PSYCHOLOGY AND MEDICINE
We are now ready to take the first step towards an examination of the problem of curing suffering mankind. So far we have spoken only of the meaning of psychology, of its principles and of its fundamental theories as to mind and brain. We have moved in an entirely theoretical sphere. Now we approach a field in which everything is controlled by a practical aim, the treatment of the sick. Yet our discussion of psychology should have brought us much nearer to the point where we can enter this realm of medicine. Everything depends on the right point of entrance. That an influence on the inner life of man may be beneficial for his health is a commonplace truth to-day for everybody. Every serious discussion of the question has to consider which influences are appropriate, and in which cases of illness the influence on inner life is advisable. The popular treatises usually start this chapter by speaking of the "mental and moral" factors; and this coupling of mental influences and moral influences characterizes large parts of the discussions of the Christian Scientists and the Christian half-scientists. Yet we must insist that the right entrance to psychotherapy is missed if the difference between morality and mentality is not clearly recognized from the beginning. The confusion of the two harms every statement. To avoid such a fundamental mistake, we had to take the long way around and to examine carefully what psychology really means and what it does not mean.
We know now that inner life can be looked on from two entirely different standpoints: a purposive one and a causal one, and we have seen that these two ways of looking on inner life bring about entirely different aspects of man’s inner experience, serve different aims, and stand in different relations to the immediate needs of our real life. We know that the one, the causal aspect, belongs to psychology, while the non-psychological, the purposive aspect, belongs to our immediate mutual understanding in the walks of life. If the physician is to make use of inner experience in the interests of overcoming sickness, he must first decide whether to take the causal or the purposive point of view in dealing with the patient’s mind. This problem is too carelessly ignored and through that neglect arises much of the popular confusion. Of course just this carelessness becomes in some ways the ground for apparent strength for many a superstition and prejudice. If the doors of the causal mind and of the purposive mind are both open, and the spectator does not notice that there are two, any trick on thought and reason can easily be played. Whatever cannot pass through the causal door slips in through the other, and whatever does not go in through the door of purpose marches through the entrance of causality. With such methods anything can be proved, and the most unscrupulous doctrines can be nicely demonstrated. If we are to avoid such logical smuggling, we must see clearly which attitude towards mental life belongs properly to the domain of psychotherapy.
But what we have discussed now leaves little doubt as to the necessary decision. The physician is interested in the mental life with the aim of producing a certain effect, namely, that of health. Thus the mental life of the whole personality comes in question for him as belonging to a chain of causes and effects; whichever levers he may move, everything is to be a cause which, in accordance with causal laws, is to produce a certain change. Inner life is thus, in the interests of medical treatment, necessarily a part of a causal system. This means the standpoint of scientific psychology is the only adequate one. The purposive view of inner life ought not to be in question when the patient enters the doctor’s office.
To characterize the difference, it may be said at once that it is a purposive view which belongs to the minister. If the minister says to his despairing parishioner, "Be courageous, my friend, and be faithful," nothing but a strictly purposive view gives meaning to the situation. The word friend indicates it, that one subject of will approaches another subject of will, with the intention of sympathy and understanding of the attitude of the other; and the advice to be courageous and faithful means an appeal which has its whole meaning in the relation to aims and ends. The speaker and the hearer are both moving in a sphere of will relations, purposes and ideals, sin and virtue, hope and belief. To take the other extreme: if the neurasthenic in his state of depression and in his feeling of inability seeks relief from the nerve specialist, he too may say: "My friend, be courageous and faithful," yet his words have an entirely different purpose. They are not appeals to a common interest of belief; they are subtle tools with which to touch and to change certain psychophysical processes, certain states in mind and brain; there each word is a sound which awakens certain mental associations, and these associations are expected to be causes of certain effects and these effects are to inhibit those disturbing states of emotional depression. If a few grains of sodium bromide were to produce the same effect, they would be just as welcome. The whole consideration moves in a sphere in which only physiological and psychological processes are happening. Thus the physician may work with the ideas of religious belief, but those ideas are then no longer religious values but natural psychophysical material, which is to be applied whenever it appears as the right means to secure a certain effect.
