Undoubtedly psycho-analysis has its place in psychotherapy and is of great value in certain cases. There is no doubt, however, in my mind that in most of these cases reported as cured after psycho-analytic methods had been employed, what really happened is that the patient's mind became diverted to another idea—that of marvelous cure through mind searching which relieved the previous concentration of mind underlying the psycho-neurosis. These are the cases that used to be cured by hypnotism. Before hypnotism was developed they were cured by mesmerism. Before mesmerism they were cured by magnets or by the Leyden jar, and during the past century they have been cured by electrical methods or by osteopathy or by Eddyism. Many of the cures were effected by stroking and touches, the use of Perkins' tractors, or Greatrakes' methods, or anything else that attracted attention very strongly. They were given a new idea which occupied them very much and so saved them from that preoccupation with themselves and their feelings and whatever slight ailment might be present that was the physical occasion for psycho-neurotic symptoms. This happened with psycho-analysis. When it was absolutely new and the operator had great confidence in it, this confidence was imparted to the patients, with the consequent cure or decided amelioration of their psycho-neurosis, just as that used to be brought about by our previous method of treating such cases by some strong suggestion.
As I emphasize in the chapter on Dreams, the examination of the dreams in order to get a hint of the dominant idea, is particularly interesting, because it represents a return to the oldest methods of suggestion of which we have record. [{596}] The fact that sexual ideas seem to represent a great many of the dominant ideas in these cases is of interest for a similar reason. It represents the tendency constantly recurring to refer most nervous ailments, as indeed most other ailments, to something pathological in the sexual or genital sphere. The old idea embodied in the word hysterical exemplifies this very well. The "vapors" or "tantrums" or fits which were supposed to be due, to some extent at least, to suppressed sexuality by medical writers of three or four generations ago, have come back to us under another form and with other terms. Psycho-analysis gives occasion for instruction in so far as it helps the patient to get rid of old persuasions and exploded ideas as to disease and diet and the various functions of the body and the mind that have often almost unconsciously been acquired and secured a dominance. It is surprising how often it will be found that people are taking too much or too little water at meals, too many or too few vegetables, too much or too little of salt or of other condiments as the result of habits and notions acquired when they were young and under influences that they may now forget. In the same way habits of life with regard to bathing, clothing and the like may be the source of unfavorable conditions in mind and body that need only to be discovered to be corrected. Their correction will often bring about the relief of symptomatic conditions that have proved quite obstinate to treatment. We have emphasized this in the chapters on the Individual Patient and the necessity for acquiring just as much knowledge as possible about both his occupations and his mental attitude in order to be able successfully to treat chronic disease.
SECTION XVIII
DISORDERS OF MIND
CHAPTER I
MENTAL INCAPACITY (PSYCHASTHENIA)
In recent years we have come to realize that many of the so-called nervous diseases, or if they do not deserve the serious name of disease, nervous symptom-complexes, are really due to a deficiency of vital energy. Some people have a store of energy that enables them to accomplish many different things successfully. Some become exhausted from a few trivial occupations. What is noteworthy in the cases to be discussed in this chapter is that they show always certain symptoms of mental tiredness or, at least, of lack of capacity for affairs. Patients complain, for instance, that they cannot make up their minds so as to reach decisions because they doubt so much whether the decision they come to will be right or wrong. Others dread the outcome of any and every act and feel that something is hanging over them. Slight sources of irritation become so exaggerated by thinking about them and dwelling on their possibilities that they may even disturb sleep and appetite and, as a consequence, the general health. Fears come over patients lest various things should happen and they dread microbes, or infections, or dirt in general, or the approach of insanity, and all to such a degree as to incapacitate them for their ordinary occupations.
Many of these patients become quite incapable of willing effectively. They not only lose initiative, the power to undertake new enterprises, but they find it difficult to make up their minds as to details of the ordinary affairs of life. As we have stated elsewhere in Professor Grasset's expressive formula, these patients say that they cannot do things, their friends say "they will not," and the physician, taking the middle course, which, as usual in human affairs, has much more of truth than either of the extremes, says "they cannot will."
