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.