b o NERVOUS STATES THEIR NATURE AND CAUSES Nervous States THEIR NATURE AND CAUSES DR. PAUL DUBOIS Professor of Neuropathology at the University of Berne ; Author of "TAe Psychic Treatment of Nervous Disorders"; "TAe Influence of the Mind on the Body " ; " Self-Control and How to Secure Jt " ; Etc. AUTHORIZED TRANSLATION By EDWARD G. RICHARDS FUNK & WAGNALLS COMPANY NEW YORK 1910 SANTA BARBARA. CALIF X. CONTENTS Chapter Page I. THE NEW NAME FOR AN OLD DIS- EASE 7 II. PSYCHONEUROSES 22 III. OVERWORK AND FATIGUE AS CAUSES 32 IV. EDUCATION OF THE MIND NECES- SARY 48 V. THE LINK BETWEEN MIND AND BODY . - 63 VI. THE MIND THE BEST WEAPON IN THE COMBAT 76 VII. CONSTANT AUTOSUGGESTIONS AS CAUSES AND REMEDIES ... 95 [5] Nervous States, Their Nature and Causes 1 THE NEW NAME FOR AN OLD DISEASE NEURASTHENIA is not a new disease entirely created by the conditions of modern life. The Neu- rasthenic States have always existed; they have Deen observed and described since the time of Hippocrates and Galen. Moreover, they must have been frequent, since Plato excluded from his Republic "those men, always occupied in dreaming of imaginary sufferings, having lost all aptitude for the arts and the sciences, incapable of understand- 1 Communication presented at the Tenth French Congress of Medicine, Geneva, September, 1908. [7] NERVOUS STATES ing and meditating." It is certainly not the insane hypochondriac, the actual alien, that these words describe; it is just our "neurasthenic" keeping his place in the world while at the same time being more or less incapable of fulfilling his task. Observe how well Plato saw the "hypochondriac" nature of the preoccupations of these subjects, and the "psychasthenia" which prevents them from understanding and medi- tating, which creates their inability to adapt themselves to life. If the new drawer, opened and la- beled "neurasthenia" by the American neurologist, Beard, has been filled so quickly and overflows, it is because at first the badly-classed contents of many pigeon-holes have been put into it, and also that, like children urged to keep order, we have crammed into it every- thing that we did not understand. Beard gave this name "neurasthenia," [8] THEIR NATURE AND CAUSES which has been so successful, to a col- lection of well-known symptoms, but whose description has to be sought for in numerous publications upon hypo- chondria, melancholia, hysteria, and in treatises upon mental alienation. By studying the bibliography of the authors who have endeavored to sum- marize the question, I find indicated, in about 70 per cent, of cases, publica- tions concerning hypochondriac affec- tions; in about 12 per cent., those which treat of hysteria, and more rarely of melancholia. In other works one ob- serves the terms vaporous affections, nervous troubles, etc. Very soon one sees the appellation nervous weakness appear, the synonym of neurasthenia; the original expression, "supplicium neuricum" (G. Cheyne, 1723-1730), indicates in a picturesque manner all these species of nervous and psychic affections, and the author designates [9] NERVOUS STATES his "morbid entity" by the name "Eng- lish malady," as Beard later called it "American nervousness." After about the year 1860 the word hypochondria disappears little by little from the literature; it is replaced by that of "nervous state," and already in many writings one sees the idea of "moral treatment" formulated. Altho the physicians of the eight- eenth century and the commencement of the nineteenth more of psycholo- gists and philosophers than we, in spite of the sharp wind of materialism which blew at that epoch were able to recog- nize the influence of mental representa- tions and the emotions, in our day somatogenic conceptions are returned to. The clinic endeavors to become more precise; it relies upon the con- quests of anatomy and of pathological physiology, and so they speak of anemia, of nervous and chloro-anemic affec- [10] THEIR NATURE AND CAUSES tions. Finally, localized neuroses are invented, limited to one organ: neu- rosis of the heart, of the stomach, of the intestine, of the larynx, of the genital organs, etc. The attempt is made to characterize in one word this polymorphic affection under the names irritable weakness, general neuralgia, spinal irritation, cerebro-cardiac neu- ropathy, etc. Since 1877, some years after Beard's publication, Moebius adopted the term "neurasthenia," and consecrated it by the authority of his name. The appella- tion passed finally into the classical works of all countries, and to-day the word is in every mouth. What was the merit of Beard ? Was it to have created a new word, to have thus circumscribed a morbid entity un- known before him? No. He had that characteristic peculiar to the Anglo- Saxons of not attaching himself too [11] NERVOUS STATES servilely to his predecessors, of ob- serving for himself among his patients, and of describing simply the clinical pictures that defiled before his eyes. It is that independence which has given a particular mark to his work. He thus attracted the attention of observers to these little-known affections, and if the word neurasthenia has become dan- gerously common, it has had the ad- vantage of provoking new studies and discussions which are always useful, even when sometimes a little confused. In such complex questions one must resign oneself to passing through a period of disorder in order to come to clear ideas. It makes us think; and of that, in my opinion, we have good need. But if we owe a just tribute of hom- age to the American author, we can not swear by the words of the master and straight away adopt his views. It is for us to pursue the analysis, to bring [12] THEIR NATURE AND CAUSES the question always more to the point; it is sufficiently difficult to demand the work of several generations. It is therefore necessary to criticize the work of Beard, to make precise the clinical picture which he sketched. First of all, I regret that he has described the symptoms of the trouble commencing at the crown of the head and ending at the feet, so that one learns to know the sensibility of the scalp, the pupillary changes, the varia- tions of the expression of the eyes, the congestion of the conjunctiva, etc., be- fore the capital stigmata of the feeling of exhaustion, the depression, the pusil- lanimity, and the want of self-mastery. He would have done well to put in the front rank these great neur- asthenic symptoms, and to have rele- gated to the second grade the multiple physiological symptoms which one ob- serves in the nervous states. It would [13] NERVOUS STATES have been necessary to seek carefully the origin of these symptoms, to indi- cate those which were caused by an emotional state, conscious or subcon- scious, those which arise through the mental representations, by the imagina- tion, and those which are the result of fatigue, physical, intellectual, and emo- tional. Such an arrangement would have rendered the work more interest- ing to read, and would have enabled us better to grasp the nature of this affec- tion, so frequent, not only in America, but everywhere, and as much in the country as in the towns. The term "neurasthenia" which he proposed has the advantage of being short and convenient, and of expressing the asthenic characteristic. It has made its tour of the world, and will remain in our nomenclature just as that of "hysteria," against which objections still more justifiable have been raised [14] THEIR NATURE AND CAUSES without a more suitable appellation being able to be substituted for it. But I must point out two drawbacks to the word neurasthenia; it makes the supposition that it is the nerves that are not equal to their task, as if it were a matter simply of a physico-chemical alteration, as yet unknown, of the nerv- ous elements. This conception has taken possession of the minds of med- ical men; it is current among the pub- lic, and it has caused the psychological influences to be forgotten the con- siderable part which the mind plays in the genesis of these states. I have dealt at length with these considera- tions in all my publications; it is this that has made me say, without wish- ing to propose a change of nomen- clature, that neurasthenia is in fact a psychasthenia; it is also the reason that I have replaced the term neuroses by that of psychoneuroses. [15] NERVOUS STATES Used as a substantive, in the singu- lar, the word "neurasthenia" encour- ages the idea of a "morbid entity," of a very limited affection which it is easy to separate distinctly from other more grave psychoneuroses. It is against this tendency that I would first of all protest. No doubt the clinician has the very natural desire to classify the affections which he ob- serves, to define the symptoms which strictly belong to them, and, even when they do not succeed, these attempts con- tribute to the widening and the deepen- ing of our knowledge. In the domain of the organic dis- eases, pathological anatomy, chemistry, and microbiology bring us new facts. Analysis defines more and more the morbid entity; it allows a positive sep- aration to be established between neigh- boring and often confounded affections. Future studies may further modify [16] THEIR NATURE AND CAUSES these classifications, but there remains to us a collection of well-established data. The situation is quite different when one considers the psychoses and psy- choneuroses. When one has thorough- ly grasped the intervention of the mind in the genesis of psychological and physiological troubles, one perceives that analysis often unites what one wishes to separate, and one experiences a growing difficulty in circumscribing the affection that one studies. Far from defining itself, the morbid entity seems to dissolve in our hands. Is it simply to the insufficiency of our knowledge that one must attribute these difficulties? No. They are due to more profound causes. The morbid entity, in the proper sense of the word, can only be created in lesional diseases, when pathological anatomy lets one put the finger upon the primitive alteration, [17] NERVOUS