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Original Articles.
 

of the few best men, the results obtained are far
better than those which follow their employment.
in a simply routine fashion. If time allowed I
 

ON THE ETIOLOGY AND TREATMENT OF should describe and praise also the team-work
THE PSYCHONEUROSES.*
 

of the neurologist and the internist, the surgeon,
the orthopedist or the gynecologist. Nevertheless
there are some forms of the psychoneuroses that
these various measures do not touch and others
where their use is often really mischievous
because in securing temporary improvements
they blind the patient and the doctor to the real
The various maladies classified as
diagnosis and the really needed treatment.
choneuroses cause perhaps more misery than The justice of this criticism becomes clearer
any other single group with which the community when the question is no longer one of treatment
is afflicted. Not only is this true, but the study by a neurologist with the aid of some skillful
of their etiology, their treatment and their colleague, but of treatment by an orthopedist
prevention, on which you have honored me with or a gynecologist or a specialist for the digestion,
an invitation to address you, has an importance acting by himself. A good share of the practice
far transcending the question of the comfort of such specialists is among patients with strictly
and happiness of those persons who come to neurological affections. The practical outcome
physicians for advice. Without understanding of their treatment is often very good and in
the nature of nervous invalidism in the individual
it is impossible to understand the true nature of
many traits which count as normal, and of many
great social problems which are constantly
pressing themselves upon our notice.
There is an additional reason why an intelligent The sentiments which one often hears that
company of physicians should think this subject
"neurasthenia is a surgical affection or that
"mental treatment should not be resorted to
worthy of being taken up afresh. As matters
now stand, some of the graver varieties of until other means have failed imply a miscon-
these psychoneuroses pass practically untreated, ception of the facts." Surgical measures are
not because physicians fail to recognize them sometimes of great service and mental measures
as serious, but because they are thought too may be ignorantly used, but it is not an indica-
serious, too nearly incurable, to be fit sub- tion of advance in the general comprehension of
jects for time-absorbing treatment. I have in these disorders that views like these should
mind, as examples, two patients, of excellent seriously be held. Good neurology may be rare,
intelligence and warm affection, who live but it would be for the benefit of all physicians
practically exiled from their homes because they and of medical theory and practice as a whole
have the obsession that they shall kill some if the responsibility and the confidence should
member of their families. I know how hard the be thrown at once where they ought to lie and
successful treatment of such cases is, but I eventually must lie. So, too, the immense
believe that the method of treatment which I importance attached in some quarters to "eye-
shall here mainly advocate holds out good hopes strain" as a real cause of fundamental defects
for unfortunate patients of these sorts.
of character and of grave psychoneurotic symp-
The next point for which I beg your attention toms may be characterized as a truly child-like
is with regard to the therapeutics of these affec- hypothesis, in view of what we now know to be
tions. Have we reason to be satisfied with the the facts. I fully appreciate the favorable practi-
means of treatment commonly employed? cal outcome, in some cases, of the eyestrain
There is a tendency, even among neurologists, treatment. But far too much importance has
to answer this question substantially in the been attached to this argument from thera-
affirmative. It is widely felt that the various peutic success in the assignment of real causes.
familiar measures, such as seclusion in private When a patient gets better under a certain
and public sanatoriums, engrossing occupation, treatment it is natural to think that the
treatment by hydrotherapy, electricity, hygiene, difficulty which the treatment removed was
rest, change, suggestion, persuasion and suitable the essential cause of his illness.
drugs, give us, when properly administered, we all know that this is false reasoning and we
all that we really need to supplement the healing all know it to be such.
powers of nature. This view 1 do not share. There are two classes of physicians who are
These modes of treatment are indeed of immense very prone, from somewhat contrary reasons,
value. They should be cultivated and studied to reach warped judgments in these matters.
as frequently representing the best means at our The first class comprises those who fail to note
command, and the fact should be recognized the relapses from which psychoneurotic patients
that when they are used with the confidence, often suffer who have been relieved by treatments
skill and devotion that characterizes the work other than the really causal, and so overrate the
* Read before the Canadian Medical Association, Toronto. June. other class is composed of those who note these
value of some radically insufficient method. The
 

BY JAMES J. PUTNAM, M.D.,
 

Professor of Neurology, Harvard Medical School.
 