On the other hand the minister also knows, of course, that every word which he speaks has its psychological effect, but he abstracts from that entirely, as his belief should appeal directly to the struggling will of the man. As minister, he is thus not a psychologist. He works with moral means; the physician, with causal means. The view which the doctor has to take of the man before him is therefore thoroughly psychological; whereas that of the religious friend is thoroughly unpsychological, or better, apsychological. Indeed it is misleading, or at least demands a special kind of definition, if people say that the minister has to be a good psychologist. It is just as misleading as the claim, which we hear so often, that for instance Shakespeare was a great psychologist. No, the poet deals with human beings from the purposive standpoint of life and the mere resolving of complex purposes into parts of purposes is not psychology in the technical sense of the term. The poet makes us understand the inner life, but he does not describe or explain it; he makes us feel with other people, but he does not make those feelings causally understood. The realistic novelists sometimes undertake this psychological task, but they are then on the borderland of literature, the analysis of their heroes becomes then a psychological one. Shakespeare understood human beings better than anyone and therefore the men and women whom his imagination created are so fully lifelike that the psychologist may feel justified in using them as material for his psychological analysis, but Shakespeare himself did not enter into that psychological dissection; he kept the purposive point of view. In the same way certainly the minister—the same holds true for the lawyer or the tradesman or anyone who enters into practical dealings with his neighbor—may resolve complex attitudes of will into their components, but each part still remains a will attitude which has to be understood and to be interpreted and to be appreciated, while the psychologist would take every one of those parts as a conscious content to be described and to be explained. But here we abstract from the purposive relations. Our attention belongs now to the doctor’s dealing with man; for him cause and effect are the only vehicles of connection. Thus he has to exclude the purposive interpretation of inner life and has to understand every factor involved from a psychological point of view: his psychotherapy must be thoroughly applied psychology.
The day of applied psychology is only dawning. The situation is indeed surprising. The last three or four decades have given to the world at last a really scientific study of psychology, a study not unworthy of being compared with that of physics or chemistry or biology. In the center of the whole movement stood the psychological laboratory with its equipment for the most subtle analysis and explanatory investigation of mental phenomena. The first psychological laboratory was created in Leipzig, Germany, in 1878. It became the parent institution for laboratories in all countries. At present, America alone has more than fifty psychological laboratories, many of them large institutions equipped with precious instruments for the study of ideas and emotions, memories and feelings, sensations and actions. Still more rapid than this external growth of the laboratory psychology was the inner growth of the experimental method. It began with simple experiments on sensations and impulses, and it seemed as if it would remain impossible to attack with the experimental scheme the higher and more complex psychical structures. But just as in physics and chemistry the triumphal march of the experimental method could not be stopped, one part of the psychological field after another was conquered. Attention and memory, association and inhibition, emotion and volition, judgment and feeling all became subjected to the scientific scheme of experiment. And that was all supplemented by the progress of physiological psychology, pathological psychology, child psychology, animal psychology. In this way the last decades created a science which of course was by principle a continuation of the old psychology, but yet which had good reason to designate itself as a "new" psychology.
But in this whole development, until yesterday, the curious fact remained that it was going on without any narrow contact with practical life; it was a science for the scientist and measured by its practical achievements in daily life, it seemed barren and unproductive. Psychology was studied as palæontology and Sanscrit were studied, without any direct relation to the life which surrounds us. And yet after all it deals with the mental facts which have to enter into every one of our practical deeds, if we are to consider mental life from a psychological point of view. The psychologists were certainly not to be blamed for sticking to their theoretical interests.
More than that, they were certainly justified in their reluctance, as everything was in the making, and incomplete theories can easily do more harm than good. But slowly a certain consolidation has set in; large sets of facts have been secured, and psychology seems better prepared to become serviceable to the practical tasks. On the other hand, it has been noticeable for some time that not a few of the psychological results have gone over into unprofessional hands and have been thrown on the market places and have been brought into many a home where no one knew how to deal with them rightly. Thus the need seems urgent that the psychologists give up their over-reserved attitude and recognize it as their duty to serve the needs of the community.