STATES and recognize the causes, multiple per- haps, but univocal. The type of these diseases is the microbic affection. Whatever may be the results of more profound study of the biology of the microorganisms, scarlatina will remain separate from measles, typhoid-fever will not be confounded with cholera; altho they have different causes traumatic, microbic, or chemical the inflammations of the organs will keep their clinical and anatomo-pathological autonomy. But already in the domain of ma- terial medicine the receptivity in regard to pathogenic agents varies according to the constitution, according to the physical and even psychic nature of the subjects; and so it is difficult to state the causes precisely to say where health ends and disease begins. Here, also, one is often obliged to recognize "Natura non facit saltus." [18] THEIR NATURE AND CAUSES As soon as one enters upon the ter- ritory where the mental element inter- venes, one finds the impossibility of cir- cumscribing true "morbid entities." According to the primitive character of the subject, his mentality, innate or ac- quired, the same etiological factors, physical or psychic, will produce differ- ent symptoms. Still, further, we will observe in the same subject disparate symptoms belonging to neighboring psychoneuroses, mixtures which in no way recall microbic associations, or the pure and simple coexistence of two or- ganic affections. P. Janet has pointed out this fact very clearly from the first pages of his studies upon the Neuroses and Fixt Ideas. Analyzing with sub- tilty the condition of his patient, M., and indicating the analogy between the "crises of dejection" and the "hyster- ical symptoms," he adds: "It will per- haps be said that we have here an [19] NERVOUS STATES aboulic and psychasthenic patient who has hysteria in addition. That is not our opinion: diseases are not entities which enter into a subject and range themselves one beside the other; that all forms but a single disease. It is the same alienation, the same mental perturbation, which may present it- self under different but neighboring forms." In certain studies in which I am en- gaged I shall not hesitate to apply these data to the mental diseases properly so called to the confirmed psychoses. They are also bound together by a nar- rower relationship than has hitherto been admitted. They arise from a great number of physical and moral causes, acting upon subjects not only vaguely "predisposed," but abnormal already in their primitive mentality, in their man- ner of reacting to the various stimuli, and the same primitive mental defect [20] THEIR NATURE AND CAUSES can induce very different psychopathic forms. Is that to say that it is necessary to suppress the appellations hitherto em- ployed, to give up classification? Do I propose to put everything in the same bag to confound everything as the authors who have interpreted me badly seem to suggest? Not at all, and I am anxious to make myself clear upon this point. [21] NERVOUS STATES II PSYCHONEUROSES I HAVE proposed to apply the term psychoneuroses to the class of the neuroses in order to indicate at once the influence of the states of mind in the genesis, the development, and the cure of these troubles. I in no way wish to resuscitate the "nervosisme" of Bouchut considered as a morbid entity, and I have employed that word only as a convenient abbreviation for "psy- choneuroses." In short, if I have insisted upon the bond which unites the different psy- choneuroses, it is in order that the truth may be grasped that In the domain of the affections in which the psychic factor intervenes in a preponderating manner, we can only outline clinical [22] THEIR NATURE AND CAUSES pictures; passing from the white of ideal mental health to the black of in- sanity, we can only circumscribe the degenerate by the conception of group- ings of neighboring shades. We also find observers contracting or enlarging these groups. Those who are skilful in psychological analysis tend to efface the boundaries, to seize the analogies which the symptoms present, to disclose the common mentality which engenders them. The pure clinicians, preoccupied with their didactic task, wish, on the other hand, to be definite, to create au- tonomous psychoneuroses. But there are not two logics that of the psy- chologist and man of science, and that of the clinician and practitioner. For every medical man who thinks, there are two preoccupations which are in no way opposed: one is to analyze the state of his patients without becom- ing alarmed if his observations lead [23] NERVOUS STATES him to regard the conditions from a higher position, from a point of view which renders the boundaries faint; that is the theory which authorizes the boldest hypotheses: the other preoccu- pation is of the practical order; it con- cerns itself with the diagnosis, prog- nosis, and treatment. Here we can not base our judgment upon views of the totality and let our patient too dis- tinctly catch sight of the link which unites the simple neurasthenias to the psychasthenias and these latter to the insanities proper. That would be not only cruel but false, for in presence of a concrete case we can almost always marshal the symptoms so as to form a sufficiently precise clinical picture, tran- quilize the patient anxious to know the name of his disease, determine the prognosis of the affection, and institute the physical or psychic treatment which is suitable in the particular form of [24] THEIR NATURE AND CAUSES psychoneurosis. In theory, we analyze and synthetize turn about, without hav- ing in view a special concrete case; in practise, we no longer are concerned with diseases we treat patients. As often said, it is necessary to individualize, and it is with the diag- nosis that this precise work begins, whose object is, in fact, the restoration of the patient. And without losing sight of the various hypotheses the views of the totality we are here obliged to speak distinctly, to, so to speak, divide the questions, by using the usual nomenclature, even altho we may have good reasons to doubt its ex- actitude. I shall even go further and say that it is necessary to define more and more, to classify the symptoms, discover those which belong to such and such a clinical form, and establish an always clearer nomenclature, which might be adopted by all clinicians. It [25] NERVOUS STATES matters little that the proposed term be very exact, expresses at once the patho- geny of the affection, or resumes hap- pily the whole symptomatology; it is sufficient that it be short, euphonic enough to enter into current medical language, and that it so labels, I can not too often repeat it, not a morbid entity, but a clinical picture, recogni- zable by all, even tho we do not all see absolutely from the same points the limits which restrict it, and even tho deeper study of a case raises new doubts and new problems. Among the psychoneuroses, it seems to me that we must now distinguish : 1. Neurasthenia; 2. Psychasthenia; 3. Hysteria; lastly encroaching upon the domain of mental alienation; 4. Hypochondria; and 5. Melancholia in their slighter forms, which as yet do [26] THEIR NATURE AND CAUSES not render the intervention of the alien- ist necessary. It is a question of de- gree, and that is why these limits can not be absolute and fixt. The alienists themselves continually reform their classifications, and if their studies de- fine at one point and seem to create a new morbid entity the dream of every classifier in another direction they efface boundaries already traced, and reopen the whole question. If there is in psychiatry a clinical picture with very distinct outlines, it is assuredly that of simple melancholia. An attempt has been made to deny its existence and to include it in circular insanity pre- senting alternately melancholia and mania. There would then no longer be a disease meriting the name of simple mania, and yet what is there more typical than the mental state of a pa- tient in maniacal delirium? In certain modern treatises of psychiatry one [27] NERVOUS STATES looks in vain for the disease called hypochondria; now it is only hypo- chondriac symptoms supervening in the course of various psychopathies that are spoken of. Cat at any is also losing the character of a morbid entity which Kahlbaum gave to it, and catatonic states only are referred to, intermin- gling in certain subjects with the ordi- nary symptoms of their psychopathy. For my part, I have for these various reasons a certain repugnance to the use of the words neurasthenia, hysteria, etc., which easily give rise to the too precise idea of the morbid entity, and I prefer to distinguish among the psy- chopathic states, which, beside the or- ganic affections of the nervous system, form the clientele of the modern neu- rologist : 1. The neurasthenic states; 2. The psychasthenic states; 3. The hysterical states; [28] THEIR NATURE AND CAUSES 4. The hypochondriac states; 5. The melancholic states. In all these patients, under the in- fluence of causes at once physical and moral, the trouble may be aggravated and take a delirious insane form. Con- finement is often then necessary, and we give place to the alienist. We ex- pose ourselves to his criticisms, for he sometimes smiles with pity on learning of our attempts at psychotherapy; he even accuses us of having aggravated the state of the patient. He is right when, owing to want of clinical ex- perience, we do not recognize general paralysis under the deceptive mask of neurasthenia, or when we neglect to confine a proved melancholic in time to protect him from suicide. But our psychiatrist is wrong when he believes that confinement suffices, and that it is perfectly useless to apply a psycholog- ical treatment, a rational psychotherapy, [29] NERVOUS STATES to these various psychopathies. He laughs best who laughs last. Let us note particularly that these various psychoneuroses, these psycho- pathic states, very characteristic with- out being narrowly limited, may arise upon the basis of organic affections of the nervous system, such as