mu i un i linn ii ii nu ii HX64125017 RC343 .D85 The psychic treatmen RECAP "ft C 3+3 285 Co jp . | - (Etflttmbia ImtirraUu, In itj? (Ettg nf N^ui fork GJollwjp nf ^Ijgatriana atto &urg?atis i&tUxmtt Stbrara Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/psychictreatmentOOdubo PSYCHIC TREATMENT OF NERVOUS DISORDERS THE PSYCHIC TREAT- MENT OF NERVOUS DISORDERS :: :: :: :: (The Psychoneuroses and Their Moral Treatment} By DR. PAUL DUBOIS Professor of Neuropathology at the University of Berne TRANSLATED AND EDITED BY SMITH ELY JELLIFFE, M.D., Ph.D. Visiting Neurologist City Hospital ; Instructor in Materia Medica and Therapeutics, Columbia University, New York AND WILLIAM A. WHITE, M.D. Superintendent Government Hospital for Insane, Washington, D. C; Professor of Nervous and Menial Diseases, Georgetown University, Washington, D. C; Professor of Menial Diseases, George Washington University, Washington, D. C. FUNK & WAGNALLS COMPANY NEW YORK AND LONDON I905 Copyright, 1905, by FU>TK & WAGNAU.S COMPACT? [Printed in the United States of Americd\ Published July, 1905 TRANSLATORS' AND EDITORS' PREFACE The preparation for the American public of a translation of Professor Dubois's " Les Psychoneuroses " has been undertaken with the conviction that its publication in this country would be particularly opportune at this time, when the effect of the mental representations upon the bodily conditions is attracting so much attention here, and when the problems connected with it are being attempted from so many and such various points of attack. It is a question as alluring as it is baffling, and it is not easy to preserve toward it an attitude at once open and balanced. Such an attitude, however, Professor Dubois has maintained from the start, and to it he owes the exceptionally convincing quality of his work. Whether in the opening chapters, where he discusses the fundamental philosophy underlying the position which he holds, or in the latter portion of the book, where he describes so clearly and charmingly the exact methods by which he has won such notable success, this sane and tranquil attitude is obvious. It is difficult to see how one who accepts the well- nigh axiomatic premises with which the author sets out can avoid accompanying him quite to his conclusions, so logical and inevitable is his progress. By the time we reach the specific instances which illustrate the power of u moral ortho- pedics," of " persuasion," and of " education of the reason," the successes chronicled there seem to the reader, as to the author, the inevitable result of the " psychotherapy " which he practises. The strong, optimistic tenor of the book, its simple, un- technical language, and the directness with which its phi- losophy is applied to life, make it capable of becoming a vital fact, not merely to physicians, but to every one who has pon- dered on the relations between the psychic and the physical — to every one, indeed, who honestly desires to keep down the 414259 iv TRANSLATORS' AND EDITORS' PREFACE sum total of needless suffering in the world. That psychic disorders require psychic treatment, that many distressing and dangerous nervous disorders are purely or primarily psychic — these are the theses for which the book contends, together with the obvious completion of the syllogism. It is safe to say that not a day passes in which any one fails of an opportunity to apply the principles set forth by Professor Dubois, and it is in the hope that the publication of his book may promote the seizing of these opportunities, as well as prove illuminating to some of the most prevalent problems of the practitioner, that the American edition has been produced. Thanks are due to the persevering labors of Mrs. Smith Ely Jelliffe, who provided the translation in large part, and of Miss Grace Goodale, who prepared the Index. SMITH ELY JELLIFFE. WILLIAM A. WHITE. New York, June 17, 1905. DR. DEJERINE'S PREFACE The work of Professor Dubois is that of a physician as well as of a psychologist who for a long time has perceived the important rôle played by psychotherapy in the treatment of the neuroses. At a period when, in spite of the works of Pinèl and Lasègue, showing the necessity for the adoption of moral methods of treatment in the psychopathies, physicians persisted in treating the neuroses solely by physical methods, Dubois has had the merit of showing, in a series of publications, the primordial (fundamental), if not unique, rôle which is played in the treatment of psychoneuroses by what I should like to call psychic pedagogy — that is to say, the reeducation of the reason. He has been the first resolutely to conduct all his therapy in accordance with this guiding idea. There is to be found in this volume, along with the most interesting psychological considerations, a description of the methods used by the author in his practise of psychotherapy. There are some very beautiful passages which would not be out of place from the pen of a philosopher or a moralist, the perusal of which must impress all, whether patients or phy- sicians, who have the desire to know how and why the psycho- neuroses develop, and how they may be cured. But what is most distinctly felt on reading these pages is that they are the work of a man with convictions, to whom one might apply the phrase of our old Montaigne : " Here is a book of good faith." It gives me, moreover, all the more pleasure to present this book to the French medical public because the author is an old friend. In wishing him the success which he deserves, I only do justice to the work of a man whose talents I esteem as much as I admire his character. J. DEJERINE. Paris, March, 1904. AUTHOR'S PREFACE Some years ago I received from a young French physician a letter, from which the following lines are an extract : " The cure of M. has made some stir in the medical world of X. Every one knows that neurasthenia is an essen- tially curable disease, but every one also knows that the meth- ods which must be employed to bring about a satisfactory result are not within the reach of all. The case of M. was not easy, and the resources of many of my acquaintances were exhausted in connection with him." In conclusion my confrère asked my advice upon some points, in order that he might obtain the same results in his medical practise, which he was just beginning. I answered him by a long letter, in which I tried to bring out the peculiarities of the psychic treatment which I had used; but I had to point out to my friend that it was impos- sible for me to condense in such a way the experiences that had been gathered during more than twenty years, chiefly devoted to the treatment of the neuroses. It was only by per- sonal conversations that he was able to see my views and put them into such form that he could use them in his practise. On the other hand, some intelligent patients among my colleagues, with whom I have had very friendly relations, have often expressed a desire to read what I had said to them. I have held out for a long time against these friendly entreaties. We live in a period of exact research, of labora- tory work, and of statistics that are more or less convincing, and I can offer only impressions and opinions which are based upon what I believe to be conscientious observations, and on reflections which are forced upon me by facts, but I do not possess the necessary scientific reputation to insure their acceptance. If, in spite of these justifiable fears, I dare to face the criticism of my colleagues, it is first because I feel that I am 2 AUTHOR'S PREFACE upheld by the friends who have become interested in my ideas ; but, above all, it is because, in the practise of my treatment by psychotherapy, I have had such good and lasting results that I should like to put into the hands of young physicians the instrument which I have found so useful. The correspondence begun with my young friend has led me to make a résumé of the results of my observations. I have made them the subject of lectures given to the Faculty of Medicine of the University of Berne, and have written them out, not for the public, but for my confrères, and to them I give them, asking only a certain measure of indulgence. PAUL DUBOIS. Berne, 1904* TABLE OF CONTENTS CHAPTER I Modern Medicine — Virchow, Pasteur, Lister — Conditions of Thought Thirty Years Ago — Progress of Surgery, Bacteriol- ogy — New Orientation of Medical Ideas — Neglect of the Neu- roses — Hysteria, Briquet, Charcot — The School of Nancy and Hypnotism — Neurasthenia : Its Existence in Former Genera- tions II CHAPTER II Classification of the Neuroses — Psychoneuroses or Nervousness — Psychic Origin of Nervousness — Tendency to Assign to it Somatic Causes — Abuse or Physical and Medicinal Therapeu- tics — Poverty of True Psychotherapy — Mixture of Practical Materialism and Doctrinal Spiritualism — Obstacles to the Development of Psychotherapy 22 CHAPTER III Rational Basis of Psychotherapy — Education of the Reason — Dualistic Spiritualism — Psychophysical Parellelism — Mgr. d'Hulst — Different Opinions Concerning the Bond of Affinity between the Mind and the Body — Practical Philosophy Founded on Biological Observation — The Importance of the Problems of Liberty, of Will, and of Responsibility .... 35 CHAPTER IV The Problem of Liberty — Determinism — Flournoy; Ernest Naville — Imperious Character of the Motives that Induce Action — Popular Conception and Philosophic Conception of Liberty — Our Slavery in the Presence of Our Innate and Acquired Men- tality — Moral Orthopedia — Uselessness of the Concept: Will, 47 CHAPTER V Absolute Responsibility — Social and Moral Responsibility — Inde- pendent Morality: Reason is its Guide — Gradual Development of Moral Sentiments — Moral Conscience — Community of Aspirations among the Believers in Free Thought — Search for Happiness: Depends on our Native or Acquired Mentality — Faults of Character or Disorder of the Mind 58 4 TABLE OF CONTENTS CHAPTER VI Difficulties of Moral Orthopedia — Criminality — The Partisans of Absolute Responsibility and the Determinists Remain Irrecon- cilable Adversaries in Theory — Possible Compromise in Prac- tise — Necessity of this Understanding — The Rôle of Human Justice — Educative End of Repression — Urgent Reforms of Penal Laws 70 CHAPTER VII Monistic Conception — Passivity of the Organism — Absence of True Spontaneity — Mechanism of the Reflex — Psychology is Only a Chapter of Biology — Interpolation of Conscious Acts in the Reflex Arc — Mental States Have Always a Material Substratum — The Ideogenic and Somatogenic Origin of Men- tal States — Riciprocal Influence which the Moral and the Physical Exercise Upon One Another — The Possibility of Act- ing on these Mental States by Physical Means and by Moral Influence; Efficacy of the Latter 80 CHAPTER VIII Slavery of the Mind in the Presence of Certain Diseases: General Paralysis, Meningitides, Epilepsies, Intoxications — Possibility of Escape from It by Education of the Moral Ego — Pinel; Cur- ative Action of the Work of Logical Reflection — The Difficulty of Psychotherapy in the Vesanias; its Efficacy in the Psycho- neuroses — Necessity of Clear Ideas on the Genesis of these Diseases — The Importance of Psychotherapy in Every Prov- ince of Medicine 93 CHAPTER IX Psychic Symptoms of Nervousness — Psychic Origin of Functional Troubles — Every Organic Disease Has Its Counterpart in Nervousness — The Characteristic Thing of Nervous Cases is Not Their Pains, but Their Mentality — Mental Stigmata: Sug- gestibility, Fatigability — Exaggerated Sensibility and Emotiv- ity — Suggestion and Persuasion — Suggestibility in a Normal State 103 CHAPTER X Fatigability — Muscular Fatigue; Its Location — Mental Troubles Connected with Muscular Fatigue; Tissiér, Féré — Psychic Ele- ment of Fatigue — Conviction of Fatigue — Cerebral Fatigue — Ergographic Curves — True Fatigue and Ordinary Fatigue — Dynamogeny and Dynamophany — Importance of these Ideas to the Physician and the Educator 120 TABLE OF CONTENTS 5 CHAPTER XI Sensibility the First Condition of All Physiological Activity — Sen- sation: Its Psychic Character — Constant Influence of the Idea, of Autosuggestions, on Our Various Sensibilities to Physical Agents: Air, Barometric Pressure, Temperature, Electricity, Light, Food 133 CHAPTER XII The Emotions — Physiological Theory; Lange, W. James, Sergi — Intellectualist Theory — Cold, Intellectual Ideas ; Warm Feel- ings — Subconscious Emotions ; Apparent Automatism of the Emotional Reaction — Psychic Origin of Emotion; Value of this Conception for Treatment — Irrationalism of Nervous Patients — Physical, Intellectual, and Emotional Fatigue ; Dangers of the Last — Unhealthy Impressionability — Tempera- ment and Character 144 CHAPTER XIII Psychasthenia: Congenital and Not Acquired — Absence of Any Dividing Line Between the Normal Mental Condition and Insanity — Clinical Forms of Psychoneuroses — Neurasthenia : Its Characteristic Stigmata: Physical, Intellectual, and Moral Fatigability — Exaggeration; Significant Contradictions — Men- tal Instability — Somatic Symptoms Due to Fatigue .... 157 CHAPTER XIV Hysteria: Its Characteristic Stigma is Autosuggestibility — Pas- sional Attitudes — Natural Predisposition — Feminine Mental- ity — Mental Infantilism — Hysteroneurasthenia — Traumatic Forms— Anesthesias — Hysterical Fevers 172 CHAPTER XV Melancholia — Danger of Suicide — Hypochondria: Its Milder Forms Approach Neurasthenia — Insufficiency of Nosographic Classifications — Hypochondriacal Melancholia — Minor Hypo- chondrias — Periodic Depression of Lange . 184 CHAPTER XVI Idea of Degeneracy: Morel and Magnan — Mental and Bodily Stig- mata — Abuse of the Idea of Degeneracy — Human Imperfec- tions : Physical, Intellectual, and Moral Malformations — Relationship of the Different States of Disequilibrium — Isolated Nervous Symptoms 198 6 TABLE OF CONTENTS CHAPTER XVII The Therapeutics of the Psyche-neuroses — Suppression of Actual Disorders — Modification of the Mentality of the Subject to Avoid Recurrences — Religious Faith; Suggestions of Char- latans; Suggestion by Medicines; Scientific Suggestion; Hyp- nosis 209 CHAPTER XVIII Rational Psychotherapy — Its Efficacy in All Domains of Medicine — The Necessity for Impressing the Patient with the Convic- tion of Cure — Blind Faith and Rational Faith — The Persist- ence that is Necessary to Establish the Idea of Cure — Organic Complications — Contrary Suggestions — Necessity of Chang- ing the Mental State of the Subject — Favorable Conditions for Attaining this End 223 CHAPTER XIX Weir Mitchell's Treatment; Modifications which Ought to be Made in It in Order to be Efficacious — Utility of the Measures of Rest in Bed — Overfeeding and Isolation — Importance of the Psychic Factor — The Treatment of Psychoneuroses Ought to be a Cure of Psychotherapy Made Under the Favorable Conditions of Rest, Overfeeding, and Isolation — Sketch of this Moral Influence 235 CHAPTER XX Various Symptoms of Nervousness — Digestive Troubles : Their Frequency — Mental Anorexia: Disgusts, Sensation of Restric- tion, and Depression — Stimulation of Appetite by Psychic Means — Gastric Dyspepsia: Its Genesis and Its Aggravation by Autosuggestion — Gastric Troubles in the Insanities; Cere- bral Affections — Broussais; Barras — Easy Diagnosis of Ner- vous Dyspepsia 249 CHAPTER XXI Treatment for Dyspeptics — Rest, Isolation, and Preparatory Milk Diet — Building Up by Overfeeding — Massage — The Value of these Measures — Necessity of Inducing Obedience by Persua- sion — Results of the Treatment and Examples 265 TABLE OF CONTENTS 7 CHAPTER XXII Influence of Mental Representations on the Intestine — Abuse of the Word "Enteritis" — Emotional Diarrhea — Necessity of Combating this Psychic Sensibility — Fixation of Thought on Intestinal Troubles — Its Inconveniences — Physiological Ex- periences ; Pavlow and Kronecker — Mucomembranous Co- litis: Its Habitual Cause, Constipation 278 CHAPTER XXIII Habitual Constipation — Uselessness of Laxatives — Efficacy of Treatment by Training — Influence of Habit — Outline of Pre- scriptions Intended to Reestablish the Intestinal Function — Suggestive Influence — Psychology of Constipated Patients . 291 CHAPTER XXIV Disturbances of Circulation — Emotional Tachycardia — Basedow Symptoms — Permanent Tachycardia : Its Existence in the Tuberculous — Arythmia: Intermittent, Accidental Murmurs — Suppression of Cardiac Disturbances by Psychotherapy — Ner- vous Dyspnea — Convulsive Cough — Stuttering — Nervous or Hysterical Aphonia — Mutism 305 CHAPTER XXV Disturbances of Urinary Functions — Retention ; Phobias — Noc- turnal Incontinence — Polyuria — Pollakiuria — Qualitative Modifications of Urine — Disturbances of Sexual Life ; Their Frequency in the Psychoneuroses — Sexual Psychopathy — Onanism — Physical and Psychic Influence — Menstruation and Menstrual Psychoses — Nervousness at the Menopause — The Critical Age — Possibility of Psychotherapeutic Intervention in these Various Conditions 319 CHAPTER XXVI Troubles with Sleep — The Uselessness and Dangers of Narcotic Medication — The Insufficiency of Various Kinds of Hydro- therapy — Efficacy of Psychotherapy — Causes of Insomnia : Physical Ones, Too Vivid Sensorial Impressions; Moral Ones, Intoxications and Autointoxications; Preoccupations or Ob- sessions — Anxiety in Trying to Get to Sleep — Psychothera- peutic Machinery — Creation of a Mental Condition Favorable to Sleep — Abuse of Medicinal and Hydrothérapie Treatment . 334 8 TABLE OF CONTENTS CHAPTER XXVII Various Nervous Attacks — Their Usual Treatment by Antispas- modics, Hydrotherapy, etc. — Advantages of Moral Treatment — Sudden Cessation of Attacks under the Influence of Change of Environment — In Hysteria Everything is Mental, and the Treatment Should be Psychotherapeutic — Possible Failures — Persistence of the Hysterical Mentality — Moral Obstacles to Cure — Spirit of Contradiction — Self-esteem — A Few Words on Traumatic Hysteria 347 CHAPTER XXVIII Disturbances of Motility — Spasms, Tics, and Myoclonias — Inter- vention of Mentality — Professional Cramps — Influence of Un- easiness, Timidity — Charcot, Brissaud, Meige and Feindel — Psychomotor Discipline — Kinesotherapy and Psychotherapy — Advantages of Pure Psychotherapy in Patients in whom the Phobic Element Predominates 360 CHAPTER XXIX Conditions of Helplessness in Various Motor Domains — Their Psychic Origin — Paraplegia — Hysterical Astasia-abasia — Stasophobic and Basophobic Symptoms in the Course of Other Psychoneuroses — Example of Cure by Pure Psychotherapy . 374 CHAPTER XXX Example of Psychic Treatment in a Case of Psychoneurosis with Multiple Symptoms — Nervous Pains Cured by Suggestion — Value of Direct Psychotherapy — Utilization of the Stoic Idea; Seneca — Pelvic Neuralgia Cured by these Measures .... 388 CHAPTER XXXI Analysis of a Case of Hysteria with Multiple Symptoms — Disas- trous Effect of Wavering in the Diagnosis and of Local Treat- ment — Only a Direct and Frank Psychotherapy Puts an End to the Vagaries of the Disease — Recent Progress of Psycho- therapy — Buttersack, of Berlin — The Works of D. P.-E. Levy, of Paris — The Education of the Will — Necessity of Holding to Psychotherapy Pure and Simple 401 TABLE OF CONTENTS 9 CHAPTER XXXII Proofs of the Value of Moral Treatment in Psychoneuroses — Modi- fication of Mentality as the Result of Advice — Relation of a Case of Psychoneuroses which, Having Resisted Physical and Moral Cure, was Cured in a Single Day by Psychic Influence — Divers Cases of Nervousness, in which the Cure has been Obtained without Physical Means (by Psychotherapy) in the Course of a Few Conversations , , 412 CHAPTER XXXIII Psychotherapeutic Treatment Without the Intervention of Phys- ical Measures — Case of Neurasthenia of a Melancholic Nature — Cure and Relapses — Case of Disequilibrium — Suppression of all Maniacal Impulsions by a Few Conversations — Incura- bility of Certain Psychoneuroses — Mental Peculiarities which Make One Foresee Failure — Moral Idiots — Disturbances of Feelings of Affection in the Psychoneuroses 425 CHAPTER XXXIV Etiology of the Psychoneuroses — The Causes the Same as those of Insanity — Definition of Nervousness — Predisposition, He- redity, and Natural Disposition — Relation of Nervousness to Physical Debility — Anemia, Arthritism or Horpetism, and Cholemia — Purely Somatic Origin of Certain Psychoneuroses — Advantages of a Persevering Psychotherapy — Necessity of Making it Rational 439 CHAPTER XXXV Conclusions — Views on Medicine in the Twentieth Century — Surgery — Internal Medicine — Medicative Therapeutics, Phys- iotherapy — Constant Intervention of Psychotherapy : Its Necessity in the Struggle Against the Psychoneuroses — The Precepts of Physical, Intellectual, and Moral Hygiene . . . 451 Index 463 PSYCHIC TREATMENT OF NERVOUS DISORDERS CHAPTER I Modern Medicine — Virchow, Pasteur, Lister — Conditions of Thought Thirty Years Ago— Progress of Surgery, Bacteriology— New Orien- tation of Medical Ideas — Neglect of the Neuroses — Hysteria, Briquet, Charcot — The School of Nancy and Hypnotism — Neurasthenia: Its Existence in Former Generations Modern medicine boasts of being scientific, and certainly with reason. The gross empiricism and doctrinal statements of the beginning of the nineteenth century have given place to exact research and the patient study of facts; medicine has become experimental. Often a more progressive person attempts some brilliant synthesis, but his theoretic views are still based on facts that are accepted as established. They are not evolved in the study ; they come from the laboratory, which everywhere, whether it be modest or elaborate, is an indispensable adjunct to the clinic. From physics, chemistry, and even mathematics we have learned methods of work and analytical processes. The allied sciences have furnished us with powerful aids to investigation, by means of which we have been able to study symptoms and make diagnoses with a precision that has been hitherto un- known, so that each day records a new conquest. A brilliant era has already begun under the influence of pathological anatomy. The microscope opens up new horizons and permits the study of the alterations of tissues in their finest details. Cellular pathology has been born, and the name of Virchow marks a date that will never be forgotten in the history of medicine. 12 PSYCHIC TREATMENT A little later the genius of Pasteur led us in a new direc- tion. Our eyes were unsealed, and we were enabled to catch a glimpse of the important rôle that microbes play in the eti- ology of a great number of diseases. Practical results were not expected ; under the stimulus of Lister, surgeons began the work of attacking the enemy before they had even learned its nature, and out of this movement arose the greatest practical discovery of the century, antisepsis. The tendency to-day is to give the place of honor to asepsis, but the principle is the same. The object is to protect the injured tissues from the micro-organisms which would hinder the natural work of healing and expose the patient to the danger of general infection. I remember very well the state of mind with which these astonishing discoveries were received some thirty years ago. They excited general enthusiasm. The younger generation was carried away by the powerful rush of ideas, and more than one old physician regretted that he was no longer on the school benches and could not be associated in this magnificent work. But, as is always the case during these periods of infancy, there were exaggerations. Surgery took the first place; it hesitated at nothing. Operations that had formerly been con- sidered dangerous became possible, and one could hear the public exclaim : Surgery has taken immense strides, but medi- cine is at a standstill; it is to-day exactly where it was in the time of Hippocrates. The watchword seemed to be: No sickness without visible lesions; behold your enemy, the microbe. Let us do battle with knife, cautery, and antisep- tics! t Since that day surgeons have had for their brothers in internal medicine a patronizing smile mingled with a little disdain, and it was from this period that one dates their tendency to make bold incursions into the classic domain of medicine. Wherever the idea of operative intervention crop- ped up in their minds they did not hesitate to act with a con- fidence in the efficacy of their weapons that may, perhaps, have been exaggerated. I would be lacking in perspicacity if I refused to recognize OF NERVOUS DISORDERS 13 the good that has resulted from this progress. I am too skep- tical on the subject of internal medication not to accept with thanks the help of the surgeon, and I believe that by the con- stant working together of physician and surgeon there can be brought about true progress which will be of great benefit to the sick. But there is a limit to everything, and one often hears a surgeon discuss his operations in a way which shows that it is not always easy to develop simultaneously his manual dex- terity, his good sense, and his moral conscience. Bacteriology continues to-day with its patient, useful work. Innumerable microbes are cultivated, and a modern laboratory constitutes a regular infinitesimal menagerie of malignant bacilli. But not content with putting them in cages their keepers subdue them with antitoxins and serums, sometimes with curative and sometimes with preventive results. Finally the thyroid gland, which the surgeons formerly extirpated as a useless glandular mass, without excretory canal and without functions, has become an important organ. We attribute to it an internal secretion, and the confirmation of this theory has thrown some light on the pathogeny of myxedema and Basedow's Disease. Here again we find the tendency to go to extremes; after having seen microbes everywhere we dream only of internal secretions, and we find ourselves in the fantastic domain of opotherapy. Thus, encouraged by the certain therapeutic action of some serums, such as that of diphtheria in particular, we have come to a conclusion too quickly, and have sought a panacea in sero- therapy. It would not matter if science alone were compro- mised by these hasty generalizations, for it is by passing through error that the truth is reached. But the sick have suffered by them; they have the right to reproach us for our lack of consideration, and often even for our mercantile spirit. Let us not forget physical means of treatment, such as hydrotherapy, massage, gymnastics, and that universal servant, electricity. If the chemists did not daily throw upon the market some new medications the druggists would become 14 PSYCHIC TREATMENT objects of pity. Really what astonishes me most, as I make this enumeration of our new means of treatment, is that there are any sick people left. By reason of these successive innovations the relation of medical studies has changed. For a long time the interest was centered first upon diseases with organic lesions. Only the study of this class of diseases seemed capable of satisfying the thirst for precision which tormented the younger gener- ation. Functional troubles and neuroses were forgotten, the psychic side of the human being was neglected; and I might almost say that for a very long time the difference between the veterinarian's art and that of the physician was only one of clientele ! This is still true to-day. However, this very natural infatuation did not overwhelm all minds, and some distinguished physicians continued, espe- cially in France, to devote their wisdom and persevering labor to the study of nervous and mental disorders. One of the important neuroses, hysteria, had particularly suffered from the neglect to which it had been subjected by the new course of medical ideas. It must be admitted that the study of the varied manifes- tations of this trouble appeared discouraging. The multiplicity and the queerness of the symptoms, as well as their dependence upon the imagination, seemed to make all attempts at classifi- cation delusive. It appeared impossible to arrive at any clear definition or to construct a satisfactory clinical picture ; one was lost in the details of an interminable enumeration of incon- gruous and incomprehensible phenomena. The practitioner, already ill at ease on scientific ground, undertook the treatment of hysterical cases only with a certain repugnance, the more because the troubled mental condition of his subjects often made the relations of the physician to the patient very difficult. Briquet, in 1859, had undertaken, in a didactic work, the classification of the symptoms, and sketched a complete noso- graphical picture of hysteria ; but it was reserved for Charcot to focus interest on this difficult question. Patient and dis- creet, he applied himself first to the simple facts that were easy to analyze or to reproduce experimentally. He passed OF NERVOUS DISORDERS IS over the more complex problems, and from his lips and his pen hysteria became interesting. It was a pleasure to follow the master over this ground which he had illuminated, and where he led with so sure a hand. The scholarly descriptions of the French master were received with enthusiasm. A rich vein had been laid bare; one could henceforth get to work and bring to the study of the neuroses the precise methods of analysis of the modern clinic. Curiously enough, however, there was some trouble in get- ting the Germans especially to take these didactic descriptions seriously. The German clinicians smiled, and insinuated that it was necessary to go to Paris to observe major hysteria. According to them the robust wives of Germany did not show their nervousness in such extravagant fashion. A matter of race, of temperament, they said; the Latin race is in its decadence ! They have had to retreat from this position and to learn to observe. Diseases which appear rare become frequent as soon as one has learned how to diagnose them, and to-day the classical symptoms of hysteria are described in all countries in almost identical terms. •/ One would almost have thought, however, that the study of the major neuroses, on account of the psychological problems which it raises, would be particularly interesting in Germany, the country of profound and sometimes obscure philosophies. On the contrary, however, it was in France that the clinicians applied themselves to the study of nervous diseases, and they brought to these researches such delicacy of psychological observation and such clearness that the foreigner was pleased to recognize them. But if the clinical picture traced by the hand of Charcot excels in the clearness of its drawing, this is due in part to the didactic methods of the master. His forte was to sketch the chief symptoms like the master artist who, with a few strokes of his pencil, throws upon paper the whole physical and moral personality of his model. At the same time, endowed with the spirit of authority, he 16 PSYCHIC TREATMENT handled his subjects as he would; and without, perhaps, taking them sufficiently into account, he suggested to them their atti- tudes and their gestures. Example is contagious in the domain of neurology, and in the great hospitals of Paris, at La Sal- pêtrière, all cases resemble each other. At the command of the chief of the staff, or of the internes, they begin to act like marionettes, or like circus horses accustomed to repeat the same evolutions. Actually one can still find at La Salpêtrière some of these old horses doing their turn. The dream or suggested fancy of these poor patients has been respected, and the exhi- bition, given to physicians who are strangers, always follows the same program. The regularity of the phenomena observed is due to the suggestion which the physician, either voluntarily or involuntarily, exercises. Under Charcot this pseudoexperimental study impelled the observer, as it were, to create hysteria and to give to it the complete reality of a morbid entity; to-day at La Salpêtrière, as elswhere, they imagine that they can cure at the