It is not sufficient for that end, simply to take odds and ends of psychology and to hand them over to anyone who can see some use for them. We must have a systematic scientific work done for the special purpose of adjusting psychological knowledge to the definite practical tasks and of examining the psychological facts with that practical end in view. A science must be developed which is related to psychology as engineering is related to physics and chemistry. Just as the technological laboratories of the engineer bring out many new problems which the physicist would never have approached, in the same way we may expect that special institutions for applied psychology will shape the psychological inquiry in a new way.
Such a new science of applied psychology of course has before it a field just as large and manifold as the field of technology, where physical engineering, chemical engineering, mechanical engineering, and electrical engineering and so on are separated. Such a future psychological technology would deal, for instance, with psychopedagogical problems. There belongs everything which refers to the psychology of memory or attention, of discipline, of fatigue, of habit, of imitation or effort; in short, all those mental factors which have to be considered whenever the schoolchild is looked on from a causal point of view. Further there is the psycholegal field where the memory and the perceptions, the suggestibility and the emotions of the witness are to be studied, where the psychological conditions which lead to crime, the means to tap the hidden thoughts of the criminal, the inhibitions for the prevention of crime, the mental effects of punishment and similar causal processes must be determined. There are the psychoscientific problems referring to psychological influences on the observations and judgments and discriminations of the scholar who watches the stars or who translates an inscription. There are the psychoæsthetic problems where the task is to examine causally the factors which lead to the agreeable effects of beautiful surroundings, and from the height of the psychology of æsthetics in painting and sculpture, the inquiry may go to the psychology of the pleasant effects in dress-making or cooking. There are the large groups of psychotechnical problems where the effort refers to the application of psychology in securing the best conditions for labor and industry and commerce. It leads from the mental effects of signals or the mental fatigue in mills to the secrets of advertisements and salesmanship. There are especially important psychodiagnostical studies where the aim is to determine the individual differences of man by experimental methods and to make use of them for the selection of the right man for the right place. There are psychosocial problems where we examine the psychological factors which have to enter into public movements, into social reforms, into legislation and into politics. In this way new and ever new groups may be added; every time the central thought is: how far can causal psychological knowledge help us to reach a certain end? Together with these forms of applied psychology, we find the psychomedical problems; here belongs everything which allows the application of causal psychology in the interests of health.
It might be answered that this demand for a strictly causal point of view can hardly be fulfilled, because, if I am acting,—it may be in the interest of education or law or technique or medicine,—I must always have an end in view and to select such an end belongs after all to my system of purposes. If I am a teacher and have to deal with children, then it may be said that after all, my knowledge of causal psychology cannot help me if I am uncertain for which ideals I want to educate these children. Psychology can tell me that I need these means, if I want to reach certain effects, but I cannot find out by psychology which effects are desirable. Psychology may tell me how to make a good business man or a good scholar or a good soldier out of my boy, but whether I want him to become a soldier or a merchant I must decide for myself with reference to general aims, and that leads me back to the purposive view of life. Such argument is entirely correct. Yes, it is evident that it is in full harmony with our whole understanding of the purpose of psychology. We saw that psychology with its causal treatment of man’s mind does not express the immediate reality, but is a certain reconstruction which allows a calculation of certain effects. Thus it is itself a system existing for a subject who has certain ends in view. The whole causal view of man is thus a tool in the service of the purposive man. This is the reason why it is indeed utterly absurd to think that psychology can ever help us to determine which end we ought to reach.
In education, for instance, very many different ends might be reached; psychology cannot decide anything. The decision as to the aims of education must be made by ethics, which indeed takes not a causal but a purposive attitude. Only after ethics has selected the aim, psychology can teach us how to reach it. Of course this principle must hold for the physician too. All his causal dealing with the mind presupposes that he has selected a certain end in harmony with his purpose. The only difference is that, in the case of the physician, there can be no possible doubt as to the desirable end; what he aims at is a matter of course, namely, the health of the patient. To desire the health of the sufferer is thus itself a function which belongs entirely to the purposive view of the world, and only in the interest of this purpose does the physician apply his knowledge of psychology or of the causal sciences of physics, physiology, and chemistry. Indeed only with this limitation have we the right to say that the psychotherapist takes the causal,—and that means the psychological,—view of his patient. As far as he decides to take care of the health of his patient, this decision itself belongs to the purposive world and to his moral system. The physician is thus ultimately just like the minister and just like anyone who deals with his neighbor, a purposive worker; but while the minister, for instance, remains on this purposive track, the physician puts a causal system into the service of his purpose. He knows the end, and his whole aim is to apply his causal knowledge of the physical and psychical world to the one accepted end of restoring the health of the patient. He has to ask thus in general: what has psychology to-day to offer which can be applied in the interests of medicine?
