia. Do not be satisfied till you know definitely what type the patient you are asked to treat comes under. Perhaps I might conclude by just repeating the most essential points in the treatment of these types. For the Neurasthenic: General massage. Relaxation exercises, and avoidance of fatigue. For the Hysteric: Explanation, suggestion, and re-education. For the Psychasthenic : Observation, encouragement, and finally — when you have definitely reached a diagnosis of the causation factor — explanation.