epilepsy, general paralysis, the encephalopathies, the myelopathies, the toxic neurites, and may appear in imbeciles, degen- erates with corporal and mental stig- mata, and complicate acute or chronic diseases of most of the organs. Let us, finally, very specially insist upon the morbid relationships, the frequent combination uniting neuras- thenia to psychasthenia and to hysteria, upon the almost constant intervention of the hypochondriac and melancholic states, and the insensible progress to paranoic and delirious forms. Not that this transformation is frequent or ne- [30] THEIR NATURE AND CAUSES cessitated by the evolution of the dis- ease, that there is therefore great danger of the neurasthenic or the psy- chasthenic becoming insane; no, these various conditions are sufficiently typ- ical to be recognized and diagnosed, and for one to be able to establish a probable prognosis. One may express oneself as if one had to do with differ- ent diseases, but one must not forget that we are dealing with psychopaths, and that one can not always stop one- self at will upon the slippery path of the troubles of the mind. [31] NERVOUS STATES III OVERWORK AND FATIGUE AS CAUSES ET us return to our subject; that is to say, to the "neurasthenic states/' It is, indeed, the most frequent dis- ease at the present day, the most spoken of. There is no medical man who does not see his consulting-room filled with these patients, more or less incapable of living their life normally; he often has too many, and if the patient, with good right, complains of the torment which his nerves impose upon him, the medical man is sometimes tempted to say "But you do not think of my burden!" By the fault of Beard himself, who put the phobias and other obsessions [32] THEIR NATURE AND CAUSES among the symptoms of his "neur- asthenia," and of the moderns who have abused the word to incorporate all kinds of morbid forms, neurasthenia has become, as has been said, the "giant of neuropathology." Far from wishing to confuse and to further enlarge this giant, I wish, on the contrary, to diminish it. Reduced to its characteristic symp- toms, neurasthenia forms a clinical picture quite as definite as hysteria, and more circumscribed and more stable than the modern psychasthenia. The neurasthenic states are charac- terized, above all, by subjective symp- toms, among which predominate the sensations of fatigue, of exhaustion, and incapacity in the physical, intel- lectual, and moral domain. One ob- serves in these patients psychic depres- sion, hypochondriac preoccupations, and a melancholic disposition. Lastly, by [33] NERVOUS STATES the complaints of the patient, as well as objective examination, we find a series of functional symptoms: cephalalgia, rachialgia, insomnia, gastro-intestinal dyspepsia, palpitation, and vasomotor disorders, innumerable troubles of the functioning of the sense organs, real and not imaginary amyosthenia, etc. At the commencement, or in the forms which remain slight, the neu- rasthenic resembles a fatigued person, and all the authors have pointed out among the etiological factors those which, by the physical or psychic path, can lessen the force of resistance of the nervous system : overwork physical, intellectual, or emotional; infectious diseases influenza, typhoid-fever, ma- laria, syphilis, and tuberculosis; con- stitutional dyscrasias gout, diabetes and arterio-sclerosis ; pregnancy, lacta- tion, senility, alcoholism, etc. Trau- matism has been recognized as a cause [34] THEIR NATURE AND CAUSES of true neurasthenia by the physical and psychic shock which accompanies it. Reduced to these dimensions, neu- rasthenia might be termed chronic ac- cumulated fatigue. This is why it has been said that we are all more or less neurasthenic at times when we have been overworked. This is so true, that the neurasthenic state can be provoked, so to speak, experimentally by fatigue in subjects otherwise normal. Tissie expresses himself as follows: "Vio- lent exercise, pushed to extreme fa- tigue, in highly trained men, healthy and robust, by a bicycle race, walking, or any prolonged and rhythmic muscu- lar work, provokes experimental and transitory psychoses. These psychoses have the same outward manifestations as the pathological psychoses of morbid subjects, hysterical, degenerate, insane, etc. As, for example, the ennui which dominates them all, and which one al- [35] NERVOUS STATES ways finds at a given moment in the gayest and best-balanced subjects." Observe how near this "petite neu- rasthenic" is to the normal state. Ennui is so characteristic of the human species that Pascal said, "Man would weary even without any cause for weariness, from the condition of his constitution." Goethe exprest the same idea in the whimsical fancy "If monkeys could suffer from ennui they would be men." Fere 2 similarly points out the mental symptoms of fatigue, and insists upon the analogies which they present to those of neurasthenia. "Fatigue," he says, "often provokes ideas of negation, persecution, and dis- paragement. Altruistic sentiments give 1 Ph. Tissie. "L'entrainement intensif a bi- cyclette," Revue scientifique, Oct., 1894. "La fatigue ches les debiles nerveux et fatigues," ibid., Oct., 1896. * Fere. "Les troubles mentaux de la fatigue," Medicine Moderne, Nov., 1898. [36] THEIR NATURE AND CAUSES place to egoism, which shows itself in the most varied forms. The subject is incapable of reacting against obsessions and impulses which may become irre- sistible." Lagrange and Gilbert Ballet have described these temporary neuras- thenias due to overwork, and appearing in the "trained" simply because they do not perceive their fatigue in time. Bin- swanger 1 points out as possible conse- quences of mountain-climbing, not only physical depression, but insomnia, sen- sibility to sound and light, hallucina- tory states, restlessness of the limbs, trembling, states of distress, irritabil- ity, sadness, tears, and jactation. Here we have, then, in the opinion of competent observers, pure fatigue creating neurasthenic states, and al- ready obsessions and impulses are seen 1 Die Pathologic und Therapie der Neurasthenic, Jena, 1906. [37] appearing an outlined sketch of the psychasthenic states. For my part I would strictly confine the term neurasthenic state to those states of fatigue due to multiple pono- genic causes. I have never employed it in a more extended sense, including with it the morbid impulses, the various phobias, obsessions, and fixt ideas. Even altho these mental symptoms were accompanied by neurasthenia which is most usually the case I have always had the impression that we were con- cerned here with graver states, entail- ing a much more serious prognosis. We shall see later the intimate bond which unites the neurasthenia thus limited to the psychasthenia of Janet, but let us keep for the present to this simple neurasthenia, to the true neu- rasthenic state. It is easy to diagnose, since all of us have experienced its symptoms, and we have only mentally [38] THEIR NATURE AND CAUSES to multiply them tenfold to put our- selves in the place of our patients; that will give us sympathy for them, and perhaps the means of comforting and curing them. Viewed thus from a distance, and closing the eyes a little, neurasthenia appears as a somewhat benign disease, much resembling ordinary fatigue, ex- aggerated in predisposed subjects. The trouble seems to be physical, and one comes quite naturally to treat it almost entirely by rest when exhaustion pre- dominates, by training and exercise when one suspects a little want of initiative under this incapacity ; re- source is had to cures by altitude, baths, douches, and physical and medicinal tonics. One is a little astonished when one observes the frequent inefficiency of all these means, the relapses which al- most continually succeed the temporary improvements, and make of so many [39] NERVOUS STATES neurasthenics the too faithful residents of the hydrotherapeutic establishments. One is then obliged to differentiate be- tween the temporary exhaustion in the overworked, and the tenacious inca- pacity of the neurasthenic. This fatigue becomes inexplicable when one has to do and that is frequently the case with people who are never overworked physically and intellectually, who have rested for so many years that their idle- ness is a burden to them. Then every- thing is explained by the predisposition, by a native nervous weakness. It is thought that harmful influences act upon physically weak people, which would have had no effect upon strong persons. But when one looks closer at the matter, one changes one's opinion; the trouble does not appear so benign when one sees it coincide with mental symp- toms, and evolve toward psychasthenia. [40] THEIR NATURE AND CAUSES All the authors have insisted upon the mental state of these patients, and have pointed out the psychic depres- sion, the feebleness of attention, aboulia, emotivity, and autosuggestibility in the sense of hypochondriac preoccupations. It is true that in order to maintain the autonomy of this psychoneurosis, or of this syndrome the name has nothing to do with it one passes over these capital symptoms a little rapidly, and specifies that there is no perversion of the judgment; that that remains intact in spite of the general depression of the debilitated and exhausted psychic faculties. It is with difficulty that I imagine this integrity of the judgment in such a mental state. In short, forgetting a little too readily the native predisposition which was postulated to explain how these subjects succumb to commonplace causes, a sort of synonymity is created [41] NERVOUS STATES between the terms true neurasthenia and acquired neurasthenia, while the new appellation psychasthenia has to designate the hereditary or constitu- tional neurasthenia of Charcot and Giles de la Tourette. Moreover, the same accidental causes are attributed to the latter as to true neurasthenia; these are I quote Pro- fessor Raymond all those which have a debilitating action: depressing emo- tions, excesses of all kinds, intellectual