It would be an inexcusable narrowness to confine that chapter of applied psychology which is to deal with the psychomedical problems to the work of psychotherapy. Medicine involves diagnosis of illness as well as therapeutics. Between the recognition and the treatment of the illness lies the observation of its development and all this is preceded by steps towards the prevention of illness. In every one of these regions, psychology may be serviceable. Psychotherapy is thus only one special part of psychomedicine. But the situation becomes still more complex by the fact that the illness to be treated or the disturbance to be removed may stand in different relations to the psychophysical processes. The illness may be a disturbance in the psychophysical brain parts, or it may belong to other brain parts which are only in an indirect way under the influence of mental states or which are themselves indirectly producing changes in the mental life. And finally the disturbance may exist outside of the brain in any part of the body, and yet again through the medium of brain and nervous system it may produce effects in the mind or be open to the influence of the mind. Thus we have entirely different groups of medical interests and it would be superficial to ignore the differences.
Both psychodiagnostic and psychotherapeutic studies must be devoted to cases in which the mind itself is abnormal, further to cases in which the normal minds registers the abnormalities in other parts of the body, and finally to cases in which the normal mind influences abnormal processes in the body. These latter two cases have to be subdivided into those where the bodily disturbance still lies in the brain parts and those where it lies outside of the brain. But the situation becomes still more complex by the mutual relations of those various processes. The impulse to take morphine injections may have reached the character of a mental obsession and thus represent an abnormality of the mind, but yielding to it produces at the same time disturbances in the whole body which thus become again external sources for abnormal experiences in otherwise normal layers of the mind.
Of course the interest of the psychologist as such remains always related to the psychological factor, but the relation of the psychological factor itself to the total disturbance may be of most different character. If I diagnose or treat the fixed idea of a psychasthenic, the psychological factor itself represents the disturbance. On the other hand, if I study the pain sensations of a patient who suffers from a disease of the spinal cord, then the sensations themselves, the only psychological factor in the case, are only indications of a disease which belongs to an entirely different physical region; the mind itself is normal. Or, on the other hand, if I try to educate a sufferer from locomotor ataxia to develop his walking by building up in his mind new motor ideas to regulate his coördinated movements, the mind again is entirely normal but the physician needs his psychology on account of the influence which the mind has on the bodily system. Again, we must insist that psychomedicine covers this whole ground. Wherever a psychical factor enters into the calculations of the physician either by reason of its own abnormality or by its relation as effect or as cause to a diseased part of the body in the brain or without, there we have a psychomedical task, and as far as it is therapeutic, we have psychotherapy.
The psychodiagnostic research lies outside of the compass of our book, but we cannot emphasize sufficiently the great importance which belongs to that work. Moreover, just in the field of psychodiagnostics, the methods of the modern experimental psychological laboratory are most promising and successful. Let us not forget that we deal with such psychological factors even when we test the functions of eye and ear and skin and nose by examining the sensations and perceptions. The oculist who analyzes the color sensations of a patient and the aurist who finds defects in the hearing of the musical scale and discovers that certain pitches cannot be discriminated, is certainly dealing, for diagnostic purposes, with the material that the psychological laboratory has sifted and studied. Even that sensation symptom which enters into so many diseases, the sensation of pain, belongs certainly within the compass of the psychologist and it is only to be regretted that the systematic study of the pain sensations, mostly for evident practical reasons, has been much neglected in the psychological laboratory.
The psychologists have been at work all the more eagerly in the fields of association and memory, attention and emotion, habit and volition, distraction and fatigue. Here subtle methods have been elaborated, methods which surely common sense cannot supply, and which showed differences of mental behavior with the exactitude with which the microscope reveals the hidden differences of form. If physicians are slow in accepting the help which the psychological laboratory can furnish, it may be in good harmony with the desirable conservative policy in medicine, but finally the time must come when this instinctive resistance against new methods will be overcome. The recent attachment of psychological laboratories to certain leading psychiatric clinics is a most promising symptom. Yet the diagnostic studies with the means of the psychological laboratory cannot be confined to the cases of mental disease. The mild abnormalities of the mind, and especially the nervous disturbances which exist outside the field of insanity, demand this support of psychology much more. And even the normal personality will be more safely protected from disease and from social dangers for its mental constitution if the resources of experimental psychology are employed. The more we know of the psychological constitution of the individual, the more we can foresee the development which is to be hoped for or feared and which may be encouraged or retarded.