THE subject with which I have undertaken to
deal is such a vast one that I can obviously only
touch on a few great mountain peaks of a vast
country.
 

2
 

psy-
 

"
 

many a given case, taken by itself, there is no
room for anything but congratulation. But, often.
too, patients are treated in these ways, perhaps
with temporary or partial gains, who ought to
 

have their illnesses studied on far different lines.
 

"
 

But in fact
 

1910.
 

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[JULY 21, 1910
relapses, but observe that they occur under as causes than we have hitherto supposed. The
various modes of treatment and then conclude first few years of a child's life are rich in emotions
that the relapses belong to the natural history of and vague thoughts. These years have never
the disease (a severe form of hysteria or impulsion been adequately chronicled, but there are grounds
for example) and that, therefore, the disorder is for thinking that traits of character are founded
hereditary and a sign of "degeneration," and or accentuated at that period which tend strongly
that no treatment whatever can be of permanent to remain through life. In view of those facts,
value. But the former conclusion is a fallacy the old phrase "the boy is father of the man'
which any one's observation can correct, and the gains a fuller and a richer meaning. A consider-
latter is an unverified assumption which no one able portion of the evidence bearing on this
has the right to adopt until he has thoroughly point is associated with the name of Freud, a
acquainted himself with the therapeutic results name to which I shall have frequent occasion to
which can be obtained by the most radical mode revert. It is obvious also that nervous children
of treatment.
have often had nervous parents, and equally so
The most distinctive feature of neurologic that certain sorts of bodily weaknesses or
therapeutics has been its effort to utilize mental delicacy which are apparently hereditary pre-
influences in the cause of health, and I wish dispose to lack of nervous strength. The boy
to characterize this feature because it is here that can play hard and work hard and who
that important changes for the better are in comes of sound stock starts life with an obvious
prospect. You can all recall the stir made by the advantage, although it may be pointed out at
rehabilitation of hypnotism and what a flood of once, as showing how difficult it is to arrive at
literature has been published upon" suggestion." positive conclusions in these matters, that
You are familiar with the therapeutic work of some of the most striking forms of the psy-
Dubois and others of his type, and remember also choneuroses are found among professional and
the recent revival of the attempt to find a more amateur athletes and that seriously nervous
scientific bond between medicine and religion. patients seem sometimes to have had healthy
The great bulk of all this therapeutic endeavor parents. Finally, common sense secus to demand
has been an attempt to cure the patient by an acquiescence with the view that the character-
leading him to dwell on the possibilities of the istics of the bodies and brains and physiological
future and to forget the miseries of the past. mechanism with which we are born must deter-
He has been urged to "look forward and not mine our actions to the strains of life, at least
back; to abandon worry as illogical and useless; by establishing predispositions of important sorts.
to see the world at its best; to project his vision But even though the hereditary or innate
beyond the obvious darkness into a region of influences are fundamentally important as giving
imagined light. The slogan has been "Do not a predisposition to the psychoneuroses, it is
get discouraged; you can do better if you try, extremely difficult to define with fairness in
and many a kindly, devoted, ambitious and confi- what this predisposition really consists. The
dent physician has stood ready to play the part of anatomical study of the brains of psychoneurotic
the inspiring leader, the friend toward whom the patients has thus far taught us nothing. The
patient could gaze with veneration and on whom chemical studies of their excretions have been
he could lean. In all these efforts there has equally without fruit. We may surmise that if
been much skill and great devotion, but the re- we had the power to make careful physiological
sults have not been wholly satisfactory. Too tests upon all the nervous functions of the new-
often the symptoms have been simply quieted born infant we might discover differences in his
for the moment; the disease veneered.
responses which would foreshadow mental
I have outlined the reasons for thinking the excitability or mental weakness; but the proofs
study of the psychoneuroses important, the of this are lacking. Towards the close of the
familiar modes of treatment insufficient, and the last century much evidence was adduced to
descriptions of the natural history and course of prove that physical marks of imperfect local bodily
these disorders often incorrect, because based on development (the so-called stigmata) — as lack of
an underestimate of what the best treatment facial symmetry, malformation of the ears or
can accomplish. Let us now turn to scrutinize
the commonly adopted causes.
 