same time that they are studying the symptoms. The influence of suggestion upon the development of symp- toms has been brought to light particularly by the work done by the school of Nancy on suggestions made in the hypnotic sleep or the waking state. These experiences, repeated every day in all countries, have shown that man in his normal state is much more credulous than he supposes himself to be — in fact, that he is suggestible in the highest degree. The doctrines of the observers at Nancy have spread in spite of the definite opposition of Charcot and his pupils. At La Salpêtrière, in short, to be hypnotizable was to be hysterical, sick. It was in the subjects attacked by major hysteria that Charcot succeeded in provoking by different means catalepsy, anesthesia, and somnambulism. When Liébault and Bernheim succeeded in producing sleep in a large number of non-hysterical patients, when they were able to reproduce in healthy persons the curious experiences brought about by somnambulism, they were just a little bit embarrassed at Paris. It was still worse when Bernheim declared that the hypnotic sleep was nothing but the result of OF NERVOUS DISORDERS 17 suggestion, that he could obtain it in ninety per cent, of the patients in the hospitals without the aid of magnetic passes, without staring at any brilliant object, merely by verbal suggestion. It was plainly necessary to give up the idea that suggesti- bility was a symptom of disease and to be considered as an indication of a true hysterical condition; it had to be frankly recognized that a healthy man is suggestible enough to accept in broad daylight, in a few seconds, the suggestion of sleep, and that in the resulting hypnotic state he can often be, at pleasure, rendered insensible to pin pricks, plunged into cata- lepsy, and, finally, made to accept suggestions of complete forgetfulness on waking. It was easy also to see that suggestibility is more pro- nounced in the sane. The autosuggestions of the hysterical and the fixed ideas of the insane often make these patients refractory to outside suggestions. It is enough, to be convinced of these facts, to pass a few hours at Nancy. But here one comes across the susceptibility of the medical fraternity, the rivalries of the schools — I was going to say of the cliques, according to the jargon of the disrespectful. At Paris they pretend to ignore Nancy. Can any good come out of Nazareth? And while physicians all over Europe were following with interest, believing in these experiences that were conclusive by their very simplicity, at Paris they were talking of the " minor hypnotism " of Nancy ! I had the pleasure of spending a day at Nancy in 1888, and what I saw in a few hours, under the kindly direction of Pro- fessor Bernheim, has sufficed to dissipate my last doubts, and to make me set out more resolutely than ever along the path of psychotherapy, in which I had walked but timidly before. Since then, nevertheless, I have resolutely and completely turned my back upon professional hypnotizers ; I have pre- served a very vivid memory of the things I saw, and a profound gratitude of the investigators who have clearly shown the immense influence of suggestion. I had at this time a talk with Bernheim to learn how he happened to take up hypnotism. He replied in these words: 18 PSYCHIC TREATMENT " As professor of the clinic I read Charcot's descriptions with enthusiasm and tried to reproduce the phenomena observed at La Salpêtrière. I did not half succeed, often not at all. It was in vain that I brought pressure to bear upon the eyeballs of patients or surprised them by making a terrible noise ; they wouldn't go into a cataleptic state. I was not able to get the contracture by pressing on the ulnar nerve, and I was a little bit ashamed of my lack of ability. I then heard some one speak of Doctor Liébault who, they said, plunged his patients into an hypnotic sleep, and I had the curiosity to be present at his experiments. I found in his office several persons in the hyp- notic state, some sleeping in a natural position and others fixed in cataleptic attitudes. I was able to satisfy myself that anesthesia could be produced in these subjects, and to study, under the direction of a physician who was convinced of it, the very strange phenomena of hypnotism. " Still quite skeptical, I made some attempts upon an inmate of an insane asylum; then on the different patients of my service. Faith came to me, and with it suggestive authority; to-day I can obtain a result by a simple verbal suggestion nine times out of ten." The facts are there; they are undeniable; they can not be ignored by those who are interested in nervous pathology ; yet, nevertheless, to-day one still sees treatises on hysteria, the authors of which seem to ignore absolutely the discoveries at Nancy. Also, in discussing the subject with one's confrères, even with those who are not bound down by any theories of their own, one is surprised to see how few can go to the end of their logic and recognize this fundamental fact of human suggestibility. Since the works of G. Beard, a new nervous disease has been imported from America, and seems to.be propagated like an epidemic. The name of neurasthenia is on everybody's lips ; it is the fashionable disease. But I am mistaken, the dis- ease is not new; it is the name by which it is known that is changed. It used to be described under the name of hypo- chondria, or melancholia ; often it was confused with hysteria. OF NERVOUS DISORDERS 19 For the public it was nervous troubles, moods, or excess of nervous excitement. In fact, physicians had often attempted to make of this nervous condition, which is now called neuras- thenia, a separate disease, and had given it successively such names as nervous weakness, irritable weakness, general neu- ralgia, spinal irritation, cerebrocardiac neuropathy, nervous- ness, and neurosis. It is possible that this affection may have become more frequent under the influence of modern life, but it must not be forgotten that we now designate by this name a combina- tion of symptoms known through all time, and which are for the first time grouped together as a whole. A morbid entity had thus been created, and nothing is more quickly adopted in medicine than a new name. It is a label that permits us to classify symptoms without making it necessary to study them very carefully. You see with what facility we have learned to use the word influenza. It saves us a great deal of mental labor, and allows us to make a diagnosis without racking our brains. But this easy method of classifying disease has its incon- venient side, and we sometimes find ourselves facing our patients in a very difficult position, when the so-called influenza becomes tuberculosis, meningitis, or typhoid fever, and we are reduced to the unpleasant expedient of making lame excuses. An old practitioner who, after sixty years of practise, had completely retained his memory and his talent for observation, once said to me in consultation: "At the beginning of my career, I noticed absolutely the same nervous troubles that you sum up in this word neurasthenia, and, it seems to me, just as frequently as to-day. When the mental condition was dis- turbed, so that the patient was sad or uneasy, we spoke of melancholia or hypochondria, but if the functional troubles seemed to exist alone, we did not dream of grouping these symptoms together; our diagnosis was cephalalgia, rachialgia, gastric or intestinal dyspepsia, etc., and we attacked each one of these symptoms separately. You have been able to discern the bond that connects these divers troubles one with the other, and to grasp the mental condition of the patient. This is what 20 PSYCHIC TREATMENT gives you the sensation of being face to face with a disease newly created in its entirety, as it were, by the conditions of modern life." At the beginning of the nineteenth century the celebrated Swiss physician, Tissot, 1 described carefully these nervous conditions, and indicated the causes, both physical and moral, that brought them on. It is enough to read the Traité sur les gastralgies, et les entéralgies nerveuses of Barras 2 to be convinced that there is nothing new under the sun, and that our ancestors possessed, like ourselves, the peculiar mental conditions that we now rec- ognize as playing such a decisive rôle in the etiology of the various neuroses. Neurasthenia, unnamed, existed as hypo- chondria, melancholia, and hysteria. The leaping and dancing (gyratory) epidemics, the acts of sorcery, the practise of exor- cism of the middle ages show rather that the generations that preceded us were infinitely more susceptible than we are to-day. Insufficiently restrained by reason, the mental representations acquired an incredible acuteness, and went as far as halluci- nation and the state of delirium in persons who hitherto had appeared sane. Modern hysteria is very modest and demure compared with the mental states revealed in Démoniaques dans l'art by Charcot and Paul Richer, and the Bibliothèque diabo- lique of De Bourneville. If Neurasthenia, this twin sister of Hysteria, has passed by and scarcely been perceived, it is because she has been evolved in a much less dramatic manner. She is more individual, less contagious, and she does not lead up to a loss of reason. Life has to-day become much more complex ; it exacts more of us, more of our cerebral activity ; it lays bare our weaknesses. On the other hand we have become more tender and more interested in our ills, and modern medicine regards the well- being of each one of us with much more solicitude than ever before. 1 Œuvres complètes de Tissot. Nouvelle édition. Published by M. P. Tissot. Paris, 1820, t IX. s Traités sur les gastralgies et les entéralgies ou maladies nerveuses de l'estomac et de l'intestin,/. P. T. Barras. Third edition. Paris, 1829. OF NERVOUS DISORDERS 21 We no longer tie our hysterical patients to the stake: we nurse them; we do not load poor fools with chains: we give them ample freedom in comfortable asylums ; we do not leave our neurasthenics to themselves, we do not let them founder as though they were abject wrecks of humanity: but we give them moral support in order to make of them useful members of society. In spite of the bitter struggle for existence, a sentiment of altruism pervades humanity. We all work for the good of all. It is only when we begin to gather up all the wrecks of life that we stop to count them, and that is, in a large measure, why they seem so numerous to-day. I do not pretend to decide here in a few words such a diffi- cult question as that of determining whether there are to-day more fools and neurotic people than in other days. But I can not fail to recognize the march of human progress and the conquests of physical hygiene. I can not believe that mental hygiene is marching in the opposite direction, and I have unshaken confidence in the very slow but continuous develop- ment of our mentality. 22 PSYCHIC TREATMENT CHAPTER II Classification of Neuroses — Psychoneuroses or Nervousness — Psychic Origin of Nervousness — Tendency to Assign to it Somatic Causes — Abuse of Physical and Medicinal Therapeutics — Poverty of True Psychotherapy — Mixture of Practical Materialism and Doctrinal Spiritualism — Obstacles to the Development of Psychotherapy It is in the class of neuroses that hysteria and neuras- thenia are placed, and it is of these neuroses that we think, first of all, when treatment by suggestion or psychotherapy is spoken of. But, as Axenfeld says, " the entire class of neu- roses has been based on a negative conception ; it was born on that day when pathological anatomy, having undertaken to explain disease by changes in the organs, found itself brought face to face with a certain number of morbid states for which no reason could be found." The number of neuroses ought, therefore, to diminish with the progress of pathological anatomy; for just as soon as a lesion is discovered that satisfactorily explains the symptoms observed during the lifetime of the patient, the disease should be stricken from the list of neuroses, and ' in such cases an anatomico-pathological name is apt to take the place of the clinical one. Nothing is more vague, however, than the definition of neuroses, and when one attempts to make a classification one finds himself in the midst of insurmountable difficulties. What can be done with this artificial group of sensory neuroses in which have been thrust pell-mell various hyperesthesias and anesthesias, the former symptomatic, and due to lesions of the nerves that are either well recognized or highly probable, the latter dependent on a general nervous condition? Of what advantage is it to construct a large group of motor neuroses, bringing together contractures, spasms, the various paralyses OF NERVOUS DISORDERS 23 and tremors, and then forcing into this list paralysis agitans, or Parkinson's Disease? In each one of these pathological conditions clinical analy- sis ought to be carefully made. In the greater number of acute and stubborn neuralgias and in the various paralyses marked lesions will be found. We should not be in too great a hurry to describe a disease as " nervous," and if we are often obliged to do so it is because we have proof that, along with the local symptoms, there are more central symptoms, a general neurotic condition. In oppo- sition to the neuroses with localized peripheral symptoms, the name of central neuroses and general or complex neuroses is given " to those that are characterized by simultaneous dis- orders of sensation, of movement, and of intelligence, and which, by the great extent of the symptoms and by their multiplicity, reveal an undoubted affection of the nervous cen- ters " (Axenfeld et Hurchard). In spite of all the restrictions that have been made, the class of neuroses is still too large, and the classic treatises upon the subject put into this class diseases which have nothing to do with it. It is no longer permissible to leave tetanus in this group, since it is due to a pathogenic micro-organism acting directly upon the nerves. We must give up the name of eclampsia, a vague term applied to epileptiform convulsions, whether they are due to intoxication or to cerebral lesions. I do not hesi- tate to strike from the list of neuroses, in the strict sense of the word, epilepsy, or, rather, the epilepsies. Epileptoid crises, with real loss of consciousness, may occasionally occur with- out any known cause, or, under the influence of moral emotion, in persons afflicted by hysteria or neurasthenia, but they are rare and transient symptoms. Confirmed epi4epsy, most often incurable or persistently rebellious, presents various cerebral changes. It is not necessary to wait to discover a single specific lesion. The epileptic crisis is only a symptom, and may, per- haps, be ascribed to lesions varying in their nature and course. A very narrow line divides the " morbus sacer " or the " sacred 24 PSYCHIC TREATMENT disease " from Jacksonian epilepsy. The surgeons know so much about it that they feel authorized to step in when medical treatment proves of no avail, and they go groping around, blindly searching for some sort of a lesion; often they have no other end than to relieve the brain of an abnormal intra- cranial pressure which is, however, for the most part purely hypothetical. In spite of the studies of Chaslin, confirmed from various sources, and which prove the existence of a cor- tical, neuroglial sclerosis, the pathological anatomy of epilepsy can not be considered as an established fact. I do not ignore, on the other hand, the loose bond which binds epilepsy to migraine, connecting the former with the neuroses and the latter with the insanities. In theory it is difficult to set forth any clear ideas upon the subject. But when in practise we make a diagnosis of epilepsy we feel the seriousness of the situation, we are seized by the idea of its more or less complete incurability. In the migraines and neu- roses, on the other hand, the prognosis is less harsh. We dare to tell our patients frankly what the trouble is, whereas we should hesitate to let the fatal word " epilepsy " fall from our lips. This shows how far removed this terrible disease is from migraine. The common chorea, or St. Vitus' dance, may, if one wishes, be kept in the class of neuroses. It may a priori be affirmed that it is not due to any profound anatomical changes,' as it is easily cured in a very short space of time. But it is what we might call a typical walking disease, of short duration, affect- ing particularly children of the female sex. Its relations with rheumatism and affections of the heart are undeniable. There have been found in autopsy various cerebral lesions which may, however, be secondary, and English physicians have been almost ready to attribute chorea to innumerable capillary emboli involving the optostriate bodies. We also find that chorea does not derive any great benefit from treatment by psychotherapy, while it is benefited by rest. The cases in which a psychic influence, particularly imita- tion, plays a prominent rôle (as in epidemics of chorea) have nothing whatever to do with the chorea of Sydenham, and OF NERVOUS DISORDERS 25 ought to be attributed to hysteria. The fact that intense emotion can act as a determining cause of chorea should not be used to classify the disease among the neuroses. One may meet the same etiology in paralysis agitans, in Basedow's dis- ease or exophthalmic goitre, and even epilepsy. Constant le- sions of the nervous system have never been found in these diseases, but the very rebellious nature of these affections and their frequent incurability leads us to think of structural changes in the nerve cells, even tho it may have been a moral emotion that had been the first cause of the attacks. I have said that we must successively erase from the list of neuroses all the affections of which the anatomist is able to discover the cause. One might thus come to the conclusion that the word neuroses is useful only as a temporary classi- fication, and that it is destined to disappear from medical terminology. In short, when pathological anatomy discovers a lesion, a focus of inflammation, a hemorrhage, a thrombosis, and when chemical analysis discloses a condition of intoxication, we no longer speak of neuroses, even tho the symptoms might have been essentially " nervous." We thus recognize the first cause of the clinical syndrome in the various somatic affections, syphilis, tuberculosis, arteriosclerosis, alcoholic intoxication, uremia, etc. These conditions do not exist in the affections which we always call neuroses, or, as I propose to do, phycho- neuroses, even when we succeed in revealing the cellular changes which have produced the nervous or mental trouble. Just here we find ourselves face to face with a fundamental factor : the influence of the mind and of mental representations. The affections of the psychic life are no longer simply sec- ondary and determined by a primary change of cerebral tissue, as in general paralysis and other diseases of the brain. The source of the trouble is, on the contrary, psychic, and it is the ideation which causes or harbors functional disorders. One could boldly classify such neuroses along with the insanities and designate them under the name of psychoses. Theoretic- ally I do not hesitate to affirm that nervousness in all its forms is a psychosis. But practically this appellation has great draw- 26 PSYCHIC TREATMENT backs. First of all, it hurts the feelings of the neuropaths. We accept the term nervous diseases without any sense of shame, but we do not like to be characterized as psychopaths. It is good, however, to separate from the confirmed psychoses those mild psychoses which, as we shall see later, differ but very slightly from the normal state. The former, the vesa- nias or insanities, call forth a much more unfavorable prog- nosis, and their treatment more often demands a sojourn in the institutions for the insane. The psychopathic states of which we speak are milder; they are compatible with family and social life; the patient does not go to a professional alienist, he seeks help from his ordinary physician or from the neurologist. For such affec- tions I have used the term psychoneuroses; it separates them from the properly called insanities, while at the same time indicating the psychic nature of the trouble. The second part of the word indicates those functional nervous troubles which accompany the psychopathic state. The only inconvenient thing about the word is that it is heavy and lacks euphony. I shall also often use the word nervousness. • It prejudices no one, and can not in any way hurt the natural susceptibility of patients. Having eliminated the neuroses which are probably somatic in origin, I only keep in this group of psychoneuroses the affections in which the psychic influence predominates, those which are more or less amenable to psychotherapy; they are : neurasthenia, hysteria, hysterical neurasthenia, the lighter forms of hypochondria and melancholia, and finally one may include certain conditions of very serious disequilibration bor- dering on insanity. If, for the convenience of speech, I use the common term nervousness, I by no means intend to suppress the clinical names consecrated by usage. They are titles which always serve to distinguish the form which the nervous troubles take. But I insist at the start on the impossibility of tracing the exact boundary line between neurasthenia, hysteria, and the hypo- chondriacal, and melancholic states. It is to these psychoneuroses, to this nervousness, that the OF NERVOUS DISORDERS 27 treatment by psychotherapy is particularly applicable. It is in this domain that we witness a slow but continual transfor- mation of our medical ideas full of import to practical medicine. Nervousness is a disease preeminently psychic, and a psy- chic disease needs psychic treatment. This is the conception that a physician should have in mind is he wishes to undertake the treatment of nervous diseases with success. These psychoneuroses are frequent, they are often very serious, and, much more than organic troubles, they can destroy the happiness of individuals and of families. The phy- sician who interests himself in the mental life of his patients, who paints, as it were, the secrets of their souls, is moved by the suffering which he sees ; he sincerely pities these unfortu- nate beings and sympathizes with them. Bodily illness, how- ever painful it may be, seems to him less cruel than these psy- choneuroses which attack the personality, the very ego. The patients themselves are aware of this change in their mental condition, and often envy all sorts of people who are suffering even with painful diseases, but whose mental condi- tion is not affected. To add to the misfortune, nervous patients are often mis- understood. They keep up an appearance of good health for a long time; they show very great variations in their dispo- sitions, to-day suffering martyrdom and to-morrow able to take up their work with a certain briskness. Their relatives, even the most loving and best meaning, do not know what to think of these fitful changes. They get into the habit of reproaching the patients for their laziness, their caprices, their lack of energy. Their encouragements are taken in the wrong spirit and only serve to increase the irri- tability, the sullenness, and the sadness of these poor nervous people. The overwhelming influence of emotions of all kinds on the development of these psychoneuroses is perfectly obvious. But, alas, the great majority of physicians go about as tho they had never noticed it ! They are so impressed with their rôle of physician to the body that they are always hunting among the organs of the 28 PSYCHIC TREATMENT abdomen for the cause of all these psychic and nervous troubles. The uterus has had the honor of being most frequently under suspicion, particularly when the question concerns an hysterical form of nervousness. The etymology of the word has contributed to keep up these etiological ideas ; the associa- tion of ideas is so easily formed in our heads, especially when the ideas are unpleasant, that the word brings up the idea. But if so much persistence has been shown in incriminating the uterus it is because hysteria, at least in its convulsive forms, is observed chiefly among women, and because it often culminates during those periods of life when some delicate function (puberty, the menstrual flow, menopause, various changes in the uterus and its adnexa) is accomplished in the genital organs. There are evidently relations there which it would be wrong to neglect. But there is a vast difference between this etio- logical idea, which recognizes the possibility that the phenom- ena of the sexual life may be an exciting cause, and the ancient idea, which is always being revived, " that the most frequent causes of hysteria are the deprivation of the pleasures of love, the vexations in connection with this passion, and the derange- ments of menstruation." As Briquet has said, the treatise of Louyer-Villirmay which contains this statement, as clear as it is exaggerated, seems to date rather from the middle ages than from 1816. But it is the same false idea; as with scandal, some frag- ment always persists, and I often hear from the lips of prac- titioners, both old and young, the aphorism : " Nubat ilia et morbus effugiet!" (Let her marry and the disease will dis- appear). When the existence and frequency of male hysteria had been duly proved, the partisans of the genital origin of hys- teria were in no wise nonplussed. Was there not in the mysterious sense awakening in boys, in onanism, in sexual excesses of all kinds, and in malthusian practises, sufficient cause to explain the genesis of hysteria and neurasthenia? Later it was the digestive organs that were dwelt upon. OF NERVOUS DISORDERS 29 The tendency was toward intoxications by the products of imperfect digestion. Everybody was seized with attacks of dilatation of the stomach, of gastroptosis, of enteroptosis, or, more generally, of organoptosis. They could hardly keep from putting the kidney back into its niche and lifting up the whole intestinal organs bodily. They had recourse to dry diet, to massage, to medicines that toned up the muscular walls of the stomach, and to intestinal antisepsis. At last the surgeons offered their radical aid and took upon themselves the respon- sibility of reducing the stomach to more suitable proportions. Nervousness was brought into line with gout, and the bold statement was made that nervousness was arthritis. To-day it is cholemia — that explains everything. Traumatism, exhaustion, and I know not what, have been accused of being sufficient to cause nervousness in all its forms. The title, neurasthenia of chronic fatigue, has been promul- gated, and complete rest, not only for several weeks, which would be useful, but for months and years, has become the only expedient of health for nervous patients. It has been the practise to stimulate energy by douches, by electric currents, by massage, by dry friction, and by bicycling. The nerves have been toned up by glycerophosphates, neurosine, injections of séquardine, or by artificial serums ; we have even seen it done by salt solution. This reminds me of a very suggestive advertisement found on the fourth page of a journal: Phys- ical and mental health may be recovered by the use of cocoa and oatmeal. But one might say only physicians with no experience and little psychology could arrive at such inane conclusions. Not at all; the specters of retroversion, of dyspepsia, of atrophic gastritis, of the dilatation of the stomach, of enteroptosis, of cholemia, still haunt the mind of the majority of physicians. There are, moreover, physicians and professors whose clientèle brings them into constant relationship with neurotic patients, and who are every day called upon to give their advice, who deny this simple idea of the psychic origin of nervousness. When I say that they deny this fundamental idea I am going, perhaps, a little too far ; but, at all events, they forget it 30 PSYCHIC TREATMENT at the moment when it would be most useful for them to remember it — that is, when they are explaining to their patients the measures that they are to take. I have had under my eyes, through the medium of my patients, a great many prescriptions proceeding from the best- known men of the medical profession, specialists in neurology and psychiatry, and I have been astonished at the poverty of their psychotherapy. After having read on the one hand the descriptions of the disease in which the author very carefully insists on modifications of the mental condition, I find on the other hand only the most foolish therapeutic indications, baths, douches, rubbings, injections of strychnine, and the inevitable bromide. These prescriptions seemed to me so out of accord with the premises that I had thought that the author had not intended to write down the psychotherapeutic part of his con- sultation, but had touched upon this subject in conversation. The patients, however, assured me that they had received no advice of this kind whatsoever. There is, nevertheless, some progress, and during the last few years I have noticed several prescriptions where, at the end of the page, after cold water, or hot water, after the bromide or the trional, was written : moral treatment. At last, I said to myself, here it is; and I questioned my patients upon the oral interpretation which had been given to these words. " But nothing was said to me about it, nothing at all; the only thing that was said was that moral treatment was necessary, and after that I was allowed to go away." This is the reply that I have received from these patients who have literally run all over Europe to find a cure. At last, quite recently, I saw some ladies who had sampled psychotherapy in all its purity, and whose fixed ideas had been studied by the methods of physiological psychology. But the interest that was shown was of too scientific a nature, and the patients were given to understand that they were nothing but mad people. To study patients is not to cure them. But you forget us, the hypnotizers will say ; yes, we agree on this point, nervousness is psychic in its nature, and our pro- OF NERVOUS DISORDERS 31 ceedings are psychotherapeutic par excellence. In the twink- ling of an eye, whether in the hypnotic sleep, in hypotaxia of the slightest nature, even in the state of being wide awake, we juggle the autosuggestions of our patients as a juggler would his little balls, and we make them well. I never forget our modern successors of Mesmer, but their case is more serious, and I will take it up when I analyze the therapeutic measures of overcoming nervousness. How is it that physicians find it so difficult to recognize the mental nature of psychoneuroses ? How is it that they do not think to combine hygienic measures, which are often very use- ful, with the necessary moral treatment ? It is, as I have hinted, because our medical education impels us to look for the lesion to prove any organic changes. The brain interests us only when there is hyperemia or anemia, hemorrhage or thrombosis, meningitis or tumors. When the brain is only affected in its functions we abandon the ground to the alienist. But physicians in asylums see the most severe forms of the psychopathies, the insanities, and, if their studies render them particularly apt in psychological analysis, it must be admitted that their influence is not as strong as could be desired. They live a little apart, overburdened with professional duties, and write but little. Instruction in psychiatry is not sufficiently followed, and many young physicians enter upon their prac- tise quite unable to recognize the first stages of a melancholia or to discover a general paralysis under the deceptive mask of neurasthenia. Often, too, the alienists submit too passively to the influ- ence