The psychologist may determine, for instance, the degree of attention with its resistance against distracting stimuli, the power of memory under various conditions and on various material, the mental excitability and power of discrimination, the quickness and correctness of perception, the chains of associations, the rapidity of the associative process for various groups, the types of reaction, the forming of habits and their persistence, the conditions of fatigue and of exhaustion, the emotional expressions and the emotional stability, the time needed for recreation and the resistance against drugs, the degree of suggestibility and the power of inhibition: and every result in any of these lines may contribute to the diagnosis and prognosis of cases. The chronoscope here measures the reaction times and association times in thousandths of a second; the kymograph, by the help of the sphygmograph, writes the record of the pulse and its changes in emotional states, while the pneumograph records the variations of breathing, and the plethysmograph shows the changes in the filling of blood vessels in the limbs which is immediately related to the blood supply of the brain. Here belongs also the ergograph, which gives the exact record of muscular work with all the influences of will and attention and fatigue, the automatograph which writes the involuntary movements, especially also the galvanoscope which may register the influence of ideas and emotions on the glands of the skin, and thus lead to an analysis of repressed mental states, and hundreds of other instruments which are used in the psychological laboratory.
Yet it would be misleading to think only of complex apparatus when experimental psychology is in question. An experiment is given whenever the observation is made under conditions which are artificially introduced for the purpose of the observation. Thus there is no need of the physical instrument. If I bring a spoonful of soup to my mouth at dinner and I become interested in the combination of warmth sensation and touch sensation and taste sensation and smell sensation, then I have performed an experiment if I take one more spoonful of soup just for the purpose of the observation. The physician too may carry out important psychological experiments, without needing the outfit of a real laboratory. Association experiments, for instance, promise to become of steadily growing importance. To make them serviceable to the problems of his office, nothing but a subtle psychological understanding is needed, inasmuch as any routine work schematically applied to every case alike would be utterly useless. Give your man perhaps a hundred words and let him speak the very first word which comes to his mind when he hears the given ones. You call rose, and he may say red or flower or lily or thorn; you call frog and he may answer pond or turtle or green or jump, and if you choose your hundred words with psychological insight, his hundred answers will allow a full view of his mental make-up. This is an experiment which does not require any instruments at all but a man’s subtle analysis of the replies. That is not seldom sufficient to secure the diagnosis of complex mental variations. The method yields still more if the time for such a reply is measured, but there again not the costly chronoscope of the laboratory is indispensable; a simple stop watch which gives the fifths of a second would be fully sufficient for all practical purposes. From such simple facts of the mental inventory the association experiments may lead to complex questions which slowly may disentangle the confused ideas, for instance, of a dementia præcox, and thus lead to subtle differential diagnosis.
The psychological laboratory alone can also elaborate the methods of studying, for instance, the feeble-minded with all the individual variations. New and ever new methods have been tried; the memory was tested by reading and repeating figures or letters, or colored papers were shown or cardboards of different forms or nonsense syllables, and the powers of remembering were studied. Or the accuracy of arm movements was examined, or the quickness of understanding associated words, or the success in planning a complex movement like throwing a ball at a target, or the tapping of a key in the rhythm of a metronome, or the discrimination and recognition of the pieces in the game of dominoes and many another scheme. The laboratory has to analyze the conditions for such methods and the psychologist has to prepare the means for the use of the physician, just as the chemist has to prepare the sleeping powders. In a similar way the laboratory may furnish means to analyze the mental disturbances by a comparison with the experimental results of artificial influences, for instance, of over-fatigue or half-sleep, of drugs or alcohol, of poisons and emotional excitements. The psychological resolving of the mental symptoms may of course, in the same way, furnish the diagnosis where the mental variation is only a distant effect of a bodily ailment. The changes in the emotions, for instance, may lead to the recognition of a heart disease; lack of attention may be a hint of the overgrowth of the adenoids; irritability or apathy or delirious character of the mental behavior may indicate whether uræmic acid is in the system or an infectious disease: anæmia and undernutrition may be diagnosed and the psychology of fever demands too a much closer analysis with the means of the psychological laboratory than it has received so far.