overwork and cerebral fatigue, trauma- tisms, infectious diseases, chronic dis- eases, severe hemorrhages, etc.; in a word, all the influences which disturb the general nutrition and the function- ing of the nervous system. Those influences which in normal in- dividuals would produce the true neu- rasthenic state often benign and cur- able induce the more severe affection, the psychoneurosis autonomous with [42] THEIR NATURE AND CAUSES psychasthenia, when they act upon ab- normal subjects impressionable, timid, hesitating, soft, lacking initiative, odd, dreamers, over-scrupulous, exagger- ating the importance of their small faults, and at the same time irritable and changeable in humor. Well, I consider that the true neu- rasthenics have been very badly ob- served. Without it being necessary to declass them, one sees in them a great many of these mental defects, and these characteristic blemishes are not pro- duced accidentally by overwork, the al- leged author of all the mischief: due to heredity first of all, and education af- terward, they existed long before the crisis of neurasthenia. In them, as in the psychasthenic, "the mechanism was ready to work ; the motive circumstance represented merely the fall of the lever permitting the starting- of the machin- ery" (Professor Raymond). [43] NERVOUS STATES One is apt to go a little too quickly in examining the heredity of these true neurasthenics. Most often, upon the simple affirmation of those interested the patient or his relatives it is de- clared that there is no psychopathic heredity, or that it is of little moment. The opinion of the patient is accepted at once, that he was well until the time when influenza, overwork, or cares overcame him, and a diagnosis is made of accidental acquired neurasthenia. The opinion would be changed if one had observed the patient and his family before the crisis, and, in fact, one ar^ rives at quite other views when one ob- tains an intimate acquaintance with the physical and mental personality of the subject, when one comes to know his parents, brothers, and sisters. One finds, then, that our true neuras- thenic belongs to a family of psycho- paths, in which one often discovers [44] THEIR NATURE AND CAUSES psychasthenic states, hysteria, epilepsy, migraine, idiots, imbeciles, or insane persons, etc. One apprehends the influence of edu- cation, which also creates psychasthenia by the false ideas and superstitions which it develops, when it ought to give us a clear view of things, and lead us to the mastery of ourselves. Often, alas, one has to withdraw from the favorable prognosis that one has made as the result of a temporary therapeutic success, for some years af- terward one finds the subject with fully developed psychasthenia, or affected, as the result of an emotion, with mental confusion of the melancholia. The psychiatrist of the University of Geneva, Professor Weber, was not wandering from the truth when he said to one of my pupils: "Pretty often the patients whom you have treated as neu- rasthenics come back to us as psycho- paths." [45] NERVOUS STATES On the other hand, one also observes many cases in which severe and in- veterate symptoms of true neurasthenia disappear in the space of a few days, under the influence of restorative con- versations, by the reading of a psy- chotherapeutic letter, or a medical work explaining clearly the influence of men- tal representations in the development of this psychoneurosis. Whether one is dealing with the in- curable invalids, who remain all their lives in this state of true neurasthenia, and whom I have compared to "spirit- less horses," with the less rebellious neurasthenias which last for some years, or the frequent cases which yield rapidly to a rational psychotherapy, it is neces- sary always in our thoughts to put in the forefront the psychic symptoms: the pusillanimity, the tendency to dis- couragement and sadness, and the ab- sence of self-mastery. [46] THEIR NATURE AND CAUSES Professor Raymond 1 has recognized this well, without drawing from it all the logical consequences, when he writes "Even those arthritic patients who have the mastery of themselves, who dominate their emotions instead of being led by them, in a word, those who have a strong and firm brain, escape neurasthenia." It could not be better exprest, and it is precisely this weak brain which constitutes a native and not acquired psychasthenia, just as with a simple dif- ference of degree in the neurasthenia termed constitutional. The ground here is also degenerative, altho we do not yet observe the gross physical and mental stigmata of degeneration, or rather of human imperfection. 1 F. Raymond. Neuroses et psychoneuroses. Legons faites a la Salpetriere, Paris, Delarue, 1907. [47] NERVOUS STATES IV EDUCATION OF THE MIND NECESSARY A> soon as one has fully grasped the significance of this primary men- tal weakness, one sees at once all the advantage to be obtained from an edu- cation of the mind. One then recog- nizes that the innumerable physiological symptoms are secondary, whether they be produced by pure mental representa- tions, or whether these latter come to keep up and aggravate disorders due to physical causes. Whether it begins by a sensation, an accidental discomfort in regard to which he distresses himself by reason of his pusillanimity, or whether, on the other hand, it commences by an emo- tion which disturbs the physiological [48] THEIR NATURE AND CAUSES functions, the subject enters into a vicious circle, or rather into a spiral. The organic discomfort which he per- ceives induces a hypochondriac preoc- cupation, an emotional disturbance. This perturbs the sleep, causes palpita- tion, or provokes gastro-intestinal dys- pepsia. These disorders in their turn distress the apprehensive patient, fresh emotion engendering new functional troubles or aggravating those which al- ready exist; it is another opportunity for the patient to take fright and to ad- vance always further in the fatal spiral. For want of having sufficiently clearly recognized the primitive psychic asthenia, many medical men lay too much stress upon the physiological symptoms, and have recourse to what is called at the present day physio- therapy to material and medicinal treatments. These means give, I know, undeniable successes, sometimes by [49] NERVOUS STATES creating a state of physical well-being, which directly influences the mental condition, sometimes by awakening a beneficent suggestion of cure. The influences which debilitate the organism contribute very distinctly to the origin and development of the psychic troubles they often explain the frequent relapses; on the other hand, improvements of the physical condition lead also to happy modifications of the mental state, in neurasthenia as in the psychasthenic states or other psycho- pathies. It must not be forgotten that the mind, in "its turn, reacts upon the body, and that the emotions can create conditions of real fatigue and disturb all the organic functions. It is neces- sary to take fully into account this reciprocal influence which the physical and the moral exercise upon each other. These ideas are of capital importance in the history of the psychoses and the [50] THEIR NATURE AND CAUSES psychoneuroses ; I may therefore be permitted to express myself in a gen- eral manner upon these relations. I shall say, first of all, that between the physical condition and the mental condition there is no direct and neces- sary bond, entailing a constant paral- lelism between the physical health and that of the mind. On the one hand, we see weak, feeble, emaciated creatures suffering from debilitating diseases, presenting no symptom of neurasthenia or psychasthenia ; these are healthy minds in sick bodies: conversely one sees the various disorders of the psy- chopathies succeeding each other in men of herculean frame, enjoying ex- cellent physical health, and who have not been subjected to any marked de- bilitating influence. It is therefore false to immediately conclude the men- tal integrity from the physical health, and to always seek in the body the [51] NERVOUS STATES cause of the psychic disequilibrium. But if the individual subjected to any debilitating causes has defects at the bottom of his mentality, the physical weakening leads to psychopathic symp- toms, or causes them to reappear after the physical and moral rest of the curative measures have silenced the episodic manifestations of the psycho- neurosis. That is why it is an advantage to combat all physical weakness in these patients, and to place them in the most favorable dynamogenic conditions. But that does not mean to say that this treatment suffices; it is yet more im- portant to reform the primitive men- tality. Our mental defects irritability, tendency to discouragement, pusillanim- ity in regard to illness and to death, impressionability, etc. exist in the in- nate and acquired disposition of our [52] THEIR NATURE AND CAUSES mind, due to heredity and to education. If the general health is good, these faults remain more or less concealed, like rocks at the bottom of the sea, covered at high tide. Let some de- bilitating influence arise physical, in- tellectual, and, above all, emotional fa- tigue and these defects are laid bare, like the rocks at low tide. Normal as we think we are, we have all these psychic debilities, and when we are fatigued and weakened, we react in the sense of this primitive mentality. Fatigue renders one irritable, another sad; it awakens the spirit of contradic- tion which sleeps in us, diminishes our patience and our sentiments of altruism, causes hypochondriac fears and anx- ieties to be born, altho the idea of sick- ness and death found us somewhat in- different in the state of physical well- being. This is why the most healthy man is susceptible of becoming tempo- [53] NERVOUS STATES rarily neurasthenic, when debilitating factors act upon him in an intense and continuous manner. The true neurasthenic finds himself, to begin with, in a condition of infe- riority; the rocks to which I have com- pared the mental defects are more