of the medical clinic. Certainly they are in the right path, when, armed with the microtome and the microscope, they investigate the changes in the nerve centers; they are right when they study the chemistry of the organism, and apply the exact clinical methods of modern medicine to the study of mental diseases. They can not go too far along these lines, but under the condition that they do not forget psychology and the undeniable influence of the mental over the physical. Narcot- ics play too important a rôle in psychiatry, and often the right 32 PSYCHIC TREATMENT word or a rational suggestion will replace to advantage the use of morphine, chloral, or sulphonal. I know well enough that the inmates of asylums are often too disturbed in mind to obey any outside suggestion, and I do not ask that the alienist should attempt to argue away by convincing syllogisms the fixed ideas of a paranoiac or the delirium of a maniac. But one sometimes sees psychiatrists using narcotic medi- cations and remedies to soothe their patients, and hydrothera- peutic methods in cases of simple neurasthenia or hysteria with hypomelancholic symptoms. A heart-to-heart talk with these patients would be worth considerably more to them than the baths, the douches, or the chloral. It has now become absolutely necessary to extend the course of instruction in psychiatry and to allow students to enter the insane asylums. In short, there ought to be more place given in medical studies to psychology and philosophy. We examine our patients from head to foot with all our instruments of diagnosis, but we forget to cast a single glance at their combined physical and moral personalities. By reason of plunging with such vigor into the details we neglect the tout ensemble, and we fall into a stupid materialism which has nothing to do with the so-called materialistic doctrines or with positivism and determinism. Do not be carried away, young people ! Do not abandon scientific ground, do not believe in the bankruptcy of science ; continue to study man with all the precision of modern biology, but do not forget that the brain is the organ of thought, and that there is a world of ideas. There is in this very generation a strange mixture of thoughtless materialism, and a spiritualism that it still more unthinking. In the practise of medicine it is this narrow materialism that reigns. It is by no means the attribute of brilliant minds, or of thinkers who dare to submit the beliefs which have been inculcated in them to the criticism of reason; one does not need to look for it among the adepts of positivism or deter- minism. It is rigorously adhered to, on the other hand, by OF NERVOUS DISORDERS 33. physicians who are satisfied with the routine of their clientèle, to those who are wearied by any thought which does not per- tain to medical or physical therapeutics. These physicians are only too happy to cure by means of their prescriptions, and their practical materialism gets along very well with those who are content with a narrow spiritualism, the fruit of an educa- tion to which they take care to add nothing new. A real difficulty hinders many physicians who would have recourse to treatment by psychotherapy. They have recog- nized the insufficiency of their therapeutic measures, and often they see very clearly in what direction they ought to turn their efforts. But it is an educative work that must be undertaken, and we are by no means prepared for it by the lessons of the schools. We are equipped to recognize the smallest functional troub- les of the organism of the human animal. We have been taught how to handle the various drugs, and we have become somewhat familiar with the action of cures by altitude, hydro- therapy, electricity, and massage. Surgery, which attracts a student by the clearness of its teachings and the unquestioned efficacy of its intervention, has given us still more powerful weapons. On leaving the hospital the young physician throws himself into his career with perfect confidence; he believes himself armed from head to foot. He quickly perceives, alas ! that he is not very often asked to perform a brilliant operation or an exquisitely careful dressing, that he can satisfy only a limited number of his patients with his prescriptions. He finds himself disarmed before the nervous patients who soon encum- ber his office. But what can be done? He follows the regular order. After having listened with a distracted ear to the troubles of his patients, he examines them, and proves with very little difficulty that their organs are sound. Then he draws out his note-book and prescribes : Bromide of potassium. At the next consultation this will be bromide of sodium, or, perhaps, the syrup will be changed. At last he has recourse — oh, ad- mirable idea ! — to the combination of the three bromides ! Not being cured, the discouraged patient turns to some 34 PSYCHIC TREATMENT other confrère who, delighted by the preference just shown him, listens a little longer, examines him with a little more patience; he reflects, passing his hand over his anxious brow. Ten to one he will end by prescribing a bromide, or at least cacodylate of soda! There are many who have practised these deceptions in their own clientèle. They ought to have said as I do: Is there really nothing better to be done? OF NERVOUS DISORDERS 35 CHAPTER III Rational Basis of Psychotherapy — Education of the Reason — Dualistic Spiritualism — Psychophysical Parallelism — Mgr. d'Hulst — Different Opinions Concerning the Bond of Affinity between the Mind and the Body — Practical Philosophy Founded on Biological Observation — The Importance of the Problems of Liberty, of Will, and of Responsibility There is something further and better to do, but, to be efficacious, the treatment of psychoneuroses must be — and I can not repeat it too often — psychic before anything else. The object of treatment ought to be to make the patient master of himself; the means to this end is the education of the will, or, more exactly, of the reason. But, it will be said, this declaration is frankly spiritualistic in its nature. Thus to give the first place to the moral influ- ence over the physical is to return to the dual spiritualism of philosophy, it is to fall back to the nosographical point of view, in the narrow conception of neuroses considered as diseases without physical foundation, morbi sine materia. I repudiate both these reproaches. The study of biology brings before us a constant parallel- ism between psychic phenomena and cerebral functions. The most ardent defenders of spiritualism do not dream of combating this statement. They easily find, among Protestant writers, thinkers ready to accept these premises, but their tes- timony may appear open to suspicion; it is tainted with bold inquiry. I prefer to draw from a more orthodox source. A Catholic prelate, Mgr. d'Hulst, 1 expresses himself very clearly on this subject: " We have all been brought up to admire a doctrine of which the author is M. de Bonald, but the inspirer Descartes : 1 M. d'Hulst, Mélanges philosophiques. Recueil d'essais consacrés à la défense du spiritualisme, etc. Paris. Ch. Poussielgue, 1892. 36 PSYCHIC TREATMENT The soul is an intelligence served by the organs. The least fault of this definition is its great incompleteness. " The intelligence is served by the organs, served, yes, with- out doubt, but also it is subject to them. It is true that every master of a household is more or less subject to his servants. " But, by making up his mind to serve himself, he could free himself from this dependence. " The soul has no such resource. On the contrary, its dependence goes still further. " If it were only a question of the lower part of the psychic life, such as sensation, or even perception, one could say : " The soul depends upon the organs in all the operations which have their origin outside the body. But in its own life, intellectual operations, it is master and not servant, it does not depend upon the body. Unfortunately for the theory, it does not go as far as this. " Even in an act of the purest intelligence there is a neces- sary, an important, cooperation of the organs. " The brain works in the skull of the thinker. There are cellular vibrations in the cerebral cortex. To render these possible there is a flow of blood that is more abundant as intel- lectual effort is more intense ; there is an elevation of tempera- ture as a result; in short, there is a combustion of organic material. " The more the mind thinks the more the brain burns its own substance. And it is thus that working with one's head causes a sensation of hunger quite as much, if not more, than muscular work." It is not necessary to say that the philosophical theologian gets away from his premises in his subsequent considerations, but the thesis of concomitance is put very succinctly. Mgr. d'Hulst is, however, very courageous. Not only does he attack with cut and thrust his adversaries, the materialists, but without ceremony he abuses those who would seem to be his natural allies, the spiritualists of the Cartesian type. He ac- cuses them of having leanings toward materialistic pretensions. But, after having indicated in such clear terms the depen- dence of the soul on the body, he faces about and reproves OF NERVOUS DISORDERS 37 the animism of the scholars, the doctrine of the spirit as dis- tinct from matter. Let us see: " Matter is not devoid of activity, but it is not autonomous. It does not act, it reacts. " The moral being acts, it feels its autonomy, its power to act, and even when it reacts (which is generally the case), 1 it puts into its reply to the stimulus from without something that was not contained in the demand." That is what I can not see. This autonomy of the moral being is apparent. The psychic reactions are always, and not only generally, determined by stimuli coming from outside under some form or other. It is these which provoke asso- ciation of ideas. One can say of man that he does not act, but reacts. It is, therefore, logical to admit that he could not have any psychic manifestations without concomitant cerebration, with- out physiochemical modifications of the brain cells, without organic combustion. One might say, by slightly changing the terms of a celebrated aphorism, that there is nothing in the mind which is not in the brain, " Nihil est in intellects, quod non sit in cerebro." It is often said that the biologist must necessarily feel him- self checked at this proof of parallelism, of the concomitance of the two phenomena, and that he is prevented from pushing his investigations any further. He is refused this right under the pretext that it is not his business to stray into the domain of metaphysics. It is on the basis of the heterogeneity of the moral world and the material world that all bonds of causal con- nection between thought and cerebral activity are repudiated. It seems to me that this draws the confines of scientific induction a little too closely. Without doubt there is, between conscious acts and the physical state of the brain, an abyss which appears to us impassable. We can not in any wise conceive how the physical work of the brain cells can engender a sensation or give birth to an idea. We can say, with Du Bois-Reymond, " ignorabimus " 1 The italics are mine. 38 PSYCHIC TREATMENT (we shall not know), or, rather, so as not to speak for the fu- ture, " ignoramus " (we do not know) . But the heterogeneity that we admit subsists in the spirit- ual hypothesis. Logically it hinders us just as much from explaining the evident influence of the soul over the body as from proving the material origin of the movements of the soul. The plain fact is there ; the concomitance exists, it is recog- nized by everybody. For, when we have a constant paral- lelism between two phenomena, however different they may appear to us, we have to choose between the two following hypotheses : Either there is a bond of cause and effect between these two concomitant phenomena, or else they are both dependent upon a third factor. This third hypothesis makes us think of the predestined harmony of Leibnitz, which assumes that the established con- comitance was foreordained by the Divine Being. In this conception there is no causal relation between the prick and the pain which follows it; the latter is born spontaneously in our soul at the precise moment when we are pricked. Let us slide over this point lest we endanger our reason ! If, leaving the follies of logic aside, we build up just as strange conceptions, good sense restrains us and makes us prefer the other conclusion, that which admits a causal relation between two parallel phenomena. But that is not all ; it must be determined in what sense this relation exists. Here we find ourselves in the position of idealists between the dualistic spiritualists and the materialists. Renewing the idea of the Greek sage, Parmenides, the Irish philosopher, Berkeley, has held that only our sensations and our mental representations exist, that that is all that we can know, and that it is not permitted for us to conclude that there is a material reality of things. , These premises are obviously impregnable. In short, we live only by sensations, and it is impossible to prove that they correspond to a reality. But these seem to me mere witticisms. There is no reason OF NERVOUS DISORDERS 39 why we should consider ourselves as subject to hallucination; we distinguish carefully between the mistakes of delirious peo- ple and the evidently psychic statements of the healthy indi- vidual. Altho to see a stick and to feel pain may be pure sensations, we have no doubt whatsoever of the material quali- ties of the stick, nor the existence of the rascal who strikes us. If by a species of mental gymnastics we can raise ourselves to these heights, the majority of thinkers prefer to remain on more solid ground. They will find it more rational to estab- lish the relation in the inverse sense — first of all to admit the existence of ourselves and of the exterior world; then they will consider thought as the product of cerebral activity. But let us leave to metaphysicians the task of following out this analysis and of taking up the problem of transcendental philosophy. It is not very probable that they will reach con- clusions that will be acceptable to all minds. In practical life, especially in the domain of medical obser- vation, the moral and psychic life presupposes the integrity of the brain, and we admit that for each mental state there is a corresponding special condition of certain cellular groups of the thinking organ. There is between the intellectual work and the ensuing fatigue a close relation as evident as that which exists in muscular exercise. It does not seem to me presump- tuous to suppose that some day it will be possible to demon- strate in this domain the law of conservation of energy. I know very well that this law has not been verified in an absolutely experimental way in all branches of physics. I know still better that it is not proved to hold true in biology. I will even admit, with certain philosophic spiritual- ists, " that the law of conservation of energy is extended to biologic phenomena by a debatable induction " (Naville). An induction always remains debatable, because it ventures beyond the limits of pure and simple proof. To discover a law we place ourselves in favorable experimental conditions, we sim- plify the problem. When the law is established on a certain number of definite facts we extend it by induction to more complex phenomena, we generalize it. There is in such a mental proceeding occasion for error and a possibility of hasty 40 PSYCHIC TREATMENT conclusions. That is why I do not allow my point of view to be obscured by this qualification of being debatable which Mr. Ernest Naville uses. But, logically, it seems to me that it would be still more debatable to say that this law is not true in the domain of biology. Any precise fact does not authorize us to make any such conclusion, and to admit an exception to a law that is everywhere recognized where experimental conditions have been favorable. One can not affirm a contrary idea simply by showing that a truth has not yet been scientifically established. The question remains open so long as a demonstration is not accomplished ; the provisory solution depends upon the mental make-up of the thinker. As all psychical action is necessarily connected with con- comitant cerebral action and with minute modifications of cel- lular chemistry, it follows that there can be no pathology per- taining to mental and nervous affections without a material substratum. If, upon autopsy, the brain of a melancholiac, a hypochondriac, or a neurasthenic patient shows in serial sec- tions no morphological lesion, we must attribute the fact largely to the insufficiency of our means of investigation. It must not be forgotten that certain slight alterations can never be proved after death. If the head were transparent, and if we could follow with the eye all the structural modifications which the cells undergo during the process of cerebration, we should detect the physiological action which, in the opinion of everybody, accompanies and, according to our hypothesis, pro- duces thought. When, in the condition which we still describe as normal, our ability to work decreases, when our emotions become more sensitive, when we are conscious of a feeling of sadness, whether or not it be justified by events, it is because some sort of change has taken place in our neurons. We are at such a time already in an ailing condition if we compare it with the ideal state of health and with the well-being of an organism that works harmoniously in all its parts. I admit, then, without being able to detect the mechanism of the transformation, that what we call thought is only the OF NERVOUS DISORDERS 41 product of cerebral activity. I conclude that no disturbance of this thought can exist without some pathological change, either slight or lasting, in the brain substance. The expression " disease without physical foundation " — morbi sine materia — has no reason for existence. Why should one, in lessons devoted to therapeutics, ap- proach these difficult problems which it is impossible to solve? Be content with curing your patients as best you can, and leave the mists of metaphysics to philosophers ! That is what our confrères will be apt to think. I am not of their opinion. In the exercise of the art of healing the moral influence plays a very important rôle. The physician, even when he has the hopeless naïveté to believe in the virtues of all the drugs in the pharmacopoeia, nevertheless practises psychotherapy every day. There are some practitioners who do it quite as unconsciously as M. Jourdain used to make prose. There are fewer, alas ! who resolutely do it, and always exercise a moral control over their patients. Would it not be useful to analyze this moral action, to learn thoroughly the nature of the tool that one uses; and could one make such a study, and neglect the problems which we have just touched upon? If, by reason of the special circumstances of his position or from personal choice, the physician finds himself in frequent contact with patients suffering from nervous diseases, it is im- possible for him to avoid these subjects; he must, cost what it may, come to some conclusion upon the matter. Without doubt these general opinions may vary greatly with one thinker and another. We would not want to fit all heads to one cap. But I can not imagine a physician so narrow as to be able to take care of his patients and yet voluntarily push all these troublesome questions to one side. The patients, however, will not allow a physician to persist in a prudent reserve. Often with the first words of a consul- tation they draw you on to philosophic ground. Yesterday it was a neurasthenic patient who told you all his discouragements, his weaknesses, and his phobias, and 42 PSYCHIC TREATMENT asked you pointblank : " Is it physical or is it psychical ? " To-day it is a mother who brings her little girl. The poor child is not very bright; she has some trouble in doing her necessary amount of school work; she is headstrong, wilful, capricious, and when she is vexed she strikes her parents. " I do not know what to think about it," says the mother ; " I can not make up my mind whether it is naughtiness or sickness." "As you like, madam," you could reply, for it is six of one and half a dozen of the other. It is certainly something that ought not to be there, and it should be corrected. It is in vain that you resolve to be a physician for the body only. Willy-nilly you are forced, if not to reply, at least to think. Oh ! you can keep your opinion to yourself ; you are not compelled to reply to these indiscreet questions by unbosoming yourself of all your religious and philosophic convictions ! Very often you would do better to hold your tongue. You will find with a great many persons a certain inability to un- derstand you, and you ought to avoid thoughtlessly upsetting the convictions of your questioner. Very often you may, as the sincere diplomat which you ought to be, tell your patients what you think will be expedient under the circumstances. You have before you, we will suppose, a somewhat tyran- nical father who brings his daughter to you with the air of dragging her to the seat of justice, and tells you in detail all the young girl's peculiarities. He declares himself ready to re- double his severity if it is necessary to subdue her. Hasten, then, to make him understand that it is a diseased condition and not a simple fault which causes his daughter's strange conduct. You may think what you like in your inner tribunal con- cerning this specious distinction, but the advice is opportune. It is by no means a lie ; it is the only thing possible when you are face to face with that kind of person, the only thing which will penetrate his understanding deeply enough to modify his state of mind, and often you will see immediate proof of the happy effects of your intervention. If the father is not a little queer himself, or even if he should be also somewhat unbalanced, he is going to be more gentle OF NERVOUS DISORDERS 43 hereafter, and a little more kind and indulgent ; sick people are excused, while those that are in fault are reprimanded. The young girl, in spite of her evident mental defects, feels the con- tagion of the gentleness and kindness. By these simple words, " This is a sickness," with which you concluded your necessary advice, you have poured oil upon the water, and have done more for the health of your patient than in prescribing for her douches and bromides. On another day you will meet a grown-up young man who is a little bit effeminate in his bearing, and who declares that he is neurasthenic. He can not do any work because he is too weak ; he can not bear to be contradicted ; and his mother and his sister, who are timorously present at the consultation, have to do their utmost in order not to make him worse. If you try to show him that up to a certain point he can repress this irritability, he will look at you with astonishment and retreat behind the fact that he is neurasthenic. He will say it in the same tone in which he would say, " I am phthis- ical, or diabetic." Do not hesitate to come back to the charge and to attack this preconceived opinion. Show him that this exaggerated irritability, even tho it may partake of the nature of disease, is not uncontrollable, that it pertains only to a physical disorder upon which he can exercise a decided influence by the educa- tion of his reason. Do not tell him this baldly in a few disdainful words, and with the air of absolutely denying the element of disease in his condition; do not accuse him of having a character that is hard to get along with and of having no energy. You would hurt his feelings, and would immediately cut short any oppor- tunity for treatment. Be content to consider him as a patient, a neurasthenic, as long as he places himself in this category ; show him true sym- pathy, make him your friend, and show him, by well-chosen examples from your experience as a man of medicine, how much worth there is in moral courage and a continual striving toward the perfection of our moral personality. The psychotherapeutic ideas that one gives to a patient may 44 PSYCHIC TREATMENT vary greatly, according to circumstances and according to the end that one has in view. They should vary according to the mentality of the subjects and the circumstances. The idea as addressed to the patient may be diametrically opposed to that which is offered to his relatives. On the one hand, it calls the patient's attention to the efficacy of moral effort as if he were not sick, while on the other hand, by laying stress on the path- ological nature of such and such a mental peculiarity, it makes the parents a little more kindly indulgent. Harmony is quickly established between two persons who are thus brought into re- lationship with each other. I will return to this necessity of not confining one's thera- peutic effort to the patients alone, but extending it to those who live with them. This is often the only way to obtain complete and lasting results. I know that in order to practise this beneficent psychother- apy it is not necessary to have cut-and-dried opinions on philo- sophical subjects. A little tact and kindness is enough. I have seen Catholic priests repeat under another form what, in the course of treatment, I have often told my patients, and so help me more in my work than many of my confrères would have been able to do. I meet pastors at the bedsides of patients, and there we find ourselves on common ground, de- spite the difference in points of departure. It is not at all necessary, however, in order to enter their brotherhood, to put on a white tie and make a profession of faith. But by coming in daily contact with these patients whose moral nature is affected, and being continually occupied with treating them in psychic ways, I have been able to analyze the ideas which have directed me thus far; I have often dis- cussed these questions with my confrères and with educated patients who were interested in these problems. I can not, however, quite bring myself to make a simple ex- position of my method ; for I ought first to state upon what philosophic basis I rest, and to point out the red thread, the trace of which one can follow through the whole tissue of my therapeutic endeavors. I have said, and I repeat, that I have no intention of mon- OF NERVOUS DISORDERS 45 opolizing the truth for myself, and that I can conceive that one might start from another point of view. I am content to think with the head that Nature put upon my shoulders; it works in its own way. In practical conclusions I am often met by minds absolutely different from mine, such as believers in the orthodox faith; we have nothing in common but the same kindly interest in the patients, the same desire to bring them health by the methods of psychotherapy. We have met each other at a certain height, like two captive balloons that have drifted together and are pursuing the same course. Follow their cables, and you will see that they are attached at points that are diametrically opposed. The physician who reflects at all will continually find in his path the problems of liberty, of will, and of responsibility. If the care of making visit after visit and of prescribing medicines is sufficient to fill his life, the doctor can avoid these troublesome reflections. I should like to hope that the majority of my brethren would feel the need of going further in analysis. Naturally all will not take the same road, and will not arrive at the same conclusions. Many will stop on the way, wavering between reason and sentiment ; but all, it seems to me, ought to be inter- ested in these subjects, and I should be very much astonished if their reflections did not have some influence on their therapeutics. I shall be pardoned, I hope, the digressions which follow. In my eyes they are of great importance in the practise of medicine, as much in the simplest therapeutic applications as in the solution of medico-legal problems. In short, it is not only in the examination of criminal questions that the physi- cian sees these difficulties crop out, and feels all the practical importance that attaches to his solution of them. There exists between neurotic patients of every stamp and delinquents and criminals more connection than one would think. The neurotics, like the delinquents, are antisocial. Plato excluded the hypochondriacs from his republic. One might, it is true, say that all sick people are antisocial. 46 PSYCHIC TREATMENT All are prevented from accomplishing their work, and they hinder the activity of others. But the sick people who die, those who are cured, even those who remain incurable, are the dead, the wounded, and the invalided in the battle of life. We bury the former, we nurse the others, and respect and honor them. The delinquents are, in our eyes, the unworthy soldiers who must be punished with discipline, even shot down. Neurotic people are stragglers from the army. We are a little less se- vere with them. They show more or less their inability to march ; they are lame, that is plain. But we do not like them much ; we are ready to throw in their faces reproaches of lazi- ness, of simulation, or lack of energy. We do not know whether to believe in their hurts and put them in the infirmary, or to handle them roughly and send them back to the ranks. We are already involved in a problem of liberty and of re- sponsibility, and it is the absence of a clear solution which makes us hesitate which course to follow. The question comes up still more imperatively in the fre- quent cases where degenerates and unbalanced persons find themselves in conflict with justice. The abnormal state of their minds and their impulsiveness drives them to culpable acts, to offenses against modesty, to violence, and even to murder. Then the problem of liberty is forced upon the physician not only as a simple question theoretically interesting, but dra- matic and moving, because on his evidence may depend the future of one of his fellow beings. You will see, then, that in touching these philosophic questions I do not stray on ground which does not belong to us ; I remain on that of prac- tical medicine, facing the duties which it imposes upon us. I hold that every physician who has understood his task ought to be interested in these subjects and try to arrive at some solution. This solution will vary, I know, according to the mentality and parts of the thinker, but it is permissible to hope for the triumph of just views founded on biology and natural philosophy. OF NERVOUS DISORDERS 47 CHAPTER IV The Problem of Liberty — Determinism — Flournoy; Ernest Naville — Imperious Character of the Motives that Induce Action — Popular Conception and Philosophic Conception of Liberty — Our Slavery in the Presence of Our Innate and Acquired Mentality — Moral Orthopedia — Uselessness of the Concept: Will There are some conclusions which we easily arrive at by using the most elementary logic, and which we dare not ex- press. They seem to be in such flagrant contradiction to public opinion that we fear we should be stoned, morally speaking, and we prudently keep our light under a bushel. The problem of liberty is one of those noli me tangere questions. If you submit it to a single individual in a theoretical dis- cussion, in the absence of all elementary passion, he will have no difficulty in following your syllogisms ; he will himself fur- nish you with arguments in favor of determinism. But address yourself to the masses, or to the individual when he is under the sway of emotion caused by a revolting crime, and you will call forth clamors of indignation, — you will be put under the ban of public opinion. Nevertheless, it involves an important problem, on the solu- tion of which depends our attitude toward our fellow human beings in the burning questions of the education of ourselves and others, in those concerning the repression of misdemeanors and crimes. My convictions on this subject have been of such help to me in the practise of psychotherapy that I can not pass this ques- tion by in silence. When there is established between the body and the mind a connection of causality, or when the ultrapru- dent biologist confines himself to stating the constant parallel- ism between psychic phenomena and brain-work, one is forced to accept determinism. This has been very explicitly recognized by a philosophic 48 PSYCHIC TREATMENT physician, Professor Flournoy. 