We have not spoken as yet about those psychological methods which themselves introduce abnormal mental states like hypnotism, and which also not seldom are only means for diagnostic purposes. The hypnotic state may bring to memory forgotten experiences of which the physiological effects may have lasted in the brain and which may have brought injury to the psychophysical system. Hypnotic inquiry can thus lead to the recognition of the first causes in many hysterical states and where hypnotism is not the best adjusted tool, a certain dreamlike staring may be more effective. We have to return to much of that later in full detail because just for instance in hysteria, the clear recognition of the sources and of the character of the disease may at the same time prove to be in itself the right starting point for curative treatment.
We have spoken so far only about the relations of psychology and medicine from the point of view of diagnosis; the relations from the point of view of therapy will make up the second part of this book. We shall describe the methods and the results, the possibilities and the limitations with manifold detail. That is the chief topic of this volume. All that is needed to prepare for this principal problem is on the one side a preparatory clearing up of some fundamental conceptions, especially of those two which have played the chief rôle in the whole discussion, namely the subconscious and suggestion. And on the other side, we may consider at first some fundamental discriminations which steadily influence the inquiries and controversies in the field. I think of the difference between normal and abnormal mental states, between psychical and physical facts in psychotherapy, between functional and organic diseases, and to return to our starting point, between mental and moral influences.
Every curative effort presupposes that the normal state of health has been lost and that a diseased state has set in. Yet the mental analysis suggests still less than the bodily inquiry, just where the normal functioning is really lost. It would be easy to draw a demarcation line if the pathology of the mind introduced any mental features which are unknown in our normal existence, but the opposite is true. No mental disease introduces elements which do not occur in the sphere of health. A degenerated brain cell looks differently under the microscope from a normal one, but the ideas of a paranoiac, the emotion of a maniac, the volition of a hysteric, the memory idea of a paralytic is each in its own structure not different from such elements in any one of us. The total change lies thus only in the proportion; there is too much or too little of it. The pathological mental life is like a caricature of a face—each feature is contained, as in the ordinary portrait, but the proportion is distorted, there is too much or too little of chin or of nose. But who can indicate exactly the point where the distortion of the features constitutes a caricature? Every grotesque change in the relations ruins the healthy state: what makes us sure that the harmony of health is spoiled?
Certainly we cannot settle it by mere statistics. The norm never means merely a majority. Even if the overwhelmingly larger part of mankind suffered from phthisis, the few who were free from it would be recognized as well and all the others would be considered ill. In mental life still more, no one ought to propose that the exceptional function is the symptom of disease. The few persons who never had a dream in their lives differ much in their mental experience from the large majority and yet their peculiarity is certainly not a symptom which needs curative treatment. The only real test of health is the serviceableness to the needs of life. We have an unhealthy state of the personality before us wherever the equilibrium of the human functions is disturbed in a way which diminishes the chances of existence, and the seriousness of the ailment depends upon the degree of this diminishing power. Seen from a strictly psychological point of view, we must expect thus a broad borderland region between the entirely normal well-balanced mental life and that unbalanced disorder of functions which really interferes with the chance for self-protection and effectiveness. That the melancholic who declines to take any nourishment, or the paranoiac who misjudges his surroundings, is unable to secure by his own energies the safety of his life cannot be doubted. The balance is completely destroyed and the will and the intellect of the physician and of the nurse must be substituted for his own mental powers, if his life is to be prolonged at all. But the misjudgment and the depression of the insane are only an exaggeration of that which may occur in any man.