For these states Janet of Paris suggested the word psychasthenia. It is formed on the model of the word neurasthenia and unless it is used with discretion will have all the objections that attach to that other term. Above all, it shares the tendency pointed out by Sir William Gowers with regard to neurasthenia of being "too satisfying. Men are apt to rest on it as they would not on its English equivalent. Physicians, if they do not actually think that they have found the malady from which the patient is suffering, have an influence exerted on them of which they are often unconscious, which lessens the tendency to go farther in the search for the whole mental state." Much more can be said in defence of psychasthenia, however, than of neurasthenia, for the substitution for it of the translation of the Greek words of [{598}] which it is composed—"mind weakness" would be alarming. While it is important, then, to realize that the term may easily be made too general and prove, as such words as rheumatism has done in our time and malaria did in the past, a cloak for ignorance and an excuse for incomplete investigation for diagnostic purposes, it represents a satisfactory answer to the patient's question as to what is the matter without committing the physician to such definitely detailed opinions as to the patient's condition as would surely prove unfavorably suggestive.
Psychasthenia, Natural and Acquired.—There are two forms of the mental incapacity that underlies many of the curious symptom-complexes that have been studied under the term psychasthenia. One is natural, that is, inherent in the special character of the individual, and the other acquired through disease or exhausting labor, worry, or anxiety. Some people are born without sufficient mental energy to do the work they attempt to accomplish. This is true, also, in the physical order. It is often pitiable to see young men who have not the physical strength necessary for athletic exercises, or the dexterity required for them, faithfully trying to accomplish by effort what others do with ease. When there is some natural defect in the way they will usually fail, no matter how much they strive. Just in the same way some persons are not able to accomplish certain more serious purposes requiring special mental ability or power which they attempt. Their brothers, their friends, their schoolmates, may have the ability, and they cannot understand why they should not have it, but the fact remains that they are not possessed of it and if they try to make up for this defect by overwork they simply break down.
Differential Diagnosis.—Each of the two forms of mental incapacity, congenital and acquired, must be carefully differentiated and treated from a special standpoint. With regard to congenital lack of mental control, all that the doctor can do is to counsel against the assumption of duties and responsibilities that are too heavy for the patient. Some people have not enough nervous energy to run a business with many details, and some even find it difficult to try to do things involving much less responsibility. There is no use for a man five feet in height, weighing one hundred pounds, to try to be a stevedore. There is no use for men of delicate muscular build to try to make their living at heavy manual labor; they simply wear themselves out in a very short time. This inadaptability is recognized at once. Just the same thing is true with regard to many nervous systems, but the recognition is not so easy or immediate. Some cannot stand the strain of intricate business details or the burden of responsibility in important transactions. They must be taught to be satisfied, then, with quiet simple lives without what is for them, excessive responsibility and without strenuous business worries. A country life with regular hours, plenty of open air and as little responsibility as possible, is the ideal for them.
The most difficult problem in this matter is the question of diagnosis. As a rule, the history is the most helpful for this. The patient tells of having found difficulty all his life whenever anything of special significance was placed on his shoulders. He is one of those who were born tired and remain so all their lives. It has been the custom to blame these people; they are rather to be pitied. If they are born in circumstances that allow of their [{599}] living quietly in the country, they accomplish a certain amount of work quite successfully and live happy, contented lives. If they are born in the city where the hurry and bustle around them and the insistence of friends that they must take up responsibilities becomes poignant, they get discouraged and even despondent. It is from this class of patients that the "ne'er-do-wells" of modern life are recruited. They form the under-stratum of trampdom, the scions of good families with the wanderlust, the willing but incapable. Certain of them become vicious and criminal, either because they do not want to work or because their mentality is perverted in some way. Such patients cannot be treated with any hope of their becoming successful exemplars of the strenuous life, but they may be directed into the less exacting occupations of country life and so live quiet, useful and happy lives. For the congenital class we can do little except to prevent them from trying to do things that are beyond their mental capacity and helping them to see just what their limitations are.