1 This is what he says on the subject of liberty: " It seems to me a desperate undertaking to attempt to pre- serve liberty in the face of a principle that is as definite as that of concomitance, and that is what it amounts to if experimental psychology is the expression of the truth in itself. " For here we have something still more evasive. It is of no use to speculate upon the nexus that unites the soul and the body ; whatever may be the nature of this bond, from the mo- ment that there is a regular concomitance, the succession of conscious states from the cradle to the tomb is necessarily also regulated, and as inevitable in each of its terms as the corre- sponding series of mechanical events. " Besides, if liberty were saved from this predicament noth- ing would be gained, for it is not only the psychophysical par- allelism which makes the obstacle, it is in a much more general way the spirit of all our sciences. What, in short, does it mean to know an event and to make it a subject of science if not to associate it with its causes — that is, to assign to it, as such, the series and general collection of previous events which have pro- duced it, and which have made it necessary? To explain a fact is always to place it among others where it implicitly be- longs, and in virtue of which it could neither not exist nor be otherwise. The fundamental axiom of all science is that of ab- solute determinism. Science ends where liberty begins." But in philosophy, which has preserved, under the influence of its environment, the impress of religious spiritualism, Dr. Flournoy states with sorrow the apparent divorce of science and morality. He thinks he is in a blind alley. " Science," he continues, " excludes free will, as it also excludes the denial of it; responsibility calls it back as an absolute condition. Must one choose between these, and sacrifice the truth of the first to the reality of the second ? This would be a hard extremity, for it would be as difficult to give up one as the other." I do not see that it is necessary to get into this troublesome dilemma. Whoever loves Truth must remain her faithful friend. i Métaphysique et psychologie. Genève, 1890. OF NERVOUS DISORDERS 49 When reason, which is our most precise instrument of work, leads us not only by experience but by induction to clear ideas we can go ahead without fear. It may be that at first we find ourselves drawn toward con- clusions which seem false ; we may fear to arrive at revolution- ary ideas that would be dangerous to the body social. I think this is not an illusion. There is at the bottom of each one of us a timid conservatism which accepts progress re- luctantly, and which fears the consequences of new ideas before knowing just what they are. Believers of all religions still voluntarily avoid this rock of dangerous repute, so that nobody may be lost upon it. They consider human reason to be a fallacious instrument, and they take care not to plunge their mass of dogmas into the dissolvent of free inquiry. Their position seems to me irrational, but it at least has the advantage of being impregnable. There are no arguments with which to attack any one who says : " I do not reason, I believe." But when one is firmly established on scientific and philo- sophic ground, one must let the donkey of his logic trot gently on. He will carry us straight to determinism, no matter how violently we make him turn about. This is what M. Ernest Naville seems to have done in his book devoted wholly to the defense of free will. 1 Let us rap- idly analyze and criticize it in the same brief way in which its principal arguments are condensed in the Preface : " Whatever man does outside of movements that are purely instinctive is the product of his will. But to conceive the will as a free power, the sole creator of his actions, to admit the will of indifference, is an error that a little closer study of psy- chology makes one promptly reject." Here we already find this human liberty compromised. The pedestal on which it was placed shrinks according to the degree in which we analyze the problems of volition. But let us continue : "A volition of which an act is the result is a fact which has many elements and which gives rise to delicate analysis. 1 Le libre arbitre, étude philosophique. Par E. Naville. Geneva, 1898. 50 PSYCHIC TREATMENT " The power of acting is always found in the presence of the motor tendencies of sensation and the motives of intelligence, but the motives only become sensory motors, according to the degree in which the stimulus creates a desire. The idea of an action has no influence unless there is an attraction or a repul- sion accompanying it. We are then in the presence of various impulses, and more often of opposite nature." Let us note these premises ; they are at the basis of the idea of determinism. " The argument of determinism," continues M. Naville, " is that these impulses produce an action in an obligatory and in- evitable way. The argument of the partisans of free will is that when different impulses arise we have the power of choos- ing — to resist some and to yield to others. Human liberty is essentially relative ; it is shown only in the possibility of choice between the inducements that existed before the act of volition, because the will could not create its own object." Here I must confess my inability to understand. Who does not see, in short, that the act of choosing, of resisting certain impulses and yielding to others, constitutes precisely a volition in the strictest sense of the word ? Now, according to M. Naville himself, a volition is always deter- mined by the attraction or repulsion with which the idea is vested. If we choose, resist, or yield, it is apparent that we are impelled to do so either by the motor tendencies of sensation or by intellectual motives. We always yield, then, to an attraction or a repulsion. It is the liberty of a piece of iron attracted by a magnet. This fallacious argument, which consists in excluding from the group of volitions the acts of choosing, resisting, and yield- ing, is the only argument that the eminent Christian philoso- pher brings up against the deterministic idea. Immediately afterward he abandons the domain of reason and scientific analysis, in order to exploit his fears on the subject of danger to morality. " In order to appreciate the gravity of the question that is brought up, it is enough to understand that without an element of liberty there is no responsibility, and that absolutely to deny OF NERVOUS DISORDERS 51 responsibility is to undermine the foundations of all our moral and social ideas; it means that we should be willing to strike out of the dictionary the words, duty, good and bad morals, or at least give these words, if they should be retained, a wholly different meaning from that which mankind has always given them." Very well, then ! It must be clearly stated : words take on a very different meaning when they are submitted to a philo- sophic analysis and when they arise from scientific induction. In current language words express only very fragmentary and incomplete ideas. They convey a first impression, and are used without any idea of the scientific truth. We shall always say that the sun rises and sets, even tho we know that it is an effect caused by the rotation of the earth. We speak of a balloon floating free in space, wilfully forgetting that it is the obedient slave of the laws controlling the density of gas. As soon as one admits the scientifically founded premises to which M. Naville gives utterance — that is, that a volition is always determined by the motor tendencies of sensation or by intellectual motives — there is no escape. There is no reason whatever for putting into a separate class the verbs to choose, to resist, and to yield. Cost what it may, we must arrive at de- terminism or else resolutely turn our backs to reason. We fear the argument of determinism which states that these impulsions produce our actions in an obligatory and fatal- istic manner, and it is the fatalism against which we rebel. We look upon evil impulses as the appetite of the human animal, and turn away from determinism as tho it implied a revolting slavery and a suppression of morality. We forget that we may also be slaves to goodness, to beauty, to moral laws, that we also yield to higher impulses of sensibility, and that the motifs of intelligence become powerful motor impulses in con- sequence of the attraction or repulsion that goes with them, and that they are those which often determine our volition. Whatever we do we are always obeying some sentiment or idea. Analyze any particular action, either the devotion of a martyr or the most shocking crime, and you will always find an imperious motor impulse which has determined the action. In 52 PSYCHIC TREATMENT one case it is native nobility of feeling, due to heredity and strengthened by education ; such are the moral or religious con- victions that have been carefully cherished in the family or social circle in which the individual has lived. In the other they are the overwhelming impulses of brutal selfishness and low passions ; these are deep-rooted perennial plants in the fer- tile soil of society. And always we yield to the impulsion which by reason of our previous mentality has held us in the power of its fascination. One also forgets that the fatality which is inevitably con- nected with the committed act does not predetermine any of the impulsions which are to follow. The culprit who has thus far been subjected to the bondage of evil may find the narrow way again; but, escaping from the control of a low sensualism, he may submit henceforth to the yoke of intelligence and of moral ideas. The hypothesis of determinism includes neither reflection, nor conversion, nor moral development. Determinism confines itself to the statement of the connecting series of conscious acts, and explains them by the continuous actions of the motor im- pulses of our thinking brain. It seems to me that one could not be very bold to retreat before these conclusions which are based on the statement of facts, and that one must be very timid to see in these ideas any danger to morality. Why, since the analysis leads us to the denial of free will, do we keep on using the terms " liberty," " will," and even " re- sponsibility " ? Why does the most convinced determinist say every day : "I am free," " I wish " ? It is because he uses these words in the sense in which they are used in ordinary language. It would be a hard and vain task to try to reform the lan- guage which is the vivid and intimate expression of our un- thinking impressions, and to dull its pictures by philosophic considerations. Let us use words in their commonly accepted sense in talk- ing with our fellows, but in delicate analysis to which we are led by philosophic thought we may permit ourselves interpre- OF NERVOUS DISORDERS 53 tations which retain their exactness even when they seem op- posed to the old conceptions. In the language of the world at large, which can not follow all fluctuations of thought, to be free means to be able to do what one wishes to do. We say that we are free when no ma- terial obstacle nor organic trouble occurs imperatively to op- pose our desires. Bars on the one hand and sickness on the other are the only obstacles which, in the eyes of those who do not reflect, restrain human liberty. But submit your own conduct or that of your friends to a less summary examination, and you will acknowledge with sorrow that we are also in bondage to our innate or acquired mentality. You, young man, altho you are so well endowed, have a fatal instability of mental disposition, you are frequently bored, and every day you perceive that you are not so free as you would like to call yourself. You, madam, by inheritance or atavism, are, as you have said, impressionable. You are so un- able to control your impulses that you have just said: " They are stronger than I." There is, then, something stronger than your will, and that in yourself ; and yet without your being con- trolled by anybody. The alcoholic believes in his liberty, and will say to you: " I am free to drink or not to drink." The unfortunate fellow does not see that he is the slave of the diseased demands of his body which can not endure abstinence, that his actions are gov- erned by dull impulses that are insufficiently restrained, because his moral ideas have lost their freshness and tone. How many people who make a great show of their will- power are only what one would call "wilful "; that is to say, they are impulsive, and slaves to their senses. Wittingly or unwittingly, we continually find obstacles in our way which are often insurmountable, which prevent us from acting, altho our liberty, in the common sense of the word, seems complete. The philosophic defenders of free will have already given the word " liberty " a wholly different meaning from the one in common use in daily speech. They call it " relative liberty " when it ap- pears alsolute to one who does not think. It is no longer a free 54 PSYCHIC TREATMENT power, an omnipotent queen ; it belongs to a constitutional mon- archy. Push the analysis further, and you will see that you are also the slave of your happy impulses and kindly feelings, of your clear ideas of truth, goodness, and beauty, and that you can not at will change your governing ideas. Like the weather- vane on the roof, you obey every wind, turning as often to one side as to the other, but you keep the direction of the prevailing wind that blows for you at the time you make up your mind. The popular conception of liberty as autocratic power is false. There is no need of delicate analysis to establish its very simple character. The spiritualists recognize the slavery which is hidden under our apparent liberty. They know the power of the motor impulses, but, held back by a moral uneasiness which is foreign to scientific induction, they add a word or two which eliminates it, and call human liberty a " relative liberty which creates itself as its own object." According to the degree in which the study of biology makes us recognize the obstacles that accumulate in our path by reason of our native and acquired mental states, as well as our natural character, it also diminishes the area in which our liberty may be exercised. Determinism sees the constant slavery in which we are brought face to face with motor impulses. It knows it to be inevitable at the very instant that the reaction takes place. It believes it to be fated as long as contrary impulsions do not come to change the direction of the movement. It denies free will as an untenable philosophic conception, absolutely inacces- sible to human reason. In the language of the people, even, we find expressions which hint at this bondage to the motor impulses. For ex- ample, some reprehensible act is proposed to some one, and at first sight would seem to be of evident advantage to him. Im- mediately a struggle begins in his mind. The individual feels at first drawn by the attractions which the wrong act would present to him. But the association of ideas steps in; moral conceptions surge up and become more distinct under the influ- ence of his reflections — perhaps the advice of other people ; the situation becomes clarified. The idea of the act loses its attrac- OF NERVOUS DISORDERS 55 tion, it even causes a feeling of repulsion. The cold, bare in- tellectual fact gives birth to warm, moving conviction, and all at once the person bursts out, saying : " No, I can not do that ! " He has yielded to the strongest impulse, and, in a naïve and intuitive expression of moral determinism, he says : " I can not do it," and not: " I will not do it." It is neither criminal nor vicious to desire. Each one of us is constantly restrained by moral barriers which, having to do with psychic and mental states, nevertheless suppress our free will as much as a wall or a policeman would restrain our lib- erty. Fatality is naturally associated with the idea of deter- minism, but it is still far from that fatality of predestination which is taught by religion. In all these religious conceptions, where " the hairs of our heads are numbered," I have vainly en- deavored to find room for liberty. It seems to me that this time one must not only modify the sense of the word, which is always permissible, but one ought to strike it bodily out of the dictionary. At the exact moment that a man puts forth any volition whatever his action is an effect. It could not either not be or be otherwise. Given the sensory motor state, or the state of the intellect of the subject, it is the product of his real mentality. Ah ! without doubt the act would have been otherwise if the personality of the acting being had itself been other than it was, if his mentality had not been clouded by fatigue, by sickness, or by alcoholic intoxication. The culprit would have been able to avoid the fault that he committed if he had kept his moral in- struction in mind, if these ideas which might have touched his understanding had been twice as attractive. But all these if s are useless, they come too late. These efficacious attractions or repulsions have not existed, and the deed has been fatally ac- complished, with all its unhappy consequences to the individual, his family, and society. But it is nowhere written that the individual is going to per- sist henceforward in a downward course, that he is fatally com- mitted to evil. But the fault having been committed, it should now be the time for some educative influence to be brought to bear, to bring together in his soul all the favorable motor ten- 56 PSYCHIC TREATMENT dencies and intellectual incentives, to arouse pity and goodness, or found on reason the sentiment of moral duty. I know of no idea more fertile in happy suggestion than that which consists in taking people as they are, and admitting at the time when one observes them that they are never otherwise than what they can be. This idea alone leads us logically to true indulgence, to that which forgives, and, while shutting our eyes to the past, looks forward to the future. When one has succeeded in fixing this enlightening idea in one's mind, one is no more irritated by the whims of an hysterical patient than by the meanness of a selfish person. Without doubt one does not attain such healthy stoicism with very great ease, for it is not, we must understand, merely the toleration of the presence of evil, but a stoicism in the pres- ence of the culprit. We react, first of all, under the influence of our sensibility; it is that which determines the first move- ment, it is that which makes our blood boil and calls forth a noble rage. But one ought to calm one's emotion and stop to reflect. This does not mean that we are to sink back into indifference, but, with a better knowledge of the mental mechanism of the will, we can get back to a state of calmness. We see the threads which pull the human puppets, and we can consider the only possible plan of useful action — that of cutting off the pos- sibility of any renewal of wrong deeds, and of sheltering those who might suffer from them, and making the future more cer- tain by the uplifting of the wrong-doer. Without doubt, the will, regarded as a free power, disap- pears in this conception of determinism. One's decisions and wishes are all determined by irresistible motor impulses at the moment when the reaction takes place, and I have shown the sophistry by which they have tried to bring under this rule the acts of choice, resistance, yielding, and their synonyms. The more I analyze my own acts of will and those of my fellows, the more I hold that the chief characteristic of the will is effort. That is why, in describing the methods of struggling against nervousness, I have preferred the term " education of the rea- OF NERVOUS DISORDERS 57 son " to " education of the will." When we obey the simple suggestion of our feelings, when we let ourselves do what we want to do, we do not speak of will, altho our volitions are concerned. We know very well that we are then slaves to our tastes and appetites, and we charge up this easy-going morality to our motor impulses. It is when we make an appeal to intel- lectual motives or to moral ideas that we like to pretend to be free, and we call him a strong man who bases his conduct on his rational principles and his moral or philosophic convictions. As a matter of fact, he does not obey suggestions of right ; he has a clear idea of the way he wants to go. He finds attrac- tions along certain roads where other people see no attractions, or he experiences, perhaps, a sense of instinctive repulsion. A clear idea of our end and aim is enough to assure our march. As Guyau has said, " Whoever does not act according to what he thinks, thinks incompletely." The objection is raised that we may have a clear knowledge of the excellence of a determination, but that we have not the strength to follow it up. I do not deny the fact, but I will not admit the explanation ; it is not strength which fails us. If we still resist, if we walk with hesitation, if even we plunge in the opposite direction, it is because we are still held by the chains of our sensibility. We see with the mind's eye what would be right, but the heart is lacking, there is no passionate, emotional feeling. Our ideas lead us only when they have become con- victions. Then there is no longer struggle or voluntary effort ; movement is started and accelerated just as it is with a body submitted to the force of gravity. As it was very neatly put by one of my patients, who, tho a sincere believer, yet grasped my meaning at once : " The will drops passively into the beaten path which sentiment and reason have worn for it." 58 PSYCHIC TREATMENT CHAPTER V Absolute Responsibility — Social and Moral Responsibility — Independent Morality: Reason is Its Guide — Gradual Development of Moral Sentiments — Moral Conscience — Community of Aspirations among the Believers in Free Thought — Search for Happiness: Depends on Our Native or Acquired Mentality — Faults of Character or Disorder of the Mind The words " liberty " and " will " may be retained in every- day speech with the restricted meaning which has always been given them. When we can obey the impulses of our sensibility and the dictates of reason, we call ourselves free, because, as we do not regard our own motor impulses as anything foreign to ourselves, we have the sensation of choosing and deciding. It is useless to cast out these terms which express so well what we mean. But if we analyze things a little more deeply, reason shows us the utter bondage in which we are placed in relation to our motor impulses. We necessarily get to the point where we deny free will, and the will, like freedom, disappears. It seems to me that no thinkers need try to avoid these syllo- gisms, which contain nothing specious or artificial. Instead of reasoning, they become alarmed, and cry : " But what becomes of morality in the hypothesis of determinism ? It can no longer exist! " This is the constant objection that is brought against biologic determinism, this is the obstacle before which they shrink back frightened, this is the divorce between science and morality which the spiritual and Christian philosophers so elo- quently point out. In short, they say, to deny free will is to do away with responsibility, for that is the basis of morality. This must be understood. True responsibility, that which will one day bring us face to face with a Supreme Being, the all-powerful judge of our deeds, is of théologie origin. In or- der to admit it one must have an anthropomorphic conception OF NERVOUS DISORDERS 59 of the Divinity, an act of faith ; and the fact is that science is not leading us in this direction. But had I succeeded even in getting these ideas into my head, I should find it revolting to see men make themselves judges of their fellow men. In this world our relation is of brother to brother, and we are nowhere authorized to set our- selves up as the instruments of Divine justice. We would have to voluntarily shut our eyes to what goes on in the world, even in our tribunals, in order to dare attribute to this human justice the infallibility which it should certainly possess if it were to take the place of the all-seeing justice of Providence. If we have a Father infinitely just and good, let Him search our hearts and distribute according to His pleasure either recom- pense or punishment ; but, with such frailties as we possess, let us not have the audacity to judge the wrong-doing of others. Responsible in the narrow, absolute sense of the word we can never be, for the moment that we leave the right path we have only acted in obedience to our present impulses and we are slaves. Our conduct always betrays our actual mentality, and this mentality is but the product of our natural temperament and our education. Our relatives and friends, and society as a whole, have largely contributed to create the condition of mind in which we find ourselves, and if fault there be we are all responsible. Do we mean to say that there is no such thing as right or wrong, or good and evil ? Should we stand and look on in pas- sive fatalism at the blooming of all these flowers of evil which, since the beginning of the world, have been spreading with the fertility of tares ? By no means ! There is a social responsibility which authorizes society to repress vice, or, what is more to the purpose, to prevent it and to hinder its recurrence. Society responds to the necessity of personal defense, and the solidarity which unites us enjoins us to contribute on our part to the maintenance of the moral order. There is a moral responsibility which leads us not only to respect these laws and to avoid conflict with society, but which forces us to bow before the ideal of a moral law as far as we can recognize it. Religious morality itself draws only those 60 PSYCHIC TREATMENT whose natural mentality and education have led to submission. In the moral domain we can obey only those laws to which we give our assent. Morality exists independent and free from all théologie ties. Its code is summed up in a collection of altruistic sentiments and ideas which are common to civilized people. Whether it be sentimental or rational in the beginning, this morality little by little becomes instinctive and automatic. It constitutes what we call " moral conscience." Without doubt, religions have contributed many stones to the edifice; they have aided, in a very great degree, in the establishment of this moral founda- tion, but it would be unjust to ascribe to them all the honor. Morality is the work of thinkers of all times, who have had an intuition of the True, the Beautiful, and the Good, and who have sought to base on reason the moral code which ought to serve us as a guide. It seems at first sight that a morality with sanction and ob- ligation, such as is evident in the religious idea, ought to make itself felt more easily and rapidly, and exercise on the masses a more powerful and educative influence. For almost two thousand years the experiment has been go- ing on, and the result is not encouraging. Without doubt, the morality of Christ remains the highest and purest. If one separates it from dogma it constitutes the ideal of independent morality, but it has only had the success to win esteem in the world. The Church, far from aiding to spread it, has suc- ceeded only in maintaining a pathological mentality which is dominated by the natural tendency to superstition and fanati- cism. One needs a very strong gift of optimism to expect of these religions alone that moral influence that ought to deliver us from our weakness in well-doing and establish the reign of justice. Religious morality itself, I repeat, only makes its be- neficent influence felt when its teachings are understood, when they agree with our inner feelings, with our natural aspirations, and when they obtain the assent of our reason. It is always in the light of independent, sentimental, and rational morality that we judge the moral dictates of religion. The devotee often accepts without thinking, in a passive OF NERVOUS DISORDERS 61 obedience to authority, certain ritual practises and dogmas which he does not discuss ; but at least only by consenting to forfeit completely his intellectual perceptions can he admit moral conceptions opposed to his natural sentiments of good and to his ideas of reason. Morality is, before everything else, social, and may be summed up in the precept : " Do not unto others what you would not have them do to you," and its corollary : " Do unto others whatever you would have them do unto you." It finds its expression in what, at first sight, is a less comprehensible sentiment : " Love thy neighbor as thyself." Whoever can not grasp this moral law is in a state of intel- lectual inferiority. It is accessible to all without the need of the intervention of Divine sanction. It is more noble, it seems to me, to obey a sentiment of goodness and beauty, and to yield to the motives of clear-sighted intelligence, than to let one's conduct be influenced by the hope of reward or the fear of punishment. Without doubt, morality is not absolute. It could not be so except on the hypothesis of a Divine revelation of a dictated moral code. Within certain limits, morality is always relative and variable, following the medium course of humanity. But progress goes slowly and surely ; it tends to the unification of moral ideas, and this growth toward perfection seems still more intense to-day, altho the masses more than ever avoid the yoke of the Church. Let us acknowledge that the moral laity have succeeded no better than the Church in changing human mentality. One must accept the situation as it is; moral development is des- perately slow. Reason, so victorious in the domain of exact sciences, encounters many enemies when she advances upon the vague domain of philosophy. She falls into the snares spread for her by selfishness, the passions, the senses, which are so often the opposites to the incentives of Reason. She has to struggle with determination, with preconceived and unreason- able opinions, born in minds under the suggestion of education. But if, in spite of all, moral perfection is attained, it in- creases by the efforts of free thought, as conscious of its weak- 62 PSYCHIC TREATMENT ness as of its power. People sometimes smile disdainfully in speaking of the goddess Reason. I am willing to admit that she may be weak, but she is the only means in our possession to help us in our search for truth. It is absolutely necessary for us to make use of her. Moral perfection consists in bringing to an end the antino- my that often exists between the senses and the reason. Moral laws, without being dictated from on high, have their beauty. We feel the influence of their charm from the cradle, by the example of those around us. We feel an instinctive sensual delight in this pleasant atmosphere. There is no effort, no con- straint, there is only a natural abandon. A little later the struggle commences, the world exercises its educative influence, which is more often inauspicious than favorable. Still obedient to a natural or acquired sensibility, upheld by the example of those we love, we avoid dangers. With an already practised glance of the eye we see something ugly, and flee from it to seek for the light of beauty. Often our sight is dimmed, but after these eclipses beauty reappears, attractive and imperious. Our discernment becomes keener, and with always firmer steps we advance along the road of goodness. Oh, I know the task is hard ! Whether man be guided by his own strength or by the teachings of a personal philosophy, or whether he lean on the staff of religion, he does not escape downfalls on this long journey. It takes all our lives to acquire the mastery over ourselves. Let us bear in mind that this does not imply a voluntary effort of which we are radically incapable, but an ever clearer vision of the charm that is associated with moral ideas. Alas ! the unfortunates who have no other interest than the pursuit of sensual pleasures accomplish no more for philosophy than those who prostrate themselves in temples. They belong to the same class as those whose prudent and selfish cal- culations lead them to regulate their lives in conformity to a moral law. Such is the materialism of modern customs as seen in our streets, despite the constant efforts of religion and the parallel action of independent morality. There is danger for the determinists. It lies in these in- OF NERVOUS DISORDERS 63 voluntary alliances. Determinist doctrines, when badly inter- preted, easily find adherents among those who are only looking for the material well-being and who are glad to give a certain appearance of justification to their conduct. It would be as unjust to impute this result to positivist doctrines as to blame the Church when a bandit goes up the sacred stairway at Rome on his knees in order to commit a crime a few minutes later. Tartuffe ought to have cast discredit on the false devotees only. Every doctrine is exposed to these false adherents. Does not one see sincere, devoted Christians, imbued with the purest morality, and social idealists mingled, against their will, in the ranks of malevolent revolutionists, who deny all social and moral order? In the same way, how few sincere Christians there are whose piety shows itself by a true change of heart. In the same way, there are not many freethinkers who, without giv- ing up their claim to reason, preserve their enthusiasm for a moral ideal, and seek to attain it by the continued perfecting of their ego. The obstacle to the development of high ideas does not lie in the doctrines born of the study of the natural sciences and of reflections that are beyond the reach of the masses; it lies in the enormous dead weight which constitutes the non thinkers, the indifferent. These are the true enemies of all morality — re- ligious or lay. Analyzing the antagonism which seems to exist between science and religion, De Candolle describes clearly the insur- mountable opposition which there is between the maxims of au- thority and free scientific investigation, 1 but he adds : " Neither scientists nor religious men sacrifice their opinions to material interests, to politics, or to pleasure. When that occurs they go out of their class, and lose the esteem of the public. Both are interested in intellectual things, and have to, if they want to succeed, lead a regular, hard-working, and even severe life when they come of a poor family. They have, in short, this 1 Histoire des sciences et des savants depuis deux siècles. Par Alphonse de Candolle. Second edition. Genève et Bâle. H. Georg, 1885. 