There are therefore thousands of steps which lead from the normal error or regret to the destructive disturbance. Everyone knows persons whose pessimistic temperament makes them inclined to an over-frequent depression, or others whose silly disposition brings out constantly those emotional tendencies which the maniac shows in an exaggerated degree. The stupid mind shows those lacks of association and connection which reach their maximum degree in the mind of the idiot. We know from daily life the timid, undecided man who cannot come to a will impulse; the hasty man who rushes towards decisions; the inattentive man who can never focus his consciousness; and the overattentive man who can never dismiss any subject; the indifferent man on whom nothing produces evident impression and feeling; the over-sensitive man who reacts on slight impressions with exaggerated emotion; and yet every one of such and a thousand similar variations, needs only the projection on a larger scale to demonstrate a mental life which is self-destructive. The silly girl and the stupid boy, the man who has the blues and the reckless creature, are certainly worse equipped for the struggles of existence than those who are intellectually and emotionally and volitionally well-balanced. They will take wrong steps in life, they may be unsuccessful, their stupidity may lead them to the poorhouse, their recklessness may lead them to the penitentiary. And yet we do not speak of them as patients because their disproportionate mental features may be sufficiently corrected by other mental states which are perhaps more strongly developed.
Further, inasmuch as human life just in its mental functions is related to its social surroundings, much must depend on the external conditions, whether the disproportion and abnormality has to be treated as pathological. The mind which may find perhaps its way under the most simple rural conditions would be unable to protect life under the complex conditions of a great city. The man who in certain surroundings may appear a crank has to be treated as a patient in a different set of life conditions. Wherever psychotherapeutic work is in question, perhaps nothing is more important than to keep steadily in mind this continuity between normal and abnormal mental features. The mental disturbance must constantly be looked upon as a change of proportions between functions which, as such, belong to every normal life. We have to train and to develop, and thus to reënforce, that which is too weak, and we have to drain off and to suppress and to inhibit that which is too strong.
Yet just this functional view of disease must remind us strongly from the beginning that it would be utterly in vain to draw any demarcation line between psychical disturbances and physical ones. We have seen from the start that from the point of view of physiological psychology, there can be no psychical process without an accompanying physiological process in the brain. Every disturbance in mental actions is thus at the same time a disturbance in the equilibrium of nervous functions. Yet that alone would not exclude the possibility of considering some diseases, for instance, exclusively from the mental side, and we should be justified in doing so if those parts of the brain which are the seat of the mental processes could remain in the diseased state without influence on other parts of the nervous system and of the whole body. In such a case it would indeed be sufficient to consider the psychophysical disturbance from the psychological point of view only, that is, to speak of the disease as a disorder of intellect, of emotion or will, without thinking of changes in the brain cells. But such isolation does not exist in nature. Not only the bodily factors like nutrition and circulation and sexual functions have a thousandfold influence on the psychophysical processes, and these in turn change the vegetative functions of the body, but especially the other parts of the brain and nervous system can be affected in most different ways. If we want to consider whether a certain variation of the personality demands curative treatment, we certainly cannot confine ourselves to the mental variations. They are after all only parts of the whole group of changes in the organism and are thus symptoms of a disease which has to be studied in its totality. The mental symptoms alone may be relatively slight variations, which in themselves might be sufficiently balanced not to disturb the equilibrium of life, and yet they may be symptoms of a brain disturbance which as a whole must interfere with the safety of life. On the other hand, mental life may appear like a chaos and yet the disturbance may be the symptom of merely a slight brain affection and the treatment of the mental symptoms in their apparent severity would be a useless effort. The mental disturbance, for instance, of the intoxicated or the hashish smoker, even the delirium of the feverish, does not suggest a fight against the mental symptoms during the attack.
On the whole, there is a far-reaching independence between the apparent mental variations and the seriousness of the brain affection. Light hysteric states may produce a strong absenting of the mind while severe epileptic conditions of the brain may be accompanied by very slight mental changes. Every neurasthenic state may play havoc with mental life, while grave brain destructions may only shade slightly the character or the intellect. To deal with the mental changes as if they belonged to a sphere by itself, to the soul which is well or ill through its own independent alterations without steadily relating the changes to the total organism, leads therefore necessarily to failure. The mind reflects only symptoms of the disease; the disease itself belongs always to the organism. Psychotherapy has suffered too much from the belief that the removal of mental symptoms is a cure of disease.