su- perficial, and show their surface as soon as the tide begins to ebb. Causes which would be insufficient to provoke a diseased state in a better endowed man induce immediately psychopathic and physiological symptoms. The smallest fatigue, the slightest emotion, annihilate the potential of the subject, and lead to incapacity, to discourage- ment, and even indeed to suicide. Also often the smallest favorable event, good news, a comforting word, produce the opposite effect with like facility, and power succeeds incapacity, and cou- rageous enthusiasm lack of initiative. This is not always a flash in the pan, [54] THEIR NATURE AND CAUSES as has been suggested; it is often a new and positive ordering. It is due to the fact that these subjects are im- pressionable, and sensitive, and capable of reacting in both senses. Within cer- tain limits this mobility of impression is a good quality. That is what caused my excellent friend, Professor de Speyr, Professor of Psychiatry at Berne, to say: "It is only the neurasthenic who do anything in this world." He meant by that that the indifference which sim- ulates equilibrium is not a good charac- teristic, and that one can only do useful work by becoming enthusiastic, and al- lowing oneself to be imprest. Sandras, 1 in 1851, noted well this variability of the symptoms which may diminish or disappear by a simple dis- traction; he saw also the "good neu- rasthenia" when he said: "Nothing is 1 Sandras. Trade pratique des maladies ner- zteuses, Paris, 1851. [55] NERVOUS STATES more admirable than this nervous state when it is at the service of a good head and a good heart." One can then without danger be a little bit neurasthenic, if one does not go too far into psychasthenia, and if one avoids "moral insanity." This psychic weakness of the neu- rasthenic, this inability to resist outside influences, has escaped no serious ob- server; but here one sees two opposite tendencies appear, that of the clinicians, often without knowing it imbued with a false materialism, and that of the psy- chologists, who are careful not to con- found soul and brain. The former maintain the morbid entities, and endeavor to introduce the precision of the hospital clinic into this "psychiatry." In a too simplistic con- ception of psychophysical parallelism or monism they carefully avoid the word soul, while abusing the terms psychism, [56] THEIR NATURE AND CAUSES psychic, psychopathy, and psycho- therapy ; the Greek word is allowed, the English word causes a smile. They seek in the brain the material primitive deformation which engenders the psy- chic disorder, and as they can not sus- pect there lesions accessible to our means of investigation, they invoke in- toxications due to malfunctioning of the stomach, the intestine, or the glan- dular organs, to hyperacidity of the blood, associating neurasthenia with the diseases due to impaired nutrition or rheumatism. They have so united these two conceptions that they com- monly speak of neuro-arthritic subjects, and that has to explain everything. But where have they seen the true gastropaths or patients affected with diarrhea or chronic constipation who were neurasthenic by that fact alone? Why does this psychoneurosis, so easy to recognize, not show itself oftener [57] NERVOUS STATES among all these debilitated, intoxicated hospital patients? No doubt they are not of a lively gaiety, for they are suf- fering, but it is a long way from that justified sadness to the depression and incapacity of the least neurasthenic. Are there not a great many gouty and rheumatic persons, if one may make use of that vague term, who are in no way neurasthenic even tho they are peevish ? Why do they not indicate neurasthenia as the almost necessary consequence of jaundice, if it be cholemia that makes all the trouble ? Why inversely do they see the neurasthenic and psychasthenic states attack subjects immune from all these constitutional maladies? How is it that they do not see the almost con- stant inefficacy of the therapeutic meth- ods which aim only at the elimination of pathogenic toxines, and do not ob- serve the influence of therapeutic sug- gestion in the cases which they benefit, [58] THEIR NATURE AND CAUSES temporarily, however, the condition of these patients? How is it that so many clinicians pass by these facts which lie under their nose without seeing them, and do not recognize the mental symptoms of their patients, their state of mind, so easy to discover, that one can make the diag- nosis after a few words of conversa- tion ? Why do they persist, except per- haps in hysteria, in always seeking for somatic causes? It is because on en- tering upon this psychiatric ground they get away from the data of ma- terial medicine. No doubt, every psy- chological fact supposes a physico- chemical modification of the cerebral cell, but that does not mean that every psychic disorder has its origin in a primary alteration of the brain. The idea which another suggests to us constitutes a psychic stimulus, of a complexity quite different to a phys- [59] NERVOUS STATES iological stimulus, and will produce quite different reactions, according to the previous mentality of the subject; that is to say, according to the sum- total of conceptions which education, acting upon an hereditary basis, has accumulated in his mind. Yes, it is the work of our Wain, stimulated by means of the sensorial organs, which produces thought, the psychic phenomena. But the essence of the soul is not known to us, and it is as absurd to say "brain" instead of "soul" as to confound "electrical ma- chine" and "electricity"; we know the latter as little as the abstraction which we name "soul." Nothing is more ab- stract, let us say metaphysical, than the conception of force or potential which is denned as "the supply of force ac- cumulated at a mathematical point." The physicists who believe that in their definitions they remain upon the solid [60] THEIR NATURE AND CAUSES ground of the physical make me smile; they sail under full canvas in the meta- physical quite as much as the most daring spiritualist. To suppress a question is not to re- solve it. Therefore, I object to the substitution of the word brain for that of soul: it is a subterfuge. We em- ploy too much the language of the anat- omist and the physiologist, and not enough that of the psychologist. What- ever be the hypothetical solutions at which the thinker arrives, whether he regards thought as a purely biological phenomenon, or whether he believes it necessary to have recourse to dualism, we do not know the essence of that thought; we express an abstraction by a word. But in spite of this obscurity in re- gard to the nexus of the soul and the body, we can always distinguish be- tween the somatogenic or ideogenic [61] NERVOUS STATES origin of a psychic or physical symp- tom. It is in the body that one has to seek the cause of a delirium provoked by fever, by intoxications, by cerebral lesions verified or probable; it is con- versely in the mind that it is necessary to locate the primitive stimulus when we obey suggestions of any kind, het- erosuggestions or autosuggestions. I shall go further and say that even when a physical cause throws our mind into disorder it does not react in a univocal manner, and we will always discover the primitive mentality of the individual in the toxic delirium. [62] THEIR NATURE AND CAUSES V THE LINK BETWEEN MIND AND BODY IT is therefore necessary to distin- guish carefully between the physical constitution and the mental constitution, between the "corpus sanum" and the "mens sana." There is a link between these two healths, we are obliged to admit it, in virtue of the verified paral- lelism of the facts of consciousness and the cerebral work; but the idea acts upon the functioning of our organs at the same time that the bodily condition reacts upon our thought. When one regards psychopaths as well as the peo- ple called normal, it would often be more exact to say that it is the healthy mind which makes the healthy body than to inverse the proposition. What creates the neurasthenic is not the ac- [63] NERVOUS STATES cidental provocative agent which acts upon so many others without troubling their functions; nor is it either the vague predisposition admitted after the event, by a logical induction it is a primitive weakness, an asthenia* Is this debility physical ? Is it neces- sary to seek its cause in a constitutional pathological state of the cerebral cell, or in alterations which it suffers later by the somatic path? I should be very sorry if it were so, for I should then no longer have the courage to enter upon the treatment of these patients. To modify a constitutional cerebral state is a very arduous task, and no one 1 In a profound study of the treatment of neu- rasthenia and hysteria, Dr. Dunin of Warsaw has clearly shown, and before me, how commonplace are the occasional causes which lead to neuras- thenia. What characterizes the neurasthenic is his mentality, which renders him pusillanimous, anxious about himself, and feeble in will (Grund- satze der Behandlung der Neurasthenic und Hysteric. Berlin, 1902). [64] THEIR NATURE AND CAUSES will make me believe that it is sufficient to add to hygiene the pitiful processes of physiotherapy in order to obtain durable results. I know of no medical means to restore such fragile cellular groups to their original state. I know very well that in these pa- tients one often finds a condition of weakness quite material, and alongside of the mental symptoms a crowd of real infirmities. Beard notes in his subjects : A frail organization, the hair fine, the skin delicate, the features small, the bones slender, the muscula- ture feeble, an evident physical feeble- ness therefore. He adds, "that this condition is often allied to a superior mind, to an active and animated nature, and that this constitution is more often met with in civilization, in the towns than in the country." He finds in the antecedents of these patients "the tend- ency to true diseases of the nervous [65] NERVOUS STATES system; in early infancy