64 PSYCHIC TREATMENT much in common : the precious sentiment of working in a pure- ly disinterested way for the good of humanity." In spite of their different points of view, there is a com- munion of soul between intellectual rationalists and truly re- ligious people. They defend the banner of the ideal against the unconscious attacks of crowds that are more indifferent than hostile. Believers and sincere freethinkers can practise the same religion — that which consists in wanting to be to-day better than they were yesterday. A clear idea of biological determinism imposes on those who understand it a special way of looking at life, and of judging their own conduct and that of their fellows. Far from weaken- ing morality, it is the most solid base of moral orthopedia that we can apply to ourselves or to others. Let us insist on these views, which appear paradoxical only to those who do not reflect. Man has never had and never will have any other object than the conquest of happiness. The majority of men seek it in the satisfaction of their desires and in their pleasures. They storm against the obstacles that are continually getting in the way of their desires ; their happiness depends, first of all, upon exterior circumstances, thus it is merely relative and ephemeral. Others, fewer in number, work only with the idea of a future life. Many, in short, thinking that a bird in the hand is worth two in the bush, take good care not to miss the good fortune here while hoping for something still better in another world. Now, whoever will reflect and search his own life will soon recognize that our happiness depends less upon the circum- stances in which we live than upon our inner state of mind — that is to say, upon our morality. Undoubtedly we may be ex- posed to misfortune for which we are not responsible, we may be the victims of natural catastrophe, succumb to inevitable disease, or lose our dearest friends, but the intensity of these sufferings depends before all upon the spirit in which we accept them. The greatest misfortunes come to us through our in- numeral faults and our abnormal mentality. We are most often the authors of our own troubles, and when we ourselves are not at fault we must bear the yoke of heredity, we pay for our OF NERVOUS DISORDERS 65 ancestors; we suffer thus for the immorality of others. The earth would soon be like Eden if we were all good and just, and if the moral law were strictly observed. Humanity, athirst for happiness, ought, therefore, to strive for moral development. All who are willing to work for the realization of this end have naturally a work of education to perform. This education begins with life itself, and it devolves, first of all, upon parents. In order to direct it, they ought to know that the faults which they detect in their children depend on their native mentality, and that this last has only one possible origin — heredity and atavism ; let us add here the influence of the factors which have acted upon the child in fetal life. There is nothing innate within us that is not the legacy of preceding generations. Also when you discover in your children some intellectual and moral blemishes, do not go too far afield in looking for the causes. Examine your own mentality, that of your father and of your mother, of your grandparents, and you will always find the germ of fatal tendencies. " The fruit does not fall far from the tree " — so a German proverb runs. That is a truth of La Palice, it seems to me ; nevertheless, how many there are who have never dwelt on this reflection! The ma- jority of parents are annoyed when they find faults in their children, and want to know where they came from. One would really think that a bold cuckoo had laid her egg in their nest. No; your heir comes into the world with nothing but what you have given him. Do not reproach him with his pov- erty. You must take him as he is, with his small capital of natural morality, as you forgive him his physical or intellectual debility. You may sometimes bemoan the hard implacability of the laws of heredity, but do not throw the weight of respon- sibility upon the poor creature you have brought into the world. It is futile to revolt and indulge in recriminations against a situation that is a fact. It is our imperative duty to correct vicious tendencies by education, to waken moral feelings, to train the Reason so that she can learn to discriminate at a glance the motives which determine conduct. Authority, and even punishment, may be used at certain times to modify the 66 PSYCHIC TREATMENT mentality, but every one will recognize that persuasive influ- ence is infinitely preferable, that it only can create a lasting vital morality, capable of outlasting the transient education which the parent can give. It is the same with men as with plants : the budding branch has its faults from the beginning; direct its growth, train it along the wall, and perhaps you will have a tree that will bear good fruit. It would be pleasant to delude one's self and believe in the constant efficacy of such culture. Alas ! there are many un- skilled gardeners, and many a slip whose natural deformity is too great at the start. The deterministic conception is particularly valuable in our relations with our fellow men. When we are quite persuaded that people are only what they can be by virtue of the mentality with which they were endowed and the education which they have received, we pardon them their mistakes and faults. Pity takes possession of us, and it is with a feeling akin to love that we try to lead them back to the right way. But the work is much more difficult than in the education of a child. The sap- ling has grown, its branches are not so flexible, and the garden- er's work is often impossible. We are not always in a favor- able position to practise moral orthopedia on our fellows. The vicious escape from our influence, and often we are obliged to throw the helve after the ax. When we express to certain persons the idea that an indi- vidual from the mental point of view can be only what educa- tion has made him, we often hear it said : " But here are two young people brought up by the same parents ; one is a charm- ing fellow, and the other a hard case ! " I am surprised that any one should bring such superficial judgment to the study of these questions. It is not certain, in the first place, that these two young people with such different conduct are so far separated from one another from the point of view of their personal mentality. Wait a few years, and you will admit that they are more like brothers than you would have believed. OF NERVOUS DISORDERS 67 In spite of appearances, their education may have been very different. We do not respond only to official education, such as that of our parents, of the school, and of the priest. Without even being able to perceive it, we are constantly brought under the sway of the contagion of example ; at every moment some strik- ing event, a sight which we should not have seen, or a word let slip from some of those around us, opens new horizons to us. The seeds of evil are scattered broadcast in the air, and it needs only the right moment of receptivity for the germ to develop. Alas ! often nothing can stop the growth of the poisonous plant ; it attains a luxurious vegetation. If we really take a look at ourselves, as one thinker has said, we come back full of horror. Have we, then, the right to criti- cise others ? No ; we have only one duty, and that is to pardon and stretch out our hands to those who have fallen. The simplistic idea of absolute or relative human liberty leads us to establish an essential difference between a fault of character and a mental malady. This distinction, and I can not repeat it too often, is artificial and untenable. At what degree do indecision, irritability, impressionability, and emotional disturbances become sicknesses? Are sorrow and pessimism faults or illnesses ? Even in bodily illness, it is often difficult to draw the line between the normal state and that of illness. At what height, when one is climbing a mountain, is it allowable to have palpi- tation of the heart or dyspnea? Are you sick because you can not stand a light meal which your neighbor has digested without any difficulty? In the mental domain it is still more impossible to try to make this distinction. It only seems to exist when one is look- ing at the extremes. It seems normal to us to be sad when we lose a dear friend, to be discouraged in the presence of failure ; but we regard any- body as diseased who commits suicide in order to escape the perplexities to which we are all subjected. We all have our periods of indecision, which often appear exaggerated to the eyes of others ; but we send a patient to a physician when he 68 PSYCHIC TREATMENT passes hours in agonizing perplexity without being able to de- cide whether he will change his shirt to-day or to-morrow. In order to make the distinction, it is sometimes said : "A fault is corrigible by the will and by educative influence ; sick- ness handicaps freedom, and does not respond to these meas- ures." This is false. Our faults are often rebellious and even incurable. Do we not often see a person who does not seem to have the faculty of acquiring tact ? Can we be taught this very estimable virtue ? Do we often lose that susceptibility, or that irritability, which makes life miserable for our neighbors ? Do we not know people who are always behind time ? They have often been punished for it, and have sworn that it shall never happen again. Ah, well, it always happens and always will happen, because it is a part of their mental make-up. On the contrary, you see disappear under the influence of certain advice some of the old mental obliquities which every- body lays at the door of the diseased. I mean certain phobias, various obsessions foreign to the mentality of the majority of people. Mental sickness, in the sense which the public gives to it, often disappears more rapidly and more completely than what we call a fault. One often thinks that mental sickness makes itself manifest by a combination of physical or mental symptoms which clearly denote the pathological condition. That is not so. There are hosts of psychopathic conditions where the physical health is perfectly sound ; even more, where the mind appears healthy — the mental obliquity is unique and isolated. The patient only needs medical treatment, properly speaking ; he has need neither of douches nor of medicines. He will recover his mental health by pure psychotherapy, by the presence of reasonable impulses which will change his abnormal mentality. Whether they call it fault, or character, or mental sickness, the deviation exists. The subject has states of mind which not only appear abnormal in the face of an ideal of moral beauty, but which trouble the life of the individual and prevent him from playing the rôle in human society for which he was cast. In short, as a last argument, mental malady is attributed to physical causes, to intoxications, and to a wholly material proc- OF NERVOUS DISORDERS 69 ess, while one attributes a fault to purely moral causes. This also is false. I have said, in virtue of the psychophysical parallelism, the abnormal mentality assumes an abnormal state of the brain. This may result from physical and moral causes, capable of act- ing concurrently in a fault as well as in a mental disease. The task of the physician as that of the educator is to ascer- tain the abnormal mentality, to find out its moral or physical causes, applying to both of them the necessary and inevitable idea of determinism, so as to be able, with the aid of physical and moral influences, to practise mental orthopedia. This is what educators have applied themselves to during all time. Unfortunately, physicians have not seen with sufficient clear- ness that they are often called upon to treat the morale of their patients, to correct their faults, and to give them a more ra- tional mentality. As to the educators, they have not enough biological knowledge and no clear views on the mental passivity of the man who believes himself to be free. Often they think that it is a fault which they have detected, and they imagine that the checking of it is only a question of redoubling severity. Often they are doubtful, and ask themselves whether it is not a diseased condition. Often, at a late day, they recognize that they have been on the wrong track, and it is not always possible to change the course. Persons imbued with absolute ideas of liberty and responsi- bility have a heavy hand in moral orthopedia. They are often cold and severe, and even when, after taxing their ingenuity to bring about some artificial good, they give their advice, the culprit feels in it all the harshness of a reproach. In order to change the state of mind of any one who has fallen, it is not sufficient to grant him extenuating circumstan- ces and to show him pity ; one must love him as a brother, and stand shoulder to shoulder with him with a profound sense of our common weakness. 70 PSYCHIC TREATMENT CHAPTER VI Difficulties of Moral Orthopedia — Criminality — The Partisans of Abso- lute Responsibility and the Determinists Remain Irreconcilable Adversaries in Theory — Possible Compromise in Practise — Necessity of this Understanding — The Rôle of Human Justice — Educative End of Repression — Urgent Reforms of Penal Laws Already in the education of children, in our daily inter- course with our fellows, in the efforts which we put forth to correct vicious habits or to cure disease, the absence of clear deterministic ideas often produces tragic results. There are thousands of these children who are intellectually and morally delinquent, in whom education, far from correct- ing the primitive deviation, has only accentuated the fault, and has led to the rupture of family ties. In families and in society nothing is so rare as harmony ; everywhere the social machinery grates, and when we search for the cause we only find a little fine sand in the wheels which a whiff of indulgence would have easily blown away. But parents do not possess this clear sight of things. Their indulgence is weakness, their firmness becomes severity. The task of parents is doubly difficult in education, for not only do they bequeath to their children certain mental defects, but they often cultivate their faults in setting before them an example of the same weakness. This insufficiency of educative aptitude becomes dangerous when one has to deal with rebellious sub- jects, and it then seems necessary to give up family education. In the institutions intended for the education of backward children the moral influence seems more efficacious. It is ex- ercised by strangers of a different mentality who are more im- partial. But to return to the family, the veneer which seemed so firmly put on is rapidly loosened ; the native tendencies reap- pear, and everything has to be begun over again. It is often the same in the case of moral orthopedia, which constitutes the OF NERVOUS DISORDERS 71 important element in a cure of nervousness. At the clinic everything goes well ; in the presence of kindly strangers the mental peculiarities are better, the subject becomes quiet and patient ; he is under the influence of the moral contagion of his environment. Often this influence persists and leads to a defi- nite change in his mental point of view, but in other cases the effort is in vain, and the disappointed parents find their son or their daughter just as egoistic, irritable, or unmanageable as before. Nevertheless, the question is one that concerns our children ; we find in them an inherited mentality ; we are conscious of the faults which we have committed in their education; we recog- nize in them the weakness of the mother and the selfish indif- ference of the father. We know that if the offspring was deformed at its birth we could not straighten it by our art ; in short, we have an instinctive indulgence for our own and for those that we love. And what becomes of this good will when there is no tie of blood, when nothing binds us but this vague and feeble human fraternity, when it is a question of delinquents and criminals whose acts arouse our indignation. Then we no longer see the numerous physical and moral causes which have led to the deformity. Forgetting our own weakness, we set ourselves up as judges and we punish accord- ing to the absurd law of retaliation. In criminal suits within the august walls of the court of assizes we listen to lamentable discussions upon responsibility. The public accuser expounds questions of metaphysics and de- clares that free will exists, as if he were discussing a legal prescription. Medical experts affirm the total or partial re- sponsibility of the delinquent. But the grocers and the wine merchants on the jury know more about these things ; they do not let themselves be led away by philosophic reflections of an anthropologist, and, without any hesitation, they send the in- sane person to prison and often to the scaffold. In these questions of criminality the situation is at bottom no more tragic than is that of education. The problem is more pointed and more dramatic, but it is less often met. In the case 72 PSYCHIC TREATMENT of the incorrigible criminal it is often a matter of indifference whether he spends the rest of his days in the asylum or in prison. But human injustice becomes disastrous when it is a question of the numerous delinquents whose mentality could be modified, and when it concerns the stray sheep who, without coming into conflict with penal law, nevertheless disturbs the peace of the body social. And everywhere at the base of these false judgments we find the sorry conception of absolute re- sponsibility, everywhere we are brought face to face with the insurmountable difficulty of deciding where liberty begins and where it ends, where health stops and where mental disease begins. It is no longer a question here of philosophic problems pure and simple, of dreams over the first causes, where each one may give full indulgence to the vagaries of imagination. These are burning questions which confront us, and on their immediate solution hangs the fate of one of our fellows. I do not by any means hug to myself the illusion that it may be possible to reach a state of perfect agreement on these ques- tions. Without doubt, right ideas are imperishable, and, tho their march may be slow, they can never be stopped ; but the progress is too slow for any one to wait for the solution of the problem. There will always be spiritualists who will believe in the liberty of indifference, in sovereign will, and in absolute re- sponsibility ; they will for a long time preserve the mental point of view of the Old Testament. Others will consent to leave their thoughts some liberty, and in a certain measure to be in- fluenced by the contagion of determinist ideas. They mingle water with their wine, and, when passion or the fear of seeing their ideas of morality submerged does not come in to trouble their judgment, they recognize the influence of heredity and of environment, and will show an unequal contingent indul- gence, often more unjust than the strictness of an orthodox person. And, last, there always has been and there always will be a growing multitude of thinkers who can not withstand the desire for knowledge, who have only one end, the search for truth, and exert in its pursuit all the forces of their being, their affective sensibility, and their reason. OF NERVOUS DISORDERS 73 These parties will always exist; they have existed from all time ; they will never change. The lawmakers who prepare our penal code, ought they to suspend their proceedings until peace is made, until the world may be converted to determinism or brought under the yoke of the Church ? No, this is not possible. We have need of laws, of political and social institutions, and they are always established on the foundation of compromise and reciprocal concessions. Tho we may be adversaries on the ground of theory, we can, how- ever, clasp hands in practise. It seems to me that in order to reach this end we must first of all throw away the apple of discord, the word "responsi- bility " in the absolute sense which has been given to it. Social responsibility is confused with the notion of culpa- bility. The first task of human justice is to prove the offense — that is, the infraction of the existing laws. Without feeling the burden of moral responsibility, which is an affair of the individual conscience, or of transcendental responsibility, which is a question of metaphysics, Justice has only one right which is at the same time a duty. She ought to do everything to oppose wrong acts, to stop their performance if there is still time ; she ought to hinder their repetition and to work to repair the harm that has been done. This repression, which ought to be prompt in order to be efficacious, authorizes such measures of rigor as arrest, impris- onment, and punishment. But this justice is not the goddess with blindfolded eyes who weighs the misdemeanor or the crime, and puts into the other scale the weight that ought to reestablish equilibrium. The best means of preventing the recurrence of a wrong act is the improvement of the culprit, and just as in the family the father uses his educative influence for this purpose, society ought likewise to make an effort to bring some favorable influ- ences to bear upon the soul of the delinquent which may im- prove his mentality. Punishment, even tho it be severe, may be used for this end ; it can help to lead the wrong-doer back into the right way 74 PSYCHIC TREATMENT and be of use as a warning to those who might be tempted to imitate him. But we all feel that brutal repression, which only takes account of the fact and closes its eyes to the circum- stances in which it was produced, is revolting to our moral conscience. We accept punishment with just so much less difficulty ac- cording to the degree in which it is just, and in which we recognize in the one who metes it out to us the desire to lead us back to the right way. On the other hand, we submit to it in a very bad spirit and with revolt in our souls when it is dic- tated by the spirit of vengeance. Without doubt, penal laws must have a certain precision, and must catalog the various crimes and decide upon the penalties which should go with them. But when it comes to the application of them there ought to be more attention paid to shades, to the appreciation of motives, to the analysis of mental states, and to the modifi- cation of the punishment within its fixed limits. This should be considered more and more in proportion as we know better the physical or the moral causes of the criminal deed. Whether one is an out-and-out determinist or whether one reserves to human liberty more or less power, one must, never- theless, recognize certain truths. It is evident, first of all, that a great many criminals bow to the yoke of heredity and are predisposed to crime. The term " born criminal " of Lombroso expresses this slavery too crudely. There are no born crimi- nals, but there are individuals whose mentality is abnormal, and who, if propitious circumstances present themselves, will grow up with criminal tendencies. If we can constantly lessen those temptations which determine their reactions they will remain inoffensive degenerates. Without doubt this is not always pos- sible ; but has society really fulfilled its duty in this direction ? Does it watch with sufficient love over the human nursery? Does it work with zeal to cure the sickly nurslings and to pre- serve the others from contagion? Evidently not. This wind of true justice has not been blowing very long, and society ought to recognize more and more that if vicious people exist it is because it allows material, intellectual, and moral destitution to exist in the cases of thousands of indi- OF NERVOUS DISORDERS 75 viduals. Society is still a negligent stepmother who has only herself to blame if her children wander away. She ought to recognize her fault, and if to reform the transgressor and pre- vent new misdeeds, she is obliged to be severe, she ought to be so with love, and with education as the only aim in view. One is aware of these facts in every circle. From them are born the institutions for the improvement of young delinquents, for the education of unmanageable children, the associations for the help of discharged criminals. It is the conception of punishment as an educative means which has produced the fer- tile idea of conditional freedom. A sentence is pronounced that is appropriate to the misdemeanor that has been commit- ted, but by reason of the circumstances under which it was done, and of the actual mental state of the delinquent, society defers the punishment, on condition that no new infringement makes it necessary to revoke the reprieve. We would go still further, for it is the law of pardon which we want to introduce into our code. Just as a father can rep- rimand his son, indicate to him the punishment which he has drawn upon himself and definitely postpone its application to him, in the feeling that the admonition will be enough, so society has the right to pardon. It is evident that this law is a difficult one to apply. In fairness it would seem as tho a father should not grant kindly pardon to one son when on the same day he has punished another for the same fault. But the difficulties of application ought not to make us throw out a sound principle at the start. Society ought always more clearly to recognize that the one and only end of justice is to prevent evil, and that it must prac- tise a conscientious and expeditious moral orthopedia. The tribunals do not have to settle the question of free will and of true responsibility. However, this question is still put to us physicians to-day in criminal suits. And the physician replies to it by admitting irresponsibility, a relative responsi- bility, or a semi-responsibility ! We take part in these cele- brated suits in these Byzantine discussions. If I were called as an expert before the tribunal I would re- fuse to reply to this inappropriate question, or, rather, I would 76 PSYCHIC TREATMENT reply : You ask me if the individual is responsible ; you put a question of transcendental philosophy to me which I can not decide in a medico-legal report ; the discussion would convince nobody. If you speak of social responsibility, that is not for me to discuss ; you have fixed it in establishing a breach of the laws and the very existence, even, of the crime. As to the moral responsibility, that concerns the delinquent only. We do not have to enter into this personal domain of the conscience. You need the information which I possess in order to ana- lyze the mentality which has determined the crime, to detect the motives that have influenced the guilty person. Very well, I will try to tell you if the patient presents the symptoms of any malady which could have influenced his determinations. I could, perhaps, tell you whether he be an epileptic, and if the deed were committed in one of those mental states that are equivalent to a convulsive crisis; I could tell you whether he were alcoholic, subject to delirium, or a general paralytic; I could enumerate for you the mental and bodily stigmata of de- generacy. All the indications that my medical experience could furnish you would be at your disposal, not to elucidate the hateful question of responsibility, but to establish the expe- diency of means of repression. The accused is plainly an epileptic: he has acted uncon- sciously, while his personality was completely clouded ; put him into a suitable asylum where he will be cared for and at the same time prevented from hurting himself. This one is an alcoholic : place him under special psychiatrical treatment ; put him in an asylum for inebriates or the insane. You have to do with a dangerous and incorrigible criminal, a perfect wild beast: keep him in prison. If he is a chance criminal, try to find out carefully the motives which led him to do the deed; take into account the influences which have affected him, not, I repeat, for the sake of fixing his responsibility (hateful word), but in order to be able to lay one's hands on the most appro- priate measures to change the mentality of the subject, and to suppress even the source of the crime. In one case you will see that the culprit will accept, without any aggravation of his moral deterioration, the punishment which by law and in his OF NERVOUS DISORDERS 77 own mind is considered appropriate to the misdeed. When he is freed he will remember