Certainly the psychophysical symptoms may often stand in the foreground of the disease, and in that case it may be left to the special needs whether we deal with them as psychical or as physical changes. Even the patient may be made to see them in one or the other way in accordance with his special needs. To tell him that his brain cells are in disorder and that they can be cured will be the right thing for him who takes only the introspective view of his suffering and is in despair because his own will seems powerless to overcome those mental changes. For the next patient, the opposite may be wiser. The belief that his brain is ill may have induced him to give up effort of the will instead of helping along by steady self-suggestion. He will be helped more if he understands that his mind is working wrongly. But the full truth is that both mind and body are in disorder; the function of the disturbed brain cells accompanies the ineffective will, and to reënforce the will means to bring into equilibrium again the disturbed brain cells. For the psychotherapist the temptation of giving the attention to the mental symptoms only is strong. The more firmly the physician sticks to the standpoint of psychophysiology, the better he will see ailment and cure in their right proportion.
This demand for the consideration of the whole personality, mind and body, ought not to be influenced by the popular separation between organic and functional diseases. If we call organic diseases of the mind those in which the mental disturbance is the accompaniment of a brain disturbance, and functional those in which no brain disturbance exists, we leave entirely the ground of modern psychology. As soon as we believe that the mind can be disturbed without a change in the functions of the brain, we give away all that which has brought scientific order into the study of psychological existence. Every mental disturbance corresponds to a disorder in the brain’s functions. But there cannot be a change in the functions of the brain without a change in its structure. Thus we must claim that all those so-called functional disturbances like neurasthenia and hysteria, fixed ideas and obsessions, phobias and dissociations of the personality, as well as the typical insane states of the maniac or paranoiac have their basis in a pathological change of the anatomical structure of the brain. This postulate cannot be influenced by the fact that the microscope has been unable to detect the character of most of these changes.
Of course all this does not exclude its being perfectly justifiable to separate those diseases for which a definite destruction of the brain parts can be detected, as in paralysis of the brain, from those where that is impossible. We may also expect that those disturbances in the brain which we cannot as yet make visible, may allow more easily an organic repair and thus a restoration to the normal functions. Just as a disjointed arm may be brought to function quickly again, a broken arm slowly, an amputated arm never, each brain cell too may suffer lesions which are reparable in different degrees. But it is evident that it remains then an entirely empirical question whether the invisible damage allows repair or not. We have no right to say that where the destruction cannot be seen under the microscope there is no organic change and the disturbance is therefore only a psychical one and can be removed by mental means. All changes are physical and experience has to decide whether they are accessible to psychological influences or not. States like epilepsy may not allow any recognition of definite brain destruction and are yet on the whole inaccessible to mental influence, while many a brain disturbance with visible alterations, resulting perhaps from anæmia or hyperæmia, may be caused to disappear. If on the other hand we say that we can cure with psychotherapeutic means only the functional brain diseases and define as functional simply those diseases which can be cured by such means, we move, of course, in the most obvious circle and yet just that is the too frequent fate of the discussions in certain quarters.
Every psychical disturbance is organic inasmuch as it is based on a molecular change which deranges the function. Some of these changes are beyond restitution; some can be brought back to a well-working structure by strictly physical agencies like drugs or electricity; others can be repaired by physiological stimuli which reach directly the higher brain cells through the sense organs and which we call psychical under one aspect, but which certainly remain physiological influences from another aspect. And these psychophysiological influences of the spoken words or similar agencies are thus indeed for therapeutic effect entirely coördinated with the douche and the bath and the electric current and the opiate. It is a stimulation of certain brain cells, an inhibition of certain others: a subtle apparatus which must be handled with careful calculation of its microscopical causes and effects. That these words from an entirely different point of view may mean a moral appeal and have ethical value, point to moral and religious ideas and reënforce the spiritual personality, lies entirely outside of the psychotherapeutic calculation. As long as the curing of the patient is the aim, the faith in God is not more valuable than the faith in the physician and the moral appeal of no higher order than the influence through the galvanic current. They come in question only as means to an end and they are valuable only in so far as they reach the end. That they can be related to an entirely different series of purposes, to the system of our moral ideas, ought not to withdraw the attention of the psychotherapist from his only aim, to cure the patient. The highest moral appeal may be even a most unfit method of treatment and the religious emotion may just as well do harm as good from the point of view of the physician. Psychotherapy has suffered too much from the usual confusion of standpoints.