convulsions, irritability, and cerebral affections; later, chorea and analogous affections; at puberty chlorosis, headaches, sper- matorrhea, and sometimes epilepsy; at adult age migraines, neuralgias, nerv- ousness and loss of flesh following dyspepsia, and in its train constipation, insomnia, functional or even organic paralyses, hypochrondria and neuras- thenia; in women hysteria, spinal irri- tation, and a whole series of nervous affections in the course of uterine dis- eases; in old age cerebral softening and organic paralyses. He resumes: "A child born nervous may have, during lactation, spasm of the glottis; in in- fancy, chorea; at puberty, pollutions; between twenty and fifty or sixty years, dyspepsia and neuralgias: he may die of apoplexy or softening of the brain." How true this picture is for many cases, but how desperate; for, however [66] THEIR NATURE AND CAUSES much a therapeutist one may be, it is hardly possible to be sufficiently naive to think to altogether change such a personality in so far as it is physical. Yes, there are some patients who cor- respond to this type, and it is these who, unfortunately, often escape our therapy. They would be at once and forever incurable if the whole of their unhealthy state depended only upon their material structure, upon all these more or less indelible defects. Happily in that there is a gross error, not in the observation of these facts one might infinitely prolong the list of these phys- ical defects but in their interpreta- tion. First of all, it must not be forgotten that there are many individuals who have presented in their life these va- rious symptoms, and who are in no way neurasthenic; there are even some of them who have numerous corporal stig- [67] NERVOUS STATES mata of degeneration receding fore- head, prognathism, the ears badly mar- gined or winged, etc., and who as much by their intelligence as by their moral worth surpass the physically better en- dowed. But, contrary to Beard, it is. before all, necessary to classify the symptoms, not in an anatomical order, but ac- cording to the determining factors, ac- cording to their rank, and to find the link which unites them to each other. The capital defect in the true neuras- thenic is fatigability, the tendency to exhaustion; it shows itself on the oc- casion of physical and intellectual work as well as in the face of moral suffer- ing. This fatigue reveals itself not only in the subjective sensation of functional incapacity, but by a mass of symptoms, among which I note: the various cephalalgias, rachialgia, pains in the [68] THEIR NATURE AND CAUSES limbs and muscular cramps, functional insufficiencies of the sense organs, con- ditions of gastro-intestinal dyspepsia, verifiable by objective examination, anomalies of the functioning of the va- rious tissues, betraying an actual lower- ing of the organic vitality all symp- toms which may arise in the individual termed normal, when temporary in- fluences have acted powerfully or in a too continuous manner. On the other hand, one finds a great many symptoms which are attributable to the emotivity of the subject, another mental stigma of the neurasthenic; these are : variations in the expression of the eyes, in the dimensions of the pupils, in the play of the physiognomy, tears, emotional blushing, sweating of the hands and feet produced by the least emotion, palpitations, insomnia fostered by preoccupations, trembling and convulsive movements, the sudden [69] NERVOUS STATES loss of muscular power by emotional inhibition, virile impotence from timid- ity, etc. When one tries to apportion the share of these two factors letting loose the functional symptoms, fatigue and emotivity, one perceives that it is im- possible to separate them exactly in every case. Thus weakness of the voice, frequent at certain times of the day, may be attributed to a real fatigue, or, on the other hand, may be due to embarrassment, emotion, or autosug- gestion. Asthenopia may follow ex- cessive work, and seem to be due to an exhaustion, but it shows itself so quick- ly, often before any effort, that one is obliged to think of autosuggestions of incapacity, of an anticipated pono- phobia derived from the pusillanimous state of mind. Sensibility to atmospheric influences, heat and especially cold, often appears [70] THEIR NATURE AND CAUSES to be due to a condition of malnutrition, to insufficiency of the peripheral circu- lation; conversely it may show itself in the absence of any circulatory trouble, and disappear so quickly under the in- fluence of a moral cause, that one is obliged to introduce the psychic state, autosuggestion. The muscular weakness may appear real ; that is to say, adequate to the ex- penditure of organic carbon, when it is seen in a debilitated or actually over- worked subject; one recognizes, on the other hand, the conviction of incapacity, the fear of fatigue, when the muscles are sufficient and there has been no work performed. The mental, auto- suggestive nature of this fatigue re- veals itself even by its exaggeration, the exhaustion surpasses all limits, or by what I have called revealing contra- dictions, the patient becoming suddenly capable of a greater effort than that [71] NERVOUS STATES which one demanded of him, or sus- taining under the influence of its at- traction an intellectual fatigue superior to that which he shunned to undertake. The pains in the limbs, spontaneous or on the occasion of any exercise, piano-playing, dressmaking, etc., are sometimes so intense that the physician hesitates to speak of algogenic auto- suggestions, and yet a few counsels of a moral nature suffice to dissipate these old and rebellious incapacities. In presence of those who declare themselves incapable of an intellectual effort, one has great difficulty in dis- tinguishing the conditions of true in- capacity and imaginary incapacity, un- til the patient himself is astonished at having been able to support without fatigue a psychotherapeutic conversa- tion of two hours, altho his head gets confused when he attends a lecture of one hour's duration. He observes this [72] THEIR NATURE AND CAUSES contradiction himself, and explains it by saying that at the lecture he allows himself to be more easily overcome by the conviction of incapacity. And henceforth the headaches no longer oc- cur after half an hour's work if you have made your patient thoroughly to understand how the autosuggestion en- gendered by pusillanimity provokes the subjective and objective symptoms of fatigue. Asthenopias which have lasted for years and resisted the treatment of the oculists yield in a few days, even in- deed after a single consultation, when one has been able to demonstrate to the patient that a healthy eye can not be exhausted in a few minutes, and that in the fatigue there is more of pono- phobia than of real exhaustion. The patients are numerous who rec- ognize that their insomnia is the fruit of a preoccupation, of the fear of not [73] NERVOUS STATES sleeping; there are some of them who confess quite frankly that they make the autosuggestion of insomnia them- selves. The palpitations of neurasthenics arise almost always from emotion, either under the influence of a definite fear, or that vague fear which results from a permanent sentiment of fragil- ity. You will easily discover the man who gets panic-stricken under the tachycardiac neurasthenic. The innumerable patients who have been termed "false gastropaths" can be easily led back to the regime of ordi- nary people, even when for years they have practised a debilitating regime, from fear or by the advice of doctors, and in vain. They then lose the con- stipation of small eaters and the muco- membranous colitis which is its conse- quence. Unhappy persons who have created [74] THEIR NATURE AND CAUSES for themselves and for those belonging to them an existence of martyrdom by their inaptitude for any physical or in- tellectual work, and by their want of resistance to trouble, often return very quickly to a normal life when they un- derstand the action, not dynamogenic, but dynamophanic, of courage. [75] NERVOUS STATES VI THE MIND THE BEST WEAPON IN THE COMBAT THE physician who studies the state of mind of his patients will have no difficulty in recognizing the primary evil in this psychic asthenia, united sometimes, but not always, with physical constitutional asthenia. He will consider pusillanimity and want of self-mastery as characteristic of these patients. He will in no way renounce the phys- ical means calculated to increase the strength and to dissipate the accumu- lated fatigue which the neurasthenic crisis represents. First of all, he will have recourse to rest that of the [76] THEIR NATURE AND CAUSES simple sojourn in the country if the corporeal condition is still satisfactory; to rest in bed, if the exhaustion de- mands it. He will lead the patient back to the ordinary diet if he be only slight- ly dyspeptic; he will subject him to a cure by superalimentation, which is not a cramming, if it be a case for inducing a rapid increase of the strength and weight, and of dissipating, at the same time, phobias on the subject of alimen- tation. He may add to these two prin- cipal measures the less active processes of massage, regulated gymnastics, or a discreet hydrotherapy. For my part, I have given up the greater part of these auxiliaries. I no longer require isolation, unless to elim- inate the absolutely undesirable in- fluences of relations; I only have re- course to rest in bed in conditions of extreme malnutrition and fatigue, when there are persistent cephalalgias and [77] rachialgias; I no longer prescribe su- per alimentation except when the emaci- ation is considerable. Massage is still practised in my clinic as a slight auxil- iary, which I readily put aside if it be badly borne, or to spare a patient not very well off this small supernumerary expense ; that is the value I attach to it. I have abandoned all hydrotherapeutic measures, while recognizing that a good hydrotherapeutic establishment, in a fine climatic situation, might be a choice sanatorium for a physician de- voted