the punishment which was imposed upon him, and, perhaps, will later bless the hand which has chastened him. For another you would, perhaps, dread the demoralizing effect of prison life and of the promiscuous ming- ling with criminals of more vicious tendencies, and you would lighten the punishment. And in certain cases, which are al- ways more numerous, you will grant the delinquent the benefit of conditional freedom or of pardon. Are these views very revolutionary ? I do not think so ; it seems to me that Christians ought first of all to remember the words of their Leader concerning the woman taken in adultery : " He that is without sin among you, let him first cast a stone at her ! " It is the fashion nowadays to decorate public buildings with allegorical frescos. Could we not reproduce this touching scene in our sumptuous palaces of justice? But, perhaps, the sight of it would suggest troublesome reflections to those pres- ent. But we won't dwell upon this point. The jurists in general are opposed to these ideas. They have an instinctive horror of criminal anthropology, and, like all of us, they are the slaves of eternal routine, and of intel- lectual sloth. Thus the aspect of our tribunals undergoes very little change. The prosecuting attorney, exaggerating his rôle of public accuser, tries to blacken the accused, in order to set forth the horror of the crime, and its cunning premeditation ; he insists upon the necessity of making an example, he entreats the jury not to allow themselves to be swayed by considerations of pity. The attorney for the defense, in his turn, works himself up into a fury, and does all he can to whitewash his client. He denies the facts because the adversary did not bring absolute proof of them ; he profits cleverly by technical slips, he imagines various expedients and takes advantage of personal peculiari- ties of the Court, and at last, in a moving voice, he appeals to the clemency and calls forth the tears of his audience. Under the influence of these contrary suggestions the judges or the jury waver. If the orator is not eloquent, they keep their 78 PSYCHIC TREATMENT opinion; they had settled it before he spoke. But words are powerful, and often the victory is to him who best knows how to arouse the sensibility, to stir up indignation, or to melt the heart with a warm breath of pity. Oratorical suggestion is not always founded upon rational persuasion, it is frequently op- posed to it. It is by no means a question of suppressing the tribunals or of reorganizing them altogether. But, impressed by the ne- cessity of combating crime by truly efficacious measures, above all to prevent its recurrence by the improvement of the guilty, judges and advocates ought to seek to establish wrong-doing upon facts, to study the mentality of the delinquent, and to choose the best means of obtaining this end. There ought to be established a certain gradation of punish- ments, but not regulated only according to the gravity of the misdemeanor. The motor impulses should be taken into ac- count, and the state of mind of the subject at the time when the deed took place. There ought to be in its application not a harmful laxity of extenuating circumstances, but a clear choice of the most useful punishment, as much from the ideal point of view of reforming the guilty one as from the very practical view which consists in putting an end to these wrong-doings. The tribunal ought to be a council of wise men of all social classes chosen by the people. It would be right and natural to give the preference to jurists, physicians, and religious or lay teachers, but not to forget the men of good common sense who are found in all social circles, men of experience who have at- tracted the attention of their fellow citizens by the integrity and uprightness of their public and private life. Assured that the accused will no longer be the victim of brutal repression, and that he will no longer profit by unjust indulgence, the advocate and the public accuser will have no right to declare themselves adversaries from the start, and to struggle for the possession of the delinquent. They will no longer represent the attack or the defense in its revolting bru- tality, but they will cooperate to elucidate the difficult problem. Instead of going into every detail, they will find it better to lay the situation before the judges, and will act upon their deliber- OF NERVOUS DISORDERS 79 ations less by their declamations than by persuasion which does not, however, exclude eloquence. There is no place in these discussions for the word " re- sponsibility " in the absolute sense which has been given to it. I have often seen men of the legal profession who recognize that the tribunal ought to constitute, as it were, a family council judging a brother firmly and gently, but they shrink from the difficulties of applying the principle. I do not at all hide the fact that there are difficulties, but they are no greater than those of the application of the actual laws ; the absence of fine shades in our laws determines a summary distribution of justice which we often feel to be bitterly unjust, the more law the more injustice ; summum jus summa injuria. The opposition which results from the feeling of the diffi- culties of the task is not great — time will correct it. What is more disturbing is the mental attitude of certain jurists. I have read somewhere that a professor of penal law had said in a discussion on the limits of penal responsibility : " The crimi- nal is he whose deed arouses our feelings of indignation; the fool is he who inspires our pity ! " Here you have a precise criterion : count the tears of your audience and you will be able to determine exactly the responsibility of the accused ! I must ask pardon for these pages, which may seem to many a useless digression. I feel, on the contrary, that they bear directly upon my subject, not only because the physician is deemed an expert in these matters, but because, as I have tried to show, the same principles ought to direct our conduct, when we sit in judgment upon our fellows, whether it is a question of education or of penal repression. We shall find the same idea in therapeutics. Wherever there is mental deviation, one must have recourse to moral orthopedia. It can vary in its methods, but it ought to be the same in its tendencies. Let us hope that some day the truth taught by anthropology and psychology will triumph over the prejudice and the oppo- sition that have blocked its road. 80 PSYCHIC TREATMENT CHAPTER VII Monistic Conception — Passivity of the Organism — Absence of True Spontaneity — Mechanism of the Reflex — Psychology is Only a Chapter of Biology — Interpolation of Conscious Acts in the Reflex Arc — Mental States Have Always a Material Substratum — The Ideogenic and Somatogenic Origin of Mental States — Reciprocal Influence which the Moral and the Physical Exercise Upon One Another — The Possibility of Acting on these Mental States by Physical Means and by Moral Influence ; Efficacy of the Latter Tho these generalities seemed so necessary in my eyes, I do not, nevertheless, wish to linger over them, and I hasten to return to my subject — that is, to medicine. But it is a medicine of the mind that I have in view, and we shall find ourselves constantly meeting such terms as mind and body, moral and physical, all expressions marking a certain duality of the human being. They all have to do with the comprehension and exami- nation of what becomes of the conceptions of mental pathology when one considers them in the light of monism. In the monistic conception, man is an entity; he is only a functioning organism, reacting under the influence of innu- merable internal or external stimuli. The body is entirely composed of cells. Therefore, no one of these microscopic organisms is capable of spontaneous activity. The cell does not act, it reacts; the total absence of stimuli would mean physiological death. Let us glance, for instance, at the muscular cell, or the ag- gregate of cells that we call the muscles. The striated muscles, during life, are obedient to the stimuli coming from the brain, or to what is commonly called the voluntary influx. They can respond to mechanical, chemical, and electrical stimuli. The smooth muscles of the organs of vegetative life are exempt from the influence of the will, but their contractions are started up in the same way by direct or reflex irritations. OF NERVOUS DISORDERS 81 And the brain itself, this king of our organs, which imperi- ously commands the whole army of muscles, is also passive. The cerebral cell has no more spontaneity than the muscular fiber, but it is more sensitive and delicate ; it is a more expert workman and capable of performing a more varied task. It also acts only under the influence of stimuli, of secret impul- sions, of organic sensations, or of stimuli which are received by our sense organs, those fine antennae which bring us into re- lation with the outside world. Fading vibrations, the results of former stimuli, continue in the form of dreams in sleep which seems to be cerebral death. It is impossible to detect in man or in animals the slightest trace of spontaneity. On waking from a profound sleep, with- out being conscious of dreams, innumerable stimuli spring up and decide the complicated functioning of our organism. The daylight acts upon our retina, noises upon our ears. Imme- diately association of ideas is awakened. It is time to get up, and the idea of duty, of necessity, and rational impulses over- come, more or less easily, our laziness, and our dislike of dis- turbing pur pleasant rest. The impulse being given, nothing stops this cerebral ac- tivity, and until night, when we sink into refreshing sleep, we are under the sway of these divers and innumerable stimuli that vary in one individual or another according to the mentality of the subject. Those who love their ease stay in bed until the hour when their duties must begin; one gives in to this desire without a thought, another can not keep back the moral goadings which are always pricking him on with reproaches. Sometimes they will be strong enough to make him jump out of bed, at other times they will only be sufficient to torment his comfort. In the activity of daytime one person will subordinate all his actions to the selfish tendencies that he owes to ancestral influ- ence and to his education ; the other will obey his moral senti- ments and will think only of performing his duty and of living for others. Both are the slaves of their motor impulses. The idea of determinism only becomes repugnant when we admit that this reaction can take place only under the base impulses 82 PSYCHIC TREATMENT of the senses, in the sense of weakness. As soon as we recog- nize that a feeling of beauty or an ideal aspiration can determine reaction, I no longer see what hinders us from giving up the idea of free will. We see before us only animated beings, men reacting under the influence of their passions, of their philosophic or religious ideas, of their reason, or their faith. The sad thing is not that this necessary and undesirable passivity exists; it is that, in virtue of the mentality of the species, it should manifest itself too often in a wrong way. Strengthen the action of noble motives and this happy passivity will lead to moral improve- ment ; it will approach the ideal toward which we are ever striv- ing without ever being able to reach it. The physiological mechanism by which this reaction is made is physical in its essence, and that is why our mental representations and the determinations which result from them are so often disturbed by an unhealthy condition of the body. This reaction takes place according to the type of the reflex. A reflex has already taken place when the motor reaction of a cell is brought under the influence of an irritant. Before the centrifugal motor phenomenon takes place, it is necessary to admit a centripetal sensory stimulus. We call it a simple medullary reflex when we quickly withdraw an extremity that has been tickled or pricked. It is so unconscious, so passive, that it takes place in natural or artificial sleep, in the frog de- prived of its brain, and in the man whose spinal cord is cut. The gesture by which we, mechanically respond to the bow of another person is also a reflex, an almost unconscious reflex when we bow abstractedly, a more complex reflex when we rapidly take in by the mind's eye the motives that prompted this act of politeness. And always and everywhere, whether it is a case of the action of the most humble organ or of the most exalted work- ings of our mind, it is just the same mechanism : the peripheral stimulus strikes the extremity of the end organs of our sensory nerves, there is a successive transmission in the hierarchies of the centers, a reflex more or less irradiated among the groups of sensory, motor, or thinking cells. OF NERVOUS DISORDERS 83 A compliment tickles our self-esteem and influences our de- terminations. A cutting word excites our wrath and makes our blood boil. The involuntary gesture is associated with our mental reactions. The phenomenon is so material that it is often accessible to physical analysis, the time of reaction in- creasing with the length of the reflex arc. Physiology must undertake the work of pursuing the study of these reactions of the organism, whether they have to do with nutrition and the ordinary reproduction of all living beings, or with the simple psychic facts that are observed in animals, or the marvelous mechanism of the human mind in its highest manifestations. Properly speaking, psychology is, then, only a chapter of physiology 7 , of biology, and we are guilty of a pleonasm when we speak to-day of physiological psychology. The study of psychology is physiology in its essence. Thus, without being the exclusive property of physiologists alone, it requires of those who wish to devote themselves to it a combi- nation of anatomical and physiological knowledge — in a word, biological culture. The literary man, who knows how to observe and to de- scribe, the artist, the philosopher, the priest, can make judicious observations on their personal state of mind, depict the psychic life of individuals or of communities, and contribute for their part to the knowledge of psychic facts ; if they have genius their perspicacity will go beyond that of most specialists, but often their works lack the physiological point of view. Many modern psychologists have felt the necessity for grounding themselves on scientific ideas, and one sees writers interviewing physicians and alienists in order to give their de- scriptions the documentary value of a medical observation. It is possible that these attempts may not always be felici- tous, that they come out in the end with conceptions that are too simplistic. On the other hand, physicians, strong in their scientific equipment, forget that the culture of a science, how- ever wide it may be, is not sufficient to make one master of it. Thus I can not follow the alienist, who, like Toulouse, thinks to monopolize the criticism of his art under the pretext that 84 PSYCHIC TREATMENT only the physician understands anything of psychology! We owe much to writers, to religious thinkers, or rationalists who have analyzed the human soul, and if I dare demand of psycho- logical writers in the future a more precise knowledge of biology, it is with the lively realization that we have no right to snatch the pen out of their hands. The physiologists have made some mistakes in trying to fortify themselves by researches in vivisection and the psychics of physiology. They become too much wrought up over the unfortunate frog and the pain that is suffered in our labora- tories. They have left to others the task of investigating the psychic life, and it is they who have, in a large degree, created the irreconcilability that seems to exist to-day between psy- chology and physiology. It is time that we advanced beyond this false position. The physiologists have studied in animals, generally sleep- ing or deprived of their brains, the reaction of different tissues under the influence of artificial stimuli. Sometimes, stimulat- ing a nerve fiber that has been laid bare, they have noticed dis- tant reactions which have followed the irritation; sometimes, sectioning the nerve trunks, they have interrupted the conti- nuity of the neuron and detected the disorders that followed in consequence. They have thus been able to determine the paths by which the nerve waves travel. Like explorers in new countries, they have pointed out the lay of the land, have noted the natural paths of communication, and have drawn up a sort of map of the region. It is far from being complete, and every day it has to undergo some alterations which often discourage the investigators. But at last we have reached solid ground, and what we do not know to-day, the explorer of to-morrow will teach us. But alongside of this conquered country, where the march, if not easy, is at least assured, there are still vast stretches where quicksands seem to have effaced all traces of our prede- cessors. It is a sandy desert, which has been abandoned to psychologists and philosophers ; they have made bold, but often imaginary, voyages across it, like those story-tellers who write OF NERVOUS DISORDERS 85 novels of adventure without ever having set foot in the coun- try to which they transport their hero. If this vague and uncertain territory of psychology were clearly denned, it would be easy for the physiologist to continue his modest experiments while remaining agnostic in regard to the things of the spirit. He would maliciously let the meta- physician stray away and flounder in the sand, and when invited to take part in the exploration, he would excuse himself by saying : " That is not in my line." But the frontier between physiology, in the limited sense of the word, and psychology is not marked by a line which one can refuse to step over. There are no precise boundaries, but re- ciprocal entanglements. Every moment, while following up physiology, one loses the way and can not find it until he has set foot on psychological ground. As soon as experiment or physiological observation takes a higher animal or man for its object, there is an interpolation of acts of consciousness in the reflex arc. It is still worse when the physician is confronted by a sickly body and phenomena that are complex and foreign to psychopathology. The physi- ology of our laboratories then becomes wholly insufficient; it appears childish in its evident obviousness. Whether he wants to or not, the physician ought to be a psychologist, and in practise he will see that his knowledge of the human heart is more useful than his ability in questions of normal or pathological physiology. That is why, tho always considering the mental states as cerebral, and insisting on the principle of concomitance, I hold to the terms moral and phy- sical, psychic and somatic, psychological and physiological. In these scientific classifications new distinctions have been created. Some spiritualists find themselves constrained to rec- ognize that certain chapters of psychology are open to experi- mentation and calculation, but they assign narrow limits to phy- siological psychology. They admit that there is beyond it a higher psychology, a study of the life of the soul, where one must proceed by introspection, and they seem tempted to snatch this branch from the biologist and hand it over to the theologian. 86 PSYCHIC TREATMENT It seems to me that this is a mistake. Biology is a study of life in all its manifestations, and as such it has the right to ap- proach psychological problems, not only by the path of pre- cision, which is often false in experimentation, but by that of induction and introspection. The law of concomitance demands that there shall always be structural modification of the nerve cell when there is a mental phenomenon ; there is chemical reaction, production of heat and electricity, expenditure of force and fatigue, all physical phe- nomena, which, if one considers the reaction in itself, would seem to interdict all differentiation between the mind and the body. But the distinction is born again and clearly established when one analyzes the stimuli which have determined the re- action, and when one examines whence they come and whither they tend. To be sad is a mental state ; it is, therefore, a psychic mani- festation, but we recognize in it a physical substratum, since every act of consciousness must have a corresponding cerebral state. In its essence the phenomenon is psychophysical, as is everything that takes place in our mentality. But the expres- sion of it is psychic, it is translated by discouraged words and by abnormal volitions. On the other hand, this disposition of mind can be provoked by mental representations and by ideas ; it is, therefore, of ideo- genic origin. It can, on the other hand, be due to the action of a poison affecting the nerve centers ; we then recognize a somatic cause for it. When we say of an individual that he raves, we character- ize at the same time his mental state and the cerebral trouble that is indicated. We perceive at the same time the two sides of the phenomenon, but, sometimes, this raving is the result of unbounded joy, it is psychological in its origin; at other times it is due to alcoholic intoxication, or the absorption of opium, and it is then somatic from the point of view of its cause. To the eyes of most people pain is physical. The thought springs immediately to the cause which is in fact generally ma- terial, and sick people make a great effort to have not only the OF NERVOUS DISORDERS 87 unquestioned reality of their sensation recognized, but also the absolute materiality of the phenomenon. This popular view is too summary. To suffer presupposes two things : on the one hand a material condition of certain groups of nerve cells, a physical phenomenon ; on the other hand a sensation perceived, a process that is psychic in its essence. The existence of pain does not by any means inform us con- cerning its cause. To seek this cause is an ulterior problem whose solution does not always belong to the patient. This same pain, as real as a conscious act, real also as a concomitant cerebral state, may have as its cause a lesion of the tissues, or an irritation attacking the neuron in its continuity ; it may, per- haps, be due only to mental representations, to fixed ideas, or to autosuggestions born in a psychological way. The pain in itself is none the less real on this account. We are in the presence of a phenomenon of a physiological nature, in the strict sense of the word, when the electric irri- tation of the inferior cardiac branch of the sympathetic causes acceleration of the heart beat. We drop right into genuine psychology when an emotion causes the palpitations. Tears can flow by simple mechanical or chemical irritation of the conjunctiva; they accompany our sorrows and our joys. The nervous crisis of the venereal orgasm reacts furiously on all the organs, and the storm can be let loose just as well by representations that are artificially produced as by the slow work of the generative organs. The appetite is normally created by the need which the organism feels of renewing its stock of energy, but it can be stimulated by the sight of an appetizing dish or by a gustatory memory; it can be suppressed, on the contrary, by a moral emotion, or by disgust. It makes little difference whether the disgust be provoked by a sense of smell or by a purely mental representation, due to a verbal suggestion. It is not without reason that one dreads to have at the table a medical " saw- bones " who confides to his neighbors the secrets of the oper- ating room and of the hospital. Vomiting may even occur as the result of such a reaction, which is ideogenic in its origin. It is important, then, to recognize that the same physio- 88 PSYCHIC TREATMENT logical manifestations and the same pathological troubles may have physical or moral causes ; it is self-evident that they may be associated. These ideas ought to be kept in mind in studying the re- ciprocal influence which the physical and the moral are con- stantly exerting, one upon the other. In ordinary speech this word " moral " has a too restricted meaning. One understands by it hardly anything else except the mental characteristics, such as a lively or sad disposition. One tries to brighten the moral tone of an invalid or a person in sorrow. One forgets that a state of bodily ill-health not only modifies our mental condition in the pessimistic or opti- mistic sense, but that it can alter all our cerebral functions and disturb our intellectual and moral life. Organic disorders, whether by known channels or by those that are still mysteries to us, affect our brain ; they involve our reason, distort mental images, and pervert, completely or in part, the delicate mechanism of our psychic life. Intoxicated by alcohol or other poisons, the most pious man will commit extravagances. Under the influence of the meno- pause or senile changes of the brain, the most modest and vir- tuous wife may be the prey of the most strange and libidinous obsessions. An old man of established virtue will fall in love, rather late in life, with a common dancing-girl, and abandon his family. A young man will lose all feeling of affection for his parents and find his love changing to aversion, even when, with such reason as remains intact, he recognizes that nothing has hap- pened to disturb the family relation. Nothing is as sad as this dependence, not only of the intel- lectual being but of the moral personality, in the presence of the lesions which the brain cells momentarily or definitely undergo. Fortunately this structural modification which leads to men- tal trouble does not always result from somatic influences. If in many cases the bondage is complete and inevitable there are others where one meets the beneficent intervention of the mind, of ideas, and of convictions. OF NERVOUS DISORDERS 89 Dualistic spiritualism describes the supremacy of the soul as it is when it escapes from the restraint of the body abandon- ing it in triumphant flight when our mortal remains shall return to dust. The conception is poetic, but does it correspond to the reality? Why does this old man who has had an attack of apoplexy become not only a little petulant, but selfish and bad? Why should he, who has until that time been a good husband and father, now cause his whole family to suffer martyrdom ? Why does he resist the gentle remonstrances of his most intimate friends ? Because his mentality is changed; because his brain is troubled in its thinking part, where those vague perceptions of pleasure and pain, which we call our sentiments, are born. Do not lecture this poor old man who has become vicious on account of cerebral disorganization ; he can not help it, and you ought to submit until his death to the fatal consequences of this incurable diseased condition. Neither must you be severe with the other, the young man who has become vicious by reason of his education and hereditary tendencies. Doubt- less his brain in an autopsy would not present the same thick- ening of the meninges, but if you could detect the minute intercellular disorder you would see that there was a lesion there also — slight, I grant you, but nevertheless real. But whereas in the case of our old man your trouble would be wasted if you described to him the beauties of altruistic sentiments, you could succeed in leading the young man into a better way. Moral ideas act as an antidote as well when the mentality is perverted by a somatic cause as when the disorder results from an idiogenic cause. The prognosis depends more upon the severity of the lesion than upon whether it is due to a physical or psychic evil. In acute alcoholic intoxication the mental state is profoundly changed, but if the intoxication is not complete the individual can regain his self-control. Under the influence of an emotion, as of shame, he is suddenly brought to his senses. An invalid who has become impatient and disagreeable by reason of his pain, even tho his trouble may be distinctly mental 90 PSYCHIC TREATMENT in character, can suddenly control himself when he perceives that he has gone too far and has keenly hurt those who are dear to him. It is because the Soul has recovered its liberty, you will say, Why has she not kept it from the first if she is so all powerful ? No ; if we sometimes succeed in escaping from these mate- rial influences and emerge from a bad disposition it is because there is some change in our brain. This cure may, perhaps, be due to the wholly material phenomenon of disintoxication, as in the case of the drunkard who has slept himself sober and whose moral personality has reappeared; it may, perhaps, be helped by rest, or by the action of therapeutic remedies, but it can also result from an idea, or of a mental representation that has come through the association of ideas. Moral ideas, born of memory or awakened by a kind word, engender in the thinking brain intense work, material activity, and a succession of physicochemical processes. The groups of intoxicated cells that have been changed by a diseased condition are influenced in the general tendency toward repair; their chemistry is modified, and the cellular body returns either rapidly or slowly to its normal state. By his helpful words and his councils as a man of sense the physician can often influence a patient whose mentality is disturbed as well as a so-called sane person who does not know how to resist his impulses. In both cases he changes the mentality of the subject, and, in virtue of the principles of concomitance, this change presupposes modifications of the chemistry of the brain. In the presence of the same mental condition, such as sad- ness, sullenness, irritability, or violence, the physician can vary his methods according to the indications of the moment; he may have recourse to the most varied physical measures, or he may limit himself to the influence of psychotherapy; often he associates them. We find ourselves in the presence of a patient with severe uremic intoxication. He is in a state of continual agitation; he jumps out of bed in spite of the entreaties of his family; he refuses food and medicine, and, if his relatives insist, he OF NERVOUS DISORDERS 91 abandons himself to violence. The physician arrives, and sur- rounds the patient with an atmosphere of calm kindness ; he puts him back into bed without trouble and gets him to drink a glass of milk. The family is delighted at this sudden and magical change, but they are also troubled by it. How is it that the patient can control himself when the physician is there, and can be as gentle as a lamb, whereas when he is alone with those who love him he seems to take a malicious pleasure in giving them trouble ! This is a natural reflection which occurs, and I have often seen the friends around the patient deeply wounded by his contradictory conduct. Yet, on the whole, no reproach should be put upon the poor patient. His brain is under the influence of toxins resulting from insufficient purification of the blood ; his bodily functions are badly performed, and his mentality is disturbed. His men- tal vision is not clear; he is vicious by reason of intoxication, and is not only disobedient and wilful but provoking. It is, indeed, intentionally, and often with a cruel delight and a sar- donic smile upon his lips, that he jumps out of bed the moment that the physician has turned his back. Why is it that the physician who is immediately recalled can succeed again? Why does his calming influence become more lasting up to the point of suppressing all such accidents ? Because he is a stranger; because, in the eyes of the patient, he holds a certain moral authority, and because he knows how to act with gentle persuasion. The relatives, on the contrary, no longer have this sug- gestive influence. The