to psychotherapy. He would, however, run a great danger, I have many times observed it, of creating in his patients too great a faith in these physical means, and of causing them to forget the task of greater importance, self -education. As the medical experience grows, the gift of persuasion increases. It acts not only by those quite personal in- [78] THEIR NATURE AND CAUSES fluences which result from the bond of confidence and sympathy which unite the patient and medical man and which are wrongly termed suggestive but by an ever closer dialectic, by an inculcation of sentimental logic. The patient is not cured when by physical or even psychic treatment we have caused the disappearance of the disorders which produced the fatigue. It is necessary to reveal the causes of this exhaustion, and to prevent their action in the future. There are only four causes of fatigue: Physical work, intellectual work, abuse of pleasures, and the emotions. It is these last which constitute the richest source of fatigue; it is this whose debit we must reduce. There are some neurasthenics who have burned the candle at both ends; they have combined severe sports with intellectual work, practised onanism or [79] NERVOUS STATES other excesses; they have, besides, cul- tivated their impressionability like artists. Many others have been so feeble all their life that it would be ridiculous to speak of overstrain, either by work or by excesses of which they would be incapable. They have had some real cares and many others imaginary, and have not been able to overcome their emotivity. They confess them- selves that they make an emotion out of anything and out of nothing. By physical treatment and simple encour- agement one pretty easily overcomes the exhaustion induced by these various influences; one helps the patient to pay the debts he has incurred. If he be sagacious, he will be able to draw some benefit from this experience, and dis- cover himself, without the aid of the physician, the causes of his crisis, and avoid it in the future. But these are the minority among the patients; the [80] THEIR NATURE AND CAUSES greater number fall again under the influence of new debilitating physical and, above all, moral causes. They will return to their habitual medical man, the gastro-therapeutist, who knows their stomach so well and the virtue of re- gimes, the past-master of the douche who directs the spray as a virtuoso, the electro-therapeutist handling with pre- cision the multiple manettes of his ma- chines, not forgetting the gynecologist who will always find something to scrape, to cauterize, or a uterus to re- place. Often, too, the discouraged pa- tient will seek a cure in some other land; one must console oneself, since no one is a prophet in his own country. It will always be so if the trouble be seen only in the symptoms of the neu- rasthenic crisis, and one thinks of elim- inating only the provoking agents, the accidental causes. The situation is the same as in hysteria, which has caused [81] NERVOUS STATES it to be said that the symptoms of that psychoneurosis are cured but not the disease, which is the hysterical men- tality. It is the neurasthenic mentality that must be attacked. Its principal charac- ter is pusillanimity. In virtue of hered- itary predispositions and educative in- fluences, the subjects susceptible of fall- ing into the neurasthenic state through the provoking agents have not that ro- bust good sense, that balance, which permits of adaptation to life. They bring into their activity inde- cision and scruples derived always from fear. In face of the least discomfort they take fright, and believe themselves af- fected with a grave malady; they in- crease their pusillanimity by reading medical works, by consulting pessimis- tic medical men, often hypochondriac themselves, who are of opinion that one [82] THEIR NATURE AND CAUSES must always be cautious and apply to every trifle the powerful weapons of modern therapy. There are clinics where indeed it seems as tho they had set themselves the task of cultivating this nosophobic neurasthenia. In all these patients you will observe the diffi- culty of adapting themselves to life as it is given to us, of supporting its vicissitudes with patience and courage; they have not yet carried out sufficient- ly the education of their moral self. It is this insufficiency of the intelli- gence, particularly in the ethical do- main, that one has to recognize the primary trouble, not a simple predispo- sition, but an actual defect, ascertain- able as soon as one knows one's patient. The patients may be very gifted in other ways, be very intelligent, have many estimable qualities of heart and mind; they lack that good sort of stoi- cism necessary in the struggle of life. [83] NERVOUS STATES The conception of this primitive de- fect has made me say, "As the tree grows, so it falls." There you see the fundamental psychopathy whose neu- rasthenic crisis is only an episodic man- ifestation, provoked by debilitating in- fluences. The situation is therefore the same as in psychasthenia, to which I must devote a few pages. Altho I am obliged already to recog- nize this psychasthenia in all my neu- rasthenics, and find it again in many psychoses, and altho doubts may be raised as to the opportuneness of this new appellation, I am glad that Janet has proposed it. In his admirable analyses he has avoided the dogma of the "morbid entity," and demonstrated the bond which unites the psychoneu- roses to each other and to the psy- choses. A fear comes to me, however, that, still more than "neurasthenia," [84] THEIR NATURE AND CAUSES psychasthenia may become the giant of neuropathology and of psychiatry. But let us await the future reconstructions. For the present the psychasthenia of Janet forms a clinical picture sufficient- ly well drawn and better named than that of Beard, in the sense that it de- notes by a word the primitive mental defect and causes it to be looked for in the mentality and not in the nerves. But it is not at all in the work of classification, in the creation of an au- tonomous psychoneurosis, that I see the astonishing originality of the French psychologist. His work has quite a different import, as much theoretical as practical. He has put into the group of the psychoneuroses, which can not only be studied, but improved and cured, psychopathic states which one readily sent to the alienist or treated only with reluctance, haunted as one was by the idea of their incurability. [85] NERVOUS STATES One rather left them lying in the large drawer of degeneration, opened too widely by Morel, and divided into small compartments by Magnan. The word degenerate was not exactly made to give us courage. No doubt a new appellation does not suffice to improve the prognosis of a disease, and our neurasthenics and psy- chasthenics remain indeed mental de- generates and will so remain in spite of all the psychological analyses. But the fine studies of Janet have enabled us to better grasp the insensible grada- tion which unites normal fear to phobia or to mania of touch ("delire du toucher"), common indecision to mania of doubt ("folie du doute"), and which turns the conscientious into sufferers from unhealthy scruples, etc. In the fine work published in col- laboration with Professor Raymond, he describes successively, at the same time [86] THEIR NATURE AND CAUSES uniting them, certain clinical pictures the neurasthenic states and the aboulic. 1 In aboulia there appear sentiments of incompletion. Then the term neuras- thenia disappears from his descriptions, in proportion as the symptoms become more mental and more severe. We are there fully into psychasthenia, which is cousin to epilepsy and migraine. We learn to know the agitations and diffuse anguish, of which it has been so often proposed to make new morbid entities. Then come the phobias, creating some- times algias and sometimes phobias of the functions, among others, that of alimentation, so frequent in the true neurasthenic, the phobia of objects, that of situations, in particular agoraphobia, common also in the "petits neuras- theniques." 1 Professors F. Raymond and Pierre Janet. Les obsessions et la psychasthenie, Paris, Felix Alcan, 1903. [87] NERVOUS STATES We proceed in this matter afterward to the tics and to innumerable manias, from those which are compatible with the normal state to those which touch upon paranoia. In the second part we find described the obsessional ideas; they comprize the hypochondriac ideas, nosomania and thanato phobia, the ob- sessions of shame, associated with modesty and timidity, the amorous ob- sessions, often associated with the need of natural direction in persons of feeble mind. Moral insanity appears in the criminal obsessions in the form of im- pulses or remorse, in the sacrilegious obsessions, whose origin is in super- stitious ideas. The last chapter is de- voted to distinctly insane conditions: mental confusion with stupor, hallucina- tions, catatonic attitudes, or system- atized insanities. Am I not right in saying that already psychasthenia has taken gigantic proportions under the [88] THEIR NATURE AND CAUSES pen of Janet ? It is not convenient for amateurs of classifications, but this de- scription is true. At the base of all these states, from the most ordinary neurasthenia, termed acquired because one sees only the accidental crisis, to the most characteristic insanity, there is a weakness of judgment, a psychas- thenia; that is to say, a difficulty in effecting that mental synthesis which alone permits of living with sensations adequate to the reality, in everything and everywhere being to the point. Janet has not neglected to point out the possible somatic origin of such states, to recognize that they may be cerebral. But he has insisted upon the influence of ideas, of mental repre- sentations created through personal experiences or suggested by others, undergoing deformations in these sub- jects of weak mind and causing, espe- cially by way of the emotions, the [89] NERVOUS STATES physical and psychic symptoms of fa- tigue pushed to exhaustion. He has seen clearly the suggestibility of these patients, their need of direction which ties them to the hypnotizer or to the psychotherapeutist ; he does not overlook the possible dangers of purely suggestive methods. In a chapter entitled Education of the Mind, he has pointed out all the benefit that may be obtained from a rational psychotherapy, from persuasion by word of mouth. I have been the better able to recognize the good foundation of these views as I have applied them during thirty years for the treatment of all my neurasthenics, to the hys- terical, and to all those psychasthenics whom formerly I approached more timidly, imbued as I was by the idea of incurable degeneration. The attentive and repeated reading of the masterly works of Janet gives me a new courage, [90] THEIR NATURE AND CAUSES by demonstrating the success which one may obtain in cases which appear des- perate. I have for a long time seen re- sults in old psychaSthenias which have surpassed my expectation. There is, however, one point in which I differ from Janet, and I noted some years ago, at the end of the fine chap- ter upon "The Education of the Mind," this remark: "This education, how- ever interesting it may be, is still too purely intellectual; it must be more moral, moralizing, and must have for its aim the giving back to the patient the mastery of himself/' No doubt the culture of the intel- lectual faculties by graduated work, literary essays, pianoforte exercises, or teaching may have a happy influence, if one takes care to avoid fatigue; but one runs against a difficulty. It would then be necessary to go over again the entire education of the subject, from [91] NERVOUS STATES the infant school to the highest class ; it would be necessary to devote oneself for some years to a single patient, to be his preceptor and form his mind. The ideas of which the patient has need are, in my opinion, of quite another order than those which give instruction school crams us with those without forming our judgment they are those which create moral intelli- gence. It is easy to show the most il- literate patient the disastrous influence of fear, the harmfulness of discourage- ment, the ugliness of egoism, to make him feel the necessity, for all of us, of adapting ourselves to life. It is upon these moral ideas that it is necessary to fix his vacillating attention, to de- velop in him the faculty of mental synthesis. The task is, in short, the same as in the education of normal people. The intellectual work to which we have devoted ourselves from school [92] THEIR NATURE AND CAUSES up to the university has not given us, alas! that healthy ethical judgment which leads to the mastery of self; one finds it often in persons without educa- tion; they have that robust good sense which is worth more than the erudition acquired at school or from books. Like Janet, I recognize in the educa- tion of the mind the most powerful weapon that we have in combatting the various psychoneuroses, but from the commencement of my efforts I have aimed in the direction of an ethical logic, a sentimental dialectic; that is why I wrote "The Psychoneuroses and their Moral Treatment." There is there a differentiation of ex- treme importance, for this education in the ethical domain is more easy to ap- ply, appeals to the least cultivated per- sons, and gives results more prompt and, above all, more durable, while adapting the subjects to social life. [93] NERVOUS STATES I do not enter here upon a more ex- tended study of the states named psy- chasthenic; that would be going beyond my subject, and it could not be better done than in the works of Janet, which every medical man ought to read and reread. One finds there that delicacy of psychological analysis and that clear- ness which characterize French writers so often, at least those who manage to avoid a certain dogmatism also inherent in our Latin nature. I am anxious also to clearly separate the more benign states, which have been designated by the term neuras- thenia, from those grave forms in which the psychopathic condition ap- pears in the forefront. [94] THEIR NATURE AND CAUSES VII CONSTANT AUTOSUGGESTIONS AS CAUSES AND REMEDIES TO recapitulate: The neurasthenic states consti- tute a very characteristic clinical pic- ture, a psychoneurosis as circumscribed as a state in which the mentality of the subject intervenes can be. Considered in the state of crisis, the disease presents symptoms which are those of fatigue, of exhaustion, creating incapacity in the physical, intellectual, and moral domain. To that is added an infinitude of painful sensations, dis- turbances of the physiological functions depending upon fatigue, emotion, or both at the same time, the emotion en- gendering the fatigue, and the latter originating the emotion. These crises of indeterminate dura- [95] NERVOUS STATES tion have, as accidental causes, all the physical and moral agents which can exercise a debilitating influence upon the body as well as upon the mind. These causes are absolutely the same as those which in other subjects create the psychasthenic states and the psy- choses properly so called. Exact and prolonged observation enables one to affirm the continual in- tervention of autosuggestions in the origin, the development, and the cure of the crisis. The symptoms of these pa- tients are not imaginary, but the atten- tion that they give to them, the hypo- chondriac ideas which they create in their subject, augment the suffering and precipitate them into that "spiral" in which the organic symptom succeeds the emotion and vice versa. During the crisis and out of it, it is generally easy to discover in these sub- jects mental defects innate or acquired [96] THEIR NATURE AND CAUSES from the earliest years of existence, and which show themselves in pusillanimity, emotivity, aboulia, indecision, etc., all symptoms which denote a weakness of the mental synthesis, particularly in the most delicate operations, those which concern our moral life. In the period of crisis, the treatment must aim at overcoming the state of exhaustion by the aid of rest, more or less complete, and by all the measures calculated to restore the vital energy; it is important among these last not to forget moral influence. But in the course of this treatment, as well as in the periods of well-being, it is very important to combat the pri- mary mental states, which have allowed causes, most often commonplace, to provoke the state of neurasthenic crisis. It is here that the education of the mind comes in, moral orthopedy by means of loyal persuasion. It alone permits of [97] NERVOUS STATES the diminution of the primitive psychas- thcnia and the avoidance of the relapses which the return of the accidental causes almost necessarily entails. Limited as a clinical picture, neuras- thenia confines itself to the normal state, for it is proved that exaggerated fatigue may induce neurasthenic states in the best-balanced individual. In the graver forms, the mental de- fects are accentuated and neurasthenia passes into psychasthenia, and from that to the insanities. If it be impossible to mark precise limits in this downward progress, one may distinguish different morbid forms, name them according to the predomi- nant symptoms, and base upon these observations the diagnosis, prognosis, and treatment of a concrete case. The nomenclature may be yet fre- quently changed, uniting these clinical pictures or establishing, on the other [98] THEIR NATURE AND CAUSES hand, new subdivisions. These classi- fications, necessary in practise, will not suppress two certain facts: (ist) the narrow relationship which unites the psychoneuroses to each other, and these to the psychoses; (2nd) the importance of the mentality of the subject as the primary cause of the symptoms which the variable and contingent provoking agents produce. To resume: I reserve the term "neurasthenic state" for the patients who present, above all, the symptoms of fatigue, ex- haustion, and incapacity; a delicate analysis alone allows one to establish in what measure this inability is phys- ical or psychic. There is already some psychasthenia in these patients; there is already some degeneration; they are not of the strong. The appellation "psychasthenia" is applicable to the patients in whom pre- [99] NERVOUS STATES dominate the phobic obsessions, the tics, or the manias, etc. Here the psycho- pathic state is evident; the mental syn- thesis is particularly defective. The "hysterical states" are charac- terized by an exaggerated auto sug- gestibility, which has enabled it to be said that these phenomena can be created and dissipated by suggestive or persuasive processes. This is not at all a certain criterion, since the same means can succeed in the other psycho- neuroses, but it is evident that imagina- tion plays a predominant part in hys- teria. There is there also a weakness of the mental synthesis, betraying itself by a tendency to submit to the yoke of the imagination. I come finally to the "hypochondriac states," the "melancholic states." They have in common a foundation of sad- ness, of despair, but the preoccupations are different; the hypochondriac pities [100] THEIR NATURE AND CAUSES himself over his state of health, while the melancholic regards exterior cir- cumstances with sadness or criticizes his conduct in a self-accusing frame of mind. Under these very different forms of "psychoneuroses" one always recog- nizes a primitive mental defect, a psy- chasthenia. In all these patients there is a fundamental inferiority; call it de- generation or imperfection, that is not of great importance. It is sufficient to know that therein lies the primary trouble, and that the form of the psy- choneurosis will depend upon the men- tality peculiar to the subject and to the accidental circumstances which provoke the conditions. Let us not forget that all these mental disorders, these emo- tions, provoke fatigue and thus create "neurasthenic" symptoms which mingle with those of the primitive psycho- neurosis. THIS BOOK IS DUE ON THE LAST DATE STAMPED BELOW. Series 9482 c./ry ii