patient knows their qualities, but also their faults; he takes their advice in the wrong way; on the other hand, the people around him lack the necessary calmness. Madame is weak and over-emotional, and she forces the patient into bed brusquely and with a sort of dull impatience. Thus the patient refuses to obey. He gains control over himself when it is the gentle hand of the physician which leads him. The same effect, less rapid but often more durable, may be obtained by material treatment, by milk diet, by drinking a 92 PSYCHIC TREATMENT great deal of fluid to cleanse the system, by the diuretic action of digitalis and diuretin. The physician often has to choose, in a few minutes, at the patient's bedside, between these measures: physical treatment, or medicaments which can only effect the mentality through the medium of the body, and pure psychotherapy which, in acting psychically, is no less efficacious. And we must never forget that in the two cases there is a mental change and a cerebral change. It is by the influence of the physical on the moral that your intoxicated patient is rebellious, impatient, and vicious. You can bring him back to reason by treating his body only, but you can employ the action of the moral over the physical and reach the same result — namely, a favorable change of the pathological mentality. Sadness is often the result of a fatigued condition. Then repose would be the physical remedy; it may be enough, but it is useful to combine moral influence with it ; it may even be all that is necessary if it is impossible to take any rest. The same state of mind may result from moral troubles. Then you are disarmed from the physical point of view, but you have to aid you in your rôle of physician the powerful support which your sympathy for the patient gives you, your constant altru- ism, and, I do not hesitate to say, these are the more efficacious. OF NERVOUS DISORDERS 93 CHAPTER VIII Slavery of the Mind in the Presence of Certain Diseases : General Paralysis, Meningitidis, Epilepsies, Intoxications — Possibility of Escape from It by Education of the Moral Ego — Pinel ; Curative Action of the Work of Logical Reflection — The Difficulty of Psy- chotherapy in the Insanities ; its Efficacy in the Psychoneuroses — Necessity of Clear Ideas on the Genesis of these Diseases — The Importance of Psychotherapy in Every Province of Medicine The idea that the moral acts on the physical is by no means new, and physicians seem to be in a good position to prove the value of this influence. But their constant preoccupation with the human animal often blinds them, and makes them put the inverse influence in the foreground. I have seen physicians who did not believe in the power of education stop short at a sort of narrow determinism which would render the individual a slave to the innate deterioration of his mentality and to the variations to which it might be subjected under the influence of disease. True determinism admits this original deterioration, but it recognizes the ever-powerful action of ideas, and of intellec- tual and moral culture. It is often possible for us, thanks to the influence of the moral on the physical, to escape from the clutches of the dis- temper, combat the effects of heredity, and struggle against disease. There are diseases in which what we call the soul is in the most complete bondage to the body ; that is to say, the cerebral deterioration is so profound that it can not be corrected by psychic influence or by the curative action of ideas. The most striking example is that of general paresis. This terrible affection first of all attacks the cortical layer of the brain. The lesion extending through the entire cortex produces 94 PSYCHIC TREATMENT not only motor and sensory paralysis, tremors, difficulties with speech or writing, and pupillary symptoms; it also gives rise to auditory, visual, and gustatory hallucinations ; it creates con- ditions of neurasthenia, melancholia, hypochondria, and acute mania. Often the insanity takes the form of delusions of grandeur; it terminates in dementia, in psychic and bodily collapse. Fortunately the clouding of the intellect prevents the patient from appreciating his fall, but sometimes lucidity persists, and the unfortunate being witnesses, with keen despair, the annihilation of his mental self. The situation is the same in some other affections that con- cern the higher portion of the brain, in the meningitides and epilepsies, where it is by no means rare to see the convulsive attacks replaced by what has been called " psychic equivalents " of a melancholic or maniacal nature, with criminal impulsions, and delusions of persecution. The stubbornness and ferocious selfishness of certain epilep- tics is not, as one often thinks, a fault corrigible by education ; it is a symptom of cerebral trouble. I have sometimes been skeptical concerning the fatality of this pathological egoism, and I have exhausted the resources of psychotherapy to awaken in these patients those sentiments of altruism that are the most instinctive, such as are confined to the friends they love the most. I might have spared myself the trouble; they listened to me, they understood me intellectually, but a moment later the patient surrendered himself to the control of the " morbus sacer " — docile slave of his diseased brain. But even in these cerebral maladies due to microscopic organic lesions,- one recognizes the influence of the mind. This does not mean, alas ! that psychotherapy can check their ad- vance, but it is easy to see that the trouble develops along the line of the mentality, innate or acquired. The previous faults of character manifest themselves. One finds in the deluded person the selfishness which withered his character in his healthy state and the tendency to fits of rage; those who were gentle and weak-minded will tend toward the melancholic and hypochondriacal forms. The stronger minds, those who were brave and accustomed to control their impulses, will endure the OF NERVOUS DISORDERS 95 anguish and will succumb only to the deadliest strokes. The horrible slavery which makes our mentality depend upon our brain shows itself also in the insanities, strictly so called, in the melancholias, the manias, and the various constitutional and acquired dementias, and in all the mental diseases where there must be a profound structural deterioration, altho it may elude our methods of investigation. The various intoxications, when they reach a certain degree, act in the same fatal way upon the brain, and the psychic part of us succumbs completely to the influence of chloroform, ether, or alcohol. But here one already sees the dawn of the psychic influence. The effect of these poisons will vary according to the mental state of the subject. He will fall asleep more easily if he is confident and tranquil ; he will resist, on the other hand, if he is agitated. In the diseases of the mind we can also, to a certain degree, prevent ourselves from working for our own cure. There is, in the healthy culture of the intellectual and moral ego, a prophylactic and curative remedy against mental de- rangement. I do not exaggerate this influence in any degree. Who would pretend that he owes his mental integrity to the moral efforts he has made, or who would dare to accuse the unfortunate psychopaths of having neglected his moral education ? But this preservative virtue is implied in the curative effi- cacy of the remedy. I have often seen psychopaths take hold of themselves, break the bonds which held them, and regain, step by step, the lost ground, not only under the influence of time, nor by measures of bodily hygiene, nor by the natural process of the disease which is essentially cyclical, but by the clear sight of the end to be obtained and the roads which lead to it. The psychological analysis of one's self, when it is well directed and made with a voluntary optimism and with the sym- pathetic aid of the physician, who enjoys not, to be sure, the perfection of psychic health — that is impossible — but an aver- age state of mental well-being, is useful in diseases of the mind. 96 PSYCHIC TREATMENT It is more efficacious than all the physical means by which efforts are made to give them health. Many alienists seem to have forgotten this moral influence, this power of ideas. And, nevertheless, these truths are not a thing of to-day. They were expressed with much heat by Pinel, the illustrious physician and man of worth, who, at Bicêtre and at la Salpêtrière, struck the chains from the insane. Before Pinel's day physical treatment was looked upon as the only thing of value. It is his glory to have first introduced psychotherapy in the treatment of mental diseases. " It is necessary," said he, " to isolate the patient from his family and friends, to take him away from all those whose imprudent affection may keep him in a state of perpetual agitation, or even aggravate the danger; in other words, it is necessary to change the moral atmosphere in which the insane person is to live. But, above all, the physician ought to be interested in the inner life of the patient, to trace out the origin, often psy- chic, of his condition, to await the favorable moment to inter- vene, and to find out with care what tract in his mental life remains intact, and to remember it in order to gain control of it, and to point out to the patient himself, sometimes by a very simple reasoning, sometimes by concrete facts, the chimerical nature of the ideas which possess him ; in some places one can employ a ruse or resort to a clever subterfuge to gain his con- fidence, enter a little into his illusion, in order to cure him of it by degrees. Sometimes it is necessary to break down the resistance that he offers, and to have recourse to physical force ; but even then one should avoid useless pain. The physician and guardians ought to appear to the insane person as persons endowed not only with a material, but, above all, with a moral superiority. It is by these means that they will succeed in arousing in him the further effort of reflection." Capo dTstria, x from whom we borrow this exposition, holds that this moral treatment, extolled by Pinel, does not offer any- thing very original. He reproaches Pinel for having believed that the insane person can be rendered docile by an effort of 1 Revue Scientifique, No. 20, 20 Mai, 1899. OF NERVOUS DISORDERS 97 logical reflection. " It was difficult to Pinel," said he, " to avoid this error of psychological analysis ; he did not have the discoveries of modern psychological physicians in the domain of suggestion to illumine his judgment." " If the insane person," he adds, " gives in to the strong will of the physician it is more often on account of his own mental weakness, and because the prestige acquired by those who care for him is in direct ratio to his psychological des- titution." Nevertheless, with all deference to modern hypnotizers and suggestors, it is Pinel who is right. Without doubt, the influ- ence which we have over our fellows it not always rational ; we often overwhelm them by the prestige which they recognize in us, and they yield the more easily to our injunctions according as they are more mentally weak. We have the right and the duty sometimes to profit by this situation if it is to cure, or to comfort, or to relieve them; but our influence is much more powerful and durable if the patient has partially preserved his good sense and can work toward his own cure along the lines of logical reflection. To make a patient obey and, for this end, to take advantage of his psychological misery in order to domi- nate him, is by no means to cure him. To attain this cure there is need of time, hygienic measures, and a devoted and unremitting psychotherapy which utilizes for the uplifting of the patient every ray of reason that remains to him. This situ- ation is less rare than people imagine. Many of the insane are more or less monomaniacs, and preserve their logic and a great deal of good sense which ought to be intelligently utilized. The end to be obtained is not to make the patient stupidly sug- gestible ; it is, on the contrary, to raise him up and to reestab- lish him as master of himself. What we have quoted forms a fine passage in Pinel's " Treatise on Mental Alienation " ( Traité sur l'aliénation men- tale). It is the work of a man of genius, who gave to the whole science of psychiatry a new direction, and was a century ahead of his contemporaries. And, indeed, Capo dTstria rec- ognized this when he concluded with these words : " For the glory of Pinel, it is enough to recall the fact that he was the 98 PSYCHIC TREATMENT promulgator of a new principle, and, in the language of modern terminology, was the first to introduce psychotherapy for the treatment of mental diseases." If the rebellious character of many of the insanities often renders this treatment of the mind futile, psychotherapy is, on the other hand, most powerful when it has to do with the psychoses of lesser degree which are called "neurasthenia," " hysteria," " hypochondria," and " want of mental balance." The reason, we shall see, is not intact in these comparatively mild states, but the patient is much more accessible to moral influence than the insane. Persuasion by logical methods is a magic wand in such cases. All that Pinel has said of the insane is true, but it is a hundred times more true with regard to the psychoneuroses. The mental trouble here seems so slight that the public refuses to see the bond which connects such nervousness with the insanities. The physicians themselves do not always recognize the close relationship. On the other hand, I have shown how slightly these psychopathies differ from the normal condition, so slightly that one often asks one's self if they are really diseases. In the presence of an abnormal mentality it is not wise to have recourse solely to physical or medicinal measures, to the douche (which is often used at random in psychiatry), to various narcotics (which have taken the place of the old- fashioned hellebore), or to brutal constraint, whether physical or moral. We must come back to the educative influence. It is an easy measure to employ ; it produces quick and last- ing effects beyond all expectation. When the patient has be- come master of himself, he will continue his education after his cure. This method will establish his moral attitude, and will preclude such relapses as might be occasioned by emer- gencies in his psychical or physical life. In order to proceed with method in this, the only rational line of therapeutics, one must clearly understand the nature of nervousness, and the causes which give birth to it or keep it alive. One must analyze the symptoms, go back to their ori- gin, distinguish those which depend more or less upon the body, OF NERVOUS DISORDERS 99 and recognize the purely psychical character of others. Only clear views on this subject can give a physician assurance, establish his moral prestige in the eyes of his patients, and give him the power to cure them. How far we are from this ideal ! There is still an incredi- ble incoherence of ideas among physicians. On this point the patients, or their near friends, can often see more clearly than their iEsculapius, and they laugh in their sleeves at the treat- ments which he makes the patients undergo. I see many young women who present a perfect picture of the various symptoms of nervousness — dyspeptic troubles, general weakness, divers pains, insomnias, and phobias. A quarter of an hour of conversation is enough to recognize the abnormal mentality of one of these subjects and her exagger- ated impressionability, which one can often trace to her earliest infancy. It is easy to detect her lack of logic and the mental genesis of a host of autosuggestions which rule her. This natu- ral nervousness, after being manifested in childhood by noc- turnal terrors and by a sickly sentimentality, is aggravated at the period of puberty — that time when, by influences which are still mysterious, the mentality of young girls often undergoes a complete change. If married, the wife does not find in the conjugal union the happiness of which she had dreamed; if she remains an old maid, she suffers in silence sharp regrets which arise from the feeling of having missed something in life. It is not always real misfortune which troubles the mind of the patient, and, as a consequence, disturb his physical health ; it is the trifling nothings, the petty annoyances, and the pin-pricks of life. A little philosophy, which is easy to incul- cate, would be enough to reestablish mental equilibrium and to suppress functional disorders. But no one ever thinks of that. A celebrated gynecologist, who, however, seems to still be wearing the blinders of the young specialist, discovers an hypertrophy of the uterus, a slight ulceration of the cervix, a little inflammation of the uterus. Behold the cause of all the trouble ! The patient may insist in vain on the moral causes of her nervousness; the operator will not let himself be thwarted; he amputates and 100 PSYCHIC TREATMENT cauterizes, performs curettages of the uterus, and expects to see the nervous symptoms disappear. He deludes himself into thinking that he has obeyed the addage: the cause being re- moved the effect will be done away with (sublata causa tollitur effectus). But, to his great astonishment, nothing of the sort occurs. ) The patient falls into the hands of a specialist in the treat- ment of diseases of the stomach. This latter is a serious physician who is not content with a superficial examination. Just think; he syphons the stomach, analyzes the gastric juice, injects air into the organ, and notes its limits with a blue pencil. With an expert hand he produces succussion, and then declares : " You have a dilatation of the stomach, with hypo- acidity; you will never be well as long as the motility and the chemistry of your stomach are impaired ! " He prescribes a bandage to support the sagging stomach, and a dry diet, and notes carefully what foods should be avoided. He makes such a long list of them that he would have lost less time in noting those that were permitted. The patient grows thinner and thinner, and becomes weak. She suffers, it is true, a little less with her stomach because she does not demand much of this organ, but she is more nervous than ever. Electricity is the next thing on the program. The patient sits down on the insulated stool of the static machine. The buzzing, the static brush, the disruptive discharges are all going to act upon her neurons as upon the " coherer " of wireless telegraphy. And it is with a feeling of profound content that the neurologist runs his electrode up and down over the surface of the body, without allowing himself to be at all discon- certed by the smile — which is oh ! so skeptical — of the patient. Frankly of the two it is difficult to decide which is subject to the greater vagary ! I have not overdrawn this picture. Molière would have enjoyed himself hugely to-day. I understand these thera- peutic vagaries up to a certain point. I have shown that it is the fruit of our medical education, and we have a great deal of trouble in getting out of the beaten track. But it is time OF NERVOUS DISORDERS 101 for this to change. And, while continuing to use for the good of our patients the physical and medicinal measures at our dis- posal, we must recognize the influence of the mind; we must analyze this action, and learn to take advantage of this helpful measure, which has been too long neglected. The specialist in neurology and psychiatry is not the only one who ought to sharpen his faculties of psychological obser- vation and resolutely enter the path of psychotherapy. The surgeon ought to know these psychopathic conditions if he wants to avoid unfortunate complications. Have we not seen them remove the appendix in patients seized with hysterical attacks of pain, open the abdomen of a confirmed hypochon- driac to prove to him that he did not have cancer, perform a gastroenterostomy in a nervous dyspeptic, and do an ovari- otomy on an hysterical patient ? They even perform operations to cure neurasthenic patients whose mental condition is dis- turbed by morbid introspection. And in the numerous specialties whose existence is justified by the fact that they call for a certain operative routine, those of the oculist, the rhinologist, and laryngologist, would it not be better to operate and cauterize and scrape less, and to rec- ognize, even in those ills which seem so localized, the enormous influence of unhealthy autosuggestion and the power of mental representations, and to remember those diathetic conditions which often render local therapy illusive. In conclusion, the practitioner of small towns and country places, who must give to everybody at least the first help, ought to know all things, and can not afford to ignore this medicine of the mind. He knows his patients better than the city man does his patrons. He is acquainted with their ordinary mental condition and their hereditary influences ; he almost lives with them. Naturally he lacks the time to deliver long psycho- thérapie conversations to them, but if he is a psychologist he will have no trouble in distinguishing what originates in the mind and what is only physical. He does not need to be a wizard to perceive that his visit does more good than his medicines. He will see that all the good that he does lies in showing a warm sympathy and in giv- 102 PSYCHIC TREATMENT ing counsels of healthy philosophy. In every land there appear brochures and articles in the papers, showing us that these truths are in the air, and that a new avenue is opening for medicine. Medical teaching of the twentieth century, without neg- lecting the conquests of the preceding one, will give a larger and larger place to rational psychotherapy. It will renounce the puerilities of hypnotism and suggestion in order to arrive at the education of the mind. With men, as with dolls, the heads are the most fragile; they are in constant need of repairs. There is a great deal to do in this field, and the physician who loves his art will under- take the work joyfully. OF NERVOUS DISORDERS 103 CHAPTER IX Psychic Symptoms of Nervousness — Psychic Origin of Functional Troubles — Every Organic Disease Has Its Counterpart in Nervous- ness — The Characteristic Thing of Nervous Patients is Not Their Pains but Their Mentality — Mental Stigmata: Suggestibility, Fatigability — Exaggerated Sensibility and Emotivity — Suggestion and Persua- sion — Suggestibility in a Normal State What symptoms, then, of nervousness, to use the most general term, are psychic in their nature, and justify my oft- repeated statements that psychic treatment is necessary for psychic ills? If one considers the very essence of the phenomenon of thought every distinction between the spirit and the body dis- appears, for it is understood that where there is a working of the mind there is cerebral vibration. But these two movements, so intimately associated that they have become one, may be incited along the lines which I have called physiological or somatic through the medium of the blood or of the sen- sory nerves; they may also give rise, by the psychological path, to mental representations which come to be interpo- lated into the reflex arc. In short, the ultimate expression of the reaction, whether the latter be somatic or psychic in origin, may itself be psychic, in that it is expressed by thoughts and by more or less conscious volitions, whether or not it arises as a bodily manifestation through the channel of the emotions. It is in this double point of view of the origin and end of the reaction that the distinction between the moral and the physical exists. The neurasthenic who complains chiefly of habitual sad- ness and chronic ennui, who feels growing within him a morbid sense of timidity and discouragement and an increasing misan- thropy, will not be astonished if you tell him that these are psychic manifestations, and he will understand how much it 104 PSYCHIC TREATMENT bears upon the treatment to find out whether this sadness is caused by a diseased condition of the body or is induced by moral suffering. Any patient who does not sleep regards his condition as physical, but he will not be slow to recognize the psychic origin of insomnia when you point out to him that what hinders him from sleeping are often distressing memories and worries over the future or the apprehension of insomnia. It is not rare to have patients state that a headache has resulted from an emo- tion, therefore from an idea, and if the headache proves to them that some material process has taken place in their brain they will willingly admit that this trouble has psychological causes, and that it arises from another source than that of the headache succeeding the abuse of alcohol or the inhalation of nitrite of amyl. But when you tell a nervous dyspeptic that his digestive troubles are psychic in their origin, or a paraplegic hysterical patient that his affection is psychic, or a hypochondriac that his pain is also psychic, you will often be met by a smile of incredulity. Your patient will feel that you abuse this word psychic. You will often detect in him some slight sign of temper, such as a sudden coloring ; he will be vexed, believing that you do not understand him and that you think his ills imaginary. Yet, nevertheless, this is wholly psychic; clinical analysis proves it more and more. Nervous symptoms do not ordi- narily arise in somatic ways under the influence of purely physical irritations, as do the unconscious nervous reflexes. We find everywhere the interpolation of these so-called psychic phenomena; everywhere the idea comes in, often creating the functional trouble out of whole cloth, and sometimes, if it has originally occurred under the influence of an accidental cause, of a traumatism (for example, some previous bodily illness or intoxication), the idea will keep it alive and nurse it along forever. The symptoms of psychoneuroses are legion. Nearly all the clinical syndromes which characterize bodily diseases have their counterpart in nervousness. OF NERVOUS DISORDERS 105 Alongside of angina pectoris there is the false nervous angina; one can detect the greater number of cardiopathie symptoms in nervous cardiac troubles. More often, from the point of view of objective symptoms, such as the condition of the tongue, the nature of the gastric juice, and disturbances of the motility of the stomach, nervous dyspepsia does not differ in any way from dyspepsia of organic origin. There are states of nervous anorexia, with vomiting, emaciation, and fever, which are diagnosed as meningitis; there are astasia-abasias, which give the idea of a cerebellar neoplasm ; there are visceral neuralgias, which lead one to believe that there is tuberculous peritonitis, and often occasion the wholly futile intervention of the surgeon. We often even mistake articular neuroses and treat them as local affections, when the painful sensations are purely ideogenic. I should never get to the end if I were to enumerate all the errors of diagnosis which result from the imperfect knowledge of normal and morbid psychology ; it would necessitate rewrit- ing the dictionary of pathology to suit the neurologist and psychiatrist. That which characterizes the psychoneuroses is not the various symptoms, the innumerable functional troubles, resembling those of organic diseases or the distressing sensa- tions that the patient may experience ; it is his state of mind, his mentality. We all of us get tired ; but we know what it is, and we are assured beforehand that a little rest is all that we need. The neurasthenic, however, is frightened; he takes his weariness with great concern, and makes it last longer by the attention that he pays to himself. The human mechanism is so compli- cated that hardly a day goes by without our noticing some creaking in the works. Sometimes it is gastric trouble, or a slight pain or palpitation of the heart, or a transient neuralgia. Full of confidence in our comparative health, we keep right on, making light of these little ailments. The hypochondriac, on the other hand, is fascinated by the idea of sickness ; it becomes a fixed idea with him. We all have to endure annoyances, but we try to rise above them and to keep our good humor. The neurasthenic and the 106 PSYCHIC TREATMENT hysterical person looks at everything with a magnifying glass ; the slightest event becomes a catastrophe. Men generally fear death, but its specter is not always before their eyes. Often they forget it in a natural careless- ness ; often they look upon it as an inevitable but remote event ; they are not inordinately frightened by it. The nervously afflicted, on the contrary, are often possessed by this idea of final dissolution, and suffer for years in terror of the specter death. The real causes of the psychoneuroses are not in the acci- dental happenings that have provoked acute symptoms, such as traumatism, illness, functional disorder, emotion, and fatigue. These provocative agents act on us every day, but they lead to no permanent trouble in our health, because we resist them with a more or less voluntary indifference. The nervous patient, on the other hand, reacts by virtue of his abnormal mentality. One finds in him the characteristic mental stigmata. These stigmata are innumerable, if one considers the va- rious forms of nervousness and the association of ideas which give rise to the phobias and foster fatal autosuggestions. Each reacts mentally in its own way. But it is possible to trace these various manifestations to some peculiarities that are mentally primordial. For I notice, first of all, in nervous patients of all kinds, a marked exagger- ation of the inherent faults of human nature. Nervous patients are suggestible, susceptible to fatigue, sensitive, and emotional to a degree. One might say, paradoxically speaking, that they are not sick. Not one of them presents any new phenomenon that is unknown in a healthy man; there is no intervention of special pathogenic agents, as in the infectious diseases, and no alter- ation of the organs determining functional troubles. In such patients there is only an exaggeration of normal reactions that is expressed, not only by the intensity of the phenomena and the facility with which they occur, but also by deviation from the primitive type of the reaction, as shown in unexpected vagaries. I hold strongly to this conception, which makes me examine the normal mentality for the general outline OF NERVOUS DISORDERS 107 of the peculiarities of our patient. It is fertile in suggestions that interpret the functional disorders; it gives us the most efficient aid in therapeutic treatment. An exaggerated suggestibility is one of the characteristic stigmata. It is common to neurasthenics and hysterical per- sons ; it is found in its most pronounced forms among degener- ate and unbalanced people; it plays an important rôle in the genesis of various insanities. Some find that this word " suggestion " is abused to-day ; others, on the contrary, give it so general a sense that they do not hesitate to say there is nothing but suggestion in the world, we live continually under the sway of suggestions. The only thing to do is to come to an understanding on the value of the term. In its primitive acceptation, to suggest means to make something enter the mind, and as, in short, our whole mental life is carried on by ideas that have penetrated our under- standing, we could say that suggestibility is the highest quality of the human mind and the absolute condition of all intellectual or moral perfection. But the dictionaries teach us that the words " suggest " and " suggestion " are used with a sinister meaning. We do not speak of suggestion when, by honest persuasion and a logical setting forth of good reasons, we have influenced the conviction of our neighbor, when we have led him to a determination which he will have no cause to regret. Suggestion does not come into the domain of exact sciences or mathematics ; here one does not suggest, one proves. Suggestion implies that good faith has been more or less imposed upon ; that, by using the subterfuges of a facile logic, one has gotten around the subject, and led him to views which he would not have admitted if he had followed the counsels of reason and his own good sense. To suggest a last will and testament implies the use of artifice or dishonest insinuation in its making. One speaks again of suggestion when our conduct is determined by some mental caprice. Marmontel has written : " It was ambition which suggested to him this rash measure." 108 PSYCHIC TREATMENT However, in the last few years the word has taken unto itself a less perplexing acceptation. One says of a book which makes one think : " It was a very suggestive work." One could also say : " It was goodness which suggested to that man such an act of devotion." Thus understood, the word " suggestibility " indicates that faculty of mind which permits any one to be persuaded, by no matter what process, of the existence of a fact, of the justice of an idea, or of the excellence of a determination. But there is interest in differentiating and even contrasting the terms " persuasion " and " suggestion." Bechterew has cleverly noted the difference in saying that suggestion enters into the understanding by the back stairs, while logical persuasion knocks at the front door. If the healthy man knew enough to obey only pure reason or just sentiments, and if only the sick man were weak enough to become the plaything of illusions, the distinction would be easy and one could say : " The men of sound mind let them- selves be persuaded; only sick people are suggestible." But in speaking thus the king of creation would manifest quite too good an opinion of himself. In spite of civilization, in spite of the enormous efforts of science, we are still very weak, and we all suffer from a most lamentable suggestibility in the most unfavorable sense of the word. As soon as we leave the firm ground of mathematical rea- soning we experience an incredible difficulty in resisting sug- gestion. When we formulate an opinion, or when we allow ourselves to be persuaded, it is very rare that logic is the only cause. Affection, esteem, the fear which those who are talk- ing to us inspire in us surreptitiously prepare the paths of our understanding, and our reason is often taken in a trap. Our sensibility intervenes, our feelings and our secret desires mingle with the cold conception of reason, and, without being con- scious of it, we are led into error. We let ourselves be capti- vated by a superficial eloquence, by the charm of language, and we yield at the first beck of attraction. In all domains of thought, even when we believe that we are enjoying the most complete independence of mind, we are submitting to the OF NERVOUS DISORDERS 109 yoke of ancient ideas which we have repudiated in our logical moments, but which have left their ineffaceable stamp upon our mind. In politics and in philosophy we are almost incapable of effacing the influence of education. Even when there is estab- lished between certain men a community of aspiration and ideas, one may still find in each one of them a mentality that is Catholic, Protestant, Jewish, etc., and it would be well if that which thus binds us to the family, to the country, or to the race, were always a healthy sympathy of which reason could approve. But how often do we find lack of judgment at the base of this dogmatism! How often do we feel that we are obeying in a spirit of contradiction and prejudice when we ought to follow reason! Fatigue, sickness, and age render more difficult the mental processes constituting reflection, and we give ourselves up, as captives bound hand and foot, to suggestive influences which, at another time, we should have rejected. Thus, mental states are contagious in the narrow circle of the family, in a social class, and in a people. Just as in the middle ages there arose epidemics of hysteria, we also have proof of collective mental troubles in different coun- tries. It seems sometimes that a country, in part or as a whole, has lost its judgment; that a wind of folly has blown over the land. During a certain time it is this country or that race which seems to show symptoms of pathological suggesti- bility ; to-morrow the strong, who were yesterday proclaiming with a disdainful smile the lack of balance in their neighbor, will in their turn lose their heads, thus illustrating the weakness of the human mind. A man pretends to be an intelligent being, and fears noth- ing so much as a reproach of folly. Nevertheless, if he wants frankly to examine his conscience he will find that it is difficult always to see clearly, and that daily he is the vfctim of un- reasonable suggestions. Our judgment is subject to continual eclipses. Sometimes this suspension of reasonable control is volun- tary, because in a certain event we do not feel the need of pro- tecting ourselves by consistent reasonableness. It is in this 110 PSYCHIC TREATMENT way that we easily become the victims of illusions when we allow ourselves to be guided by a single sense. If we see, in a place where we might naturally suppose it possible for a cat to be, a gray mass about the size of that animal, we do not often take the trouble to test this perception, and we affirm the existence of the cat with a conviction which would draw other persons into our error. Under the sway of distraction, we often arrive at such summary judgments. It is thus by the mechanism of a hasty conclusion that we allow ourselves to be led into sensorial illusions. Everybody can find in his own memory examples of this suggestibility, and see that he could have escaped the illusion if he had kept better control of his attention and brought his reason into play. Error by autosuggestion is greatly facilitated by the fact that a mental representation is already a sensation. The prin- ciple of concomitance demands it; there is a cerebral state corresponding to every idea, whether it be born by virtue of a true sensorial impression, or whether it be a purely mental representation, the same sensation ought to correspond to the same cerebral condition. When the testimony of a sense Is too quickly accepted a suggested sensation accompanies it; it encourages us in our error, and fixes it. The wine which we pour out of a dusky bottle bearing the label of a celebrated vineyard always seems better than it really is ; a connoisseur among smokers will let his judgment be influenced if he recognizes the make of the cigar that he is smoking. Certain people experience a sensation of touching oil and the smell of petroleum in taking up a lamp which has never held any. The majority of people feel various sensa- tions in touching the pole of an electric apparatus when it fur- nishes neither currents nor discharges. At my advice, Dr. Schnyder, of Bern, has studied this suggestibility in my patients. Instructed to note the condition of tactile and painful sensibility, to experiment upon the cuta- neous and tendinous reflexes, he ended with a so-called test of electric sensibility. The posts of a hand rheostat which contained no source of electricity were fastened to two wires terminated by rings which were put upon the fingers of the OF NERVOUS DISORDERS 111 patients. Avoiding all other suggestion, the observer begged the subjects on whom he was experimenting to tell him simply just what they felt. The illusion of an electric current which one could make stronger or weaker was strengthened by ma- nipulating the rheostat, by sliding it onto the various contact buttons. More than two-thirds of the patients complained of various sensations of pricking, warmth, or burning, and took pleasure in describing them minutely. Hack Tuke * has quoted many of these illusions born of a hasty conclusion and strengthened by the autosuggestion giving rise to the sensation. I will quote some personal examples. It has happened to me several times, on entering the homes of my patients, that I perceived heat radiating from a stove which I believed to be lighted. This hasty conclusion was suggested by the coolness of the air which made me suppose that they would have lighted it. I was quite astonished when I proved by touching it that I was deceived. One of my friends went into the barber's in winter, and put his chilled feet on one of those ornamented brass rests with which every one is familiar. Immediately he felt a gentle warmth steal over his feet, and said to himself : " Now that is a practical idea; you can put your feet up and get them warmed at the same time ! " He could not believe his senses when the absence of all heating apparatus was proved to him. Question eye-witnesses concerning the details of some event at which they were present, and you will see that they have all seen differently because they have all looked through the spectacles of their understanding, distorted by preconceived opinions and autosuggestions. Judges and lawyers know how little credence they often can give to the declarations of even disinterested witnesses. It would be of interest to collect examples of these illusions and to analyze their origin with care, but the task is not as easy as it seems. Even in such scientific analysis we have to avoid autosuggestions, as in the analysis of dreams which we try to remember, and which we embellish at the same time. 1 Le corps et Vesprit, trad. Parent, : 112 PSYCHIC TREATMENT The fairy of autosuggestion slips in everywhere with her magic wand. In the scientific domain we always try to make experiments under careful control. We have recourse to the testimony of the different senses, we submit the facts to the control of several people, we repeat the experiment, and, even in hypotheses, we try to be logical. Thus, people whose scientific intellect is developed are less naturally suggestible. But even in this domain it is impossible to avoid error. I am not speaking now of those scholars who, tho often illustrious, are sometimes slightly unbalanced, who can show superior logic in mathematical work, and yet who let themselves be caught in the net of the gross superstitions of spiritualism and telepathy. Even those who escape these weaknesses are subject to error, and often confound their desire with realities and their sugges- tions for facts. There is no human brain capable of completely resisting illusions and of allowing reason supreme control. If autosuggestion is capable of leading us into error con- cerning even the existence of a fact, and capable of giving rise to a purely suggested sensation, it is still more powerful when we enter the world of internal sensations, sentiments, or convic- tions. Here we no longer have the question of the possibility of control by our five senses ; we have to do with vague sensa- tions and mental views which have no objective reality. The sensations of hunger, thirst, and the needs of mictu- rition and defecation, the sexual appetites, and the general feeling of being well or of being sick occur still more easily under the influence of a purely mental representation than under the localized sensations of touch, pain, heat, or cold, or the perceptions which are so exact as those of sight, hearing, taste, or smell. To those who doubt the influence of an idea on the sensations and on the workings of the various physio- logical apparatus, I recommend a few moments' reflection on the facts of the sexual life in old age and in dreams. Listen to Montaigne : " And burning youth flames up, so impatient in his ardor that while asleep he gratifies his amorous desires in dreams." This suggestibility becomes extreme when our convictions OF NERVOUS DISORDERS 113 seek to become established in strange and unknown realms. Ignorance renders us more suggestible, but, whatever our cul- ture may be, we do not escape this failing, for our intelligence is always fragmentary, we are always ignorant of something. Modern science has a slightly exaggerated predilection for the experimental method, and suggestibility to-day is studied by scientific processes. 1 One makes experiments by avoiding all voluntary suggestions and letting the subject fall naturally into the trap without pushing him into it. The dominant idea which has encouraged the error is then analyzed, and thus is detected the mechanism of suggestion. In this way one suc- ceeds, without hypnosis, in fixing the coefficient of suggesti- bility of the individuals under experiment, in determining their reaction under moral influence, and their tendencies to imitation. These interesting researches ought to be followed up more completely. They teach us to know the defects of our minds, and, in consequence, to overcome them. We can hold ourselves back better if we see the declivity down which we are on the point of sliding. But, without awaiting the results of psychological labors, and limiting ourselves to the analysis of our mentality by intro- spection, we can recognize the following truths : Human suggestibility is incommensurable. It enters into every act of life, colors all our sensations with the most varied tints, leads our judgment astray, and creates those continual illusions against which we have so much trouble to defend ourselves, even when we exert all the strength of our reason. The power of an idea is such that, not only does it distort a preexisting sensation or an idea, but it can create the sensa- tion in its entirety. There is no difference for the individual who feels it between a pain provoked by a peripheral sensation and that which results from a simple mental representation — between the real pain and the imaginary pain. More often the patient does not possess any criterion by which to decide the question, and the physician himself is frequently puzzled over 1 La suggestibilité . Par Alfred Binet. Paris, 1900. 114 PSYCHIC TREATMENT its settlement. He can, nevertheless, come to some conclusion by making an analysis of the mental genesis of the representa- tion — in showing, for example, the inadequacy of the trau- matism which has provoked the pain and the autosuggestions which are aroused in the mind of the patient. The demonstra- tion is at last completed by the rapid disappearance of the trouble under the influence of some suggestion. Then the sick man himself sees clearly and recognizes the illusion of which he has been the victim often for long years. There are patients who have themselves reached this same conclusion; there are those who at the first consultation tell you : " The moment I am told about any sickness of which I am afraid I immediately feel the symptoms.'"' The physician ought to remember that if exact sensations habitually transmitted by our five senses can be born through autosuggestion, the mental representation acts still more powerfully on those vaguer sensations which have been termed cravings for action or inaction, functional sensa- tions, ccenesthesias, emotional sensations, and sensations of pain and of pleasure. 1 I have shown that one must distinguish between suggestion, which acts by the circuitous paths of insinuation, and persua- sion, which honestly appeals to the reason of the subject. However useful the final result may be, the mental mechanism has been distorted by the suggestion, and the determination is more or less abnormal. What is more absurd than to fall asleep by daylight, when one has no need of sleep, by stupidly yielding to the command of the hyponotizer ? Must not one be credulous in order to have one's arms held up in the air or to keep one's eyelids shut because a magician has told you that you can not lower your arms and that you can not raise your eyelids? It cruelly abuses the mental weakness of the subject to make such suggestions to him. Thus, suggestibility shows in general a lack of judgment, and I have heard hypnotizers tell me : " We shall easil get control of this man ; his brain is debilitated by alcohol ; he ïvill offer less resistance to suggestion." 1 La sensations internes. Pa* Beaunis. Felix Alcan, Paris, 18 OF NERVOUS DISORDERS 115 It is also to hasty conclusions, a sign of mental weakness, that we owe the majority of our illusions. But the rule is by no means general, and even when the subject is led by suggestion to a reaction that is absurd in its essence it might have also followed that he could have reached the same point by rational ways. Here is a workman afflicted with rheumatism which has resisted all treatment. He is discouraged, and has only one desire — to be cured and to get back to his work. They propose hypnotism to him. " I am willing," replies the patient ; " I don't know what it is, but my comrades have told me that it does good ! " And he falls asleep the moment that the doctor has pronounced the sacramental words : " Sleep, sleep, sleep ! " Well, here we have a man of good sense who is absolutely reasonable in his incredible suggestibility! He has no reason to suppose that they are deceiving him, nor has he any reason to doubt the encouraging reports of his comrades. Ignorant of medical things, and making no pretense to have any knowl- edge of them, he is in a normal state of mind, in the favor- able psychological position to accept suggestion. His error is excusable. It is the same way with the young soldier whose arm was suddenly paralyzed by a suggestion. He had entered the hos- pital for treatment for angina, and the professor who examined him suddenly flung this question at him : " How long is it since your right arm was paralyzed?" Astonished, he timidly protested, and asserted that there was nothing the matter with his arm. But the professor did not lose his assurance, and, addressing himself to the assem- blage of students, said : " You see, gentlemen, here is a young man who has a psychic paralysis of the right arm, and, as is generally the case in this curious disease, the subject has no knowledge of his helplessness. But, nevertheless, you will admit his arm is inert, and when I let go of it after having raised it up it falls like a dead weight ! " And the arm re- mained paralyzed until the day when an opposite suggestion restored the use of it to the young man. " What a stupid that young soldier must have been ! " doubt- 116 PSYCHIC TREATMENT ers will say. Not at all. His mental state was quite natural. Doubtless he could have thought : " Why, no ; my arm was not paralyzed when I came; I saluted with my right hand; I did such and such work before coming." But he is a timid young peasant who has lost his nerve in the presence of these wise gentlemen. He knew nothing of suggestion, either as a word or as a thing ; he could not grasp the idea of a practical joke. The only thing left for him was to admit that these wise men knew more about it than he did ; he believed it, and he was paralyzed. The error was absurd, but it is inevitable in the psychological conditions of the experi- ment. Credulity is here the fruit of ignorance and emotions which are quite pardonable. It is none the less true that suggestibility is only a defect, and that the individual who wishes to preserve the integrity of his good sense and to assure his mental health ought at every turn to appeal to his reason and keep watch over his mentality. He will perhaps lose the slight advantage of some day being able to be cured by hypnotic methods, but he will gain the ability to escape from his numerous false autosuggestions ; for we know that it is better to prevent diseases than to cure them. A critical spirit is by far the best preservative against the numerous functional troubles which are called forth by means of mental representations. It is our moral stamina which gives us strength to resist these debilitating influences. The labors of hypnotizing physicians show unmistakably the incredible suggestibility of the human being. In the hypnotic state we can turn a person into a veritable automaton, make him accept suggestions of changed identity, double his person- ality at will, suggest to him that he is king, make him shrink back in fright before an imaginary lion. It is not even neces- sary to resort to hypnosis in order to obtain this passive obe- dience; a verbal suggestion is enough in the waking state. Hypnosis is nothing in itself; it is itself suggested in the waking state, and more frequently than not there is no use in making the patient pass into this state of semisleep or artificial somnambulism. These facts are true; it is easy to be convinced of it in OF NERVOUS DISORDERS 117 following the experiments of expert physicians in this matter. I am also astonished to note how many physicians are still in the greatest ignorance on these subjects. Many have not taken the trouble to see or to think, and still believe that hypnosis is a pathological condition provoked by somatic processes acting directly by means of the nerves or the blood-vessels. They forget that hypnosis is only suggestion, and that the most com- plete automatism may be obtained without preliminary sleep. The demonstrations of physicians are, perhaps, not so deci- sive because they obtain the most curious results only on such subjects as have already been hypnotized, on hysterical patients, or on the poor alcoholic wretches which we hesitate to recog- nize as our fellows from the mental point of view. The experience of wandering hypnotizers and suggesters are often more instructive. They clearly show the passivity of the human being in the presence of heterosuggestions, the rapidity with which these latter become autosuggestions, and the facility with which the mental representation is transformed into sensation and action. From this point of view I have found of particular interest the demonstrations of a German, M. Krause, who styles himself " Suggestor," and has given séances in different towns of Germany and Switzerland. He made his début some eighteen years ago as a hypnotist; since then, probably to escape the intervention of the police, he has limited himself to verbal suggestion in the waking state. After having a very plain talk, in which he defines " sug- gestion " to his audience, he begins his experiments on a dozen young people who are on the stage. He speaks to one of them, and tells him to throw his head far back, to open his mouth wide, and to shut his eyes. Then in a low voice he insinuates : " You can not open your eyes ! " The subject opens them without any difficulty, shuts his mouth, and resumes a normal position ; the experimenter sends him back into the hall as a refractory subject. The same performance occurs with the second subject, who also opens his eyes, smiling. The third obeys no better, and 118 PSYCHIC TREATMENT the public begins to believe that the experiments are not going to succeed. But M. Krause is not at all disturbed, and says, calmly: " Yes, you succeeded in opening your eyes very well, but did you not have some trouble? It wasn't quite as easy as in the normal state ? " " Yes, I did have a little difficulty," stammers the young man, doubting himself. From this moment on nearly all the subjects in the experi- ments are under the charm, and proceed to obey the most absurd suggestions. The fourth subject the experimenter handles without gloves. He places him on a chair and bends him over backward, he throws his head sharply back, opens his jaws, closes his eyes with his hand; then, in a tone of conviction, he says to him: " You can no longer open your eyes, nor close your mouth, nor even pronounce your own name. Try ; you can not do it ! " And lo! and behold, our astounded young man stays in this position, exposed to the ridicule of the public. How is he going to be delivered ? That is very simple. M. Krause orders a neighbor to put his hand on the breast of the subject and to count " One, two, three ! " And, sure enough, at three the patient under suggestion opens his eyes and behaves like any normal person. Why this passive obedience? Because the subject has be- lieved what was. told him. Frightened, disturbed, and plunged into a state of expectant anxiety, he has admitted the sugges- tion, and the representation of powerlessness has been followed by a true lack of power. After this first success has been obtained M. Krause pro- ceeds rapidly and surely. He leans one of his subjects against a column and suggests to him that he can not get away from it, and now the man makes vain efforts to free himself. Cata- lepsy of the arms and legs is immediately obtained in the majority of subjects in the waking condition. Soon the assur- ance of the experimenter knows no bounds. Without verbally suggesting a preliminary sleep, he makes his subjects accept the most absurd suggestions. He doubles their personality, OF NERVOUS DISORDERS 119 transforms them into other persons, sends them to purloin watches from the audience, then, plunging the subject back into the representation of his moral personality, he allows us to see the astonishment of these young men who are completely bewildered by the actions which they have committed in this secondary state. This secondary state, observed often without suggestion from outer sources in hysterical people, is purely imaginary ; it is only the result of an accepted suggestion ; it is due to nothing but the incredible credulity of the subject. Now, ninety per cent, of people are suggestible on this point, and theoretically we are all so as long as we are ignorant of the subject. Nobody is absolutely refractory to suggestion. All depends on the psychological moment in which we find our- selves, and the personality of the suggester counts but slightly in the success. It is enough for him to be a psychologist and to have audacity. Education ought to undertake the task of delivering us from such imbecile suggestibility. Reason is the sieve which stops unhealthy suggestions, and allows only those to pass which lead us in the way of truth. 120 PSYCHIC TREATMENT CHAPTER X Fatigability — Muscular Fatigue; Its Location — Mental Troubles Con- nected with Muscular Fatigue; Tissiér, Féré — Psychic Element of Fatigue — Conviction of Fatigue — Cerebral Fatigue — Ergographic Curves — True Fatigue and Ordinary Fatigue — Dynamogeny and Dynamophany — Importance of these Ideas to the Physician and the Educator I have indicated among the mental stigmata of the neu- roses exaggerated fatigability. The word, I believe, is not in the dictionary, but it deserves a place there because it expresses exactly what it means. This fatigability is only diseased when it is exaggerated, for every organ that function- ates will tire. Activity in no matter what domain supposes the use of materials, combustion, disorganization of the cell, and accumulation of the products of combustion. Work ought to be followed by rest, which allows the cell to recuperate its used-up strength and to recover its normal structure. The phenomenon of fatigue is more complex than it seems at first glance, and we are still in ignorance of its real nature and of its seat. I raise a weight a great many times, and immediately I notice muscular fatigue; the functional activity diminishes, and I raise it less and less high ; at last I can no longer move it. What has happened ? Is it my brain that has grown tired of giving orders ; is it the changed nerve which will no longer transmit the voluntary influx to the muscles? Is it the per- ipheral organs or the terminal plates of the muscles that do not respond completely to the transmitted stimulus ? Could it be, after all, that moral incentives are lacking to determine reactions which we call voluntary? Is the fatigue localized, or does it occur everywhere at once throughout the whole neuro-muscular apparatus? This last hypothesis is the more OF NERVOUS DISORDERS 121 probable, since all work leads to fatigue and all the organs act simultaneously. Physiologists have studied muscular fatigue in the isolated muscle, and they have proved that the catabolism of the mus- cle causes glycogen, carbonic acid, lactic acid, and other dele- terious substances to accumulate in the muscle. Muscular fatigue may thus be considered as an intoxica- tion by the products of combustion. An injection of salt so- lution into the principal artery of a muscle spent by repeated electrical stimuli is enough, for the moment, to overcome the exhaustion and to restore to the muscle its power of con- traction. On the other hand, a muscle that no longer responds to cerebral influences can still react under the influence of an electric current; this would make us think that it is the brain which has suffered the deleterious influence. But one also meets the inverse phenomena: the muscle no longer obeys the stimulus of the current, but contracts again under the influence of the will or of the reflex. Thus, attempts to localize fatigue are foiled, and it becomes probable that the changes which hinder the activity are at the same time central and peripheral, and that fatigue pervades the whole neuron. There is an evident analogy between the organ that tires and the electric battery that polarizes. The potential of the latter is lowered not by the use of the zinc that is still present, but chiefly by the accumulation on the electrodes of the prod- ucts of polarization, and in order to raise the electromotive force it is only necessary to eliminate by a slight shock, a breath, the bubbles of hydrogen which cover the carbon. In the same way muscular fatigue may be dissipated by the elimination of the toxins produced by the very act of functioning of the muscle. Regarding the other organs, and particularly the brain, we are not so well informed as in the case of the muscle. We have no exact ideas concerning the toxins that accumulate in its tis- sue during cerebral activity, or of the effects produced by this fatigue, or of the constancy of the physical or mental symptoms which accompany it. 122 PSYCHIC TREATMENT But, as has been noticed by Mosso, 1 the brain is eminently more sensitive than the muscle. There is greater need than in the latter for the constant flow of blood, destined not only to bring to it elements of nutrition and combustion, but chiefly to eliminate functional wastes and deleterious toxins. The muscle can still contract normally when its local circulation is sup- pressed by an Esmarch bandage. The loss of consciousness occurs, on the other hand, in a few seconds, if by pressing on the carotids one hinders the flow of blood to the brain, even tho the large vessels and the vertebrals escape the compression. This is the process which, they say, the Japanese employ to produce narcosis in their painful operations. The most apparent phenomenon of all fatigue is the grad- ual diminution of functional power and the difficulty of con- tinuing work already begun. But it is accompanied by other phenomena, such as pain, contracture, and extreme lassitude. If one persists, the fatigue extends over the whole body, pro- ducing breathlessness, palpitation of the heart, and perspira- tion; and in the end is followed by headache and mental troubles with distinct pessimistic and melancholy tendencies. Tissié x has studied fatigue following the violent exercises of bicyclists. " Enthusiasm for exercise, pushed to the point of excessive fatigue, in well-developed, healthy, robust men, by a long course of bicycling, or walking, or by prolonged and rhythmical muscular effort, provokes a sort of transient psy- chosis. These psychoses have the same exterior manifesta- tions as the pathological psychoses of subjects who are morbid, hysterical, degenerate, or insane, etc. Such, for example, is the ennui to which they are all subject, and which always comes on, even in the most cheerful and best balanced, the moment they give themselves up to any intense enthusiasm." Féré 1 also pointed out the mental troubles of fatigue, and insisted on the analogies which they present to the mental troubles of neurasthenia. 1 A. Mosso. La Fatica, quinta edizione. Milano, 1892. 3 Ph.Tissé. "I/entrainement intensif à bicyclette." Revue Scientifique, October, 1894. 'I