17
 

eyes-were to be found with such frequency
among these patients as to indicate that processes
In the minds of most persons the hereditary or of "degeneration" were silently at work, in
innate tendencies take the first place as causes psychoneurotic families, tending towards still
of these psychoneurotic illnesses. It is not graver disorders, such as idiocy and sterility,
remarkable that this is so, when we consider as their final outcome. Even when no obvious
that the signs of nervous weakness in the child physical stigmata were present it was assumed
usually taking the form of shyness, timidity, that the nervous systems of such patients might
sensitiveness, self-consciousness or of excita- be in some way defective, and many mental pecu-
bility, jealousy and passion are recognizable so
early that they seem to be inborn. Something
which prepares the way for these symptoms
doubtless is inborn, but evidence has been rapidly
accumulating of late years which tends to show
that experiences after birth are more significant
 

1A very important series of observations boring on the innate dif-
ferences in functional vitality between the various mechanisms of tw
body and their significance for the subsequent evolution of charneter
and temperament has been published by Adler (Alfred Adler: Ueber
neurotische Disposition. Jahrb. für Psycho-analyt. u. Psychopath.
Forschungen, Bd. 1, p. 520. See also onrlier papers by the same
author); this work is entirely in line with that of Froud and others of
his school, but the principle involved is too important and complex to
be discussed in a general summary of this sort.
 

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liarities were enumerated which were supposed to the actual disease may never show itself provided
be the outcome of these states. As a portion of the patient can be suitably protected against
this doctrine it was sought to bring every form of causes operative after birth. So true is this
eccentricity and even genius into the baleful that even where the disease" runs true "through
circle of the degenerative tendencies. But to several generations, as in those cases of hysteria
take such an attitude as this was to assign to or obsessional disorders, for example, where
stolidity and commonplaceness a position of parent and child exhibit the same symptoms, it
prominence in a way that mocked at progress, can often be shown to have been the influence
and the credit of the whole scheme suffered of the ignorant, nervous mother, driven by a fatal
severely in consequence. Sterility and idiocy impulse to strive toward reproducing herself
are not characteristic of psychoneurotic fami- in her child and the fatalistic impulse of the child
lies. The creative genius of the artist and the to imitate the mother, rather than any real
imaginative writer does indeed rest on a similar hereditary tendency, that brought the result.
basis with the symptoms of the psychoneuroses, to pass. This line of thought is so important that
but neither of these tendencies points necessarily we must leave it now only to take it up again.
or regularly to "degeneration" as their cause.
The main thing to be said in this connection is
that there is a real correlation between mental
and bodily conditions such as is deserving
of careful study. But it is essential that this
should be made in a very liberal spirit.
 

The strain of modern living is the next influ-
ence on which stress is often laid, but its consid-
eration need not detain us long. The telephone,
the morning paper, the noise of crowded streets,
the seething competition and the pressure for
a narrow and exclusive individualism such as
everywhere makes itself manifest, seem foes of
tranquility and health.
 

It is true that defects of bodily nutrition
are found among these patients which serve
both as indications or consequences and also as But it is probable that these strains appear to
intensifying causes of their impaired nervous be greater than they are and, on the other hand,
states. The enteroptoses, the dry hair and skin, they bring, in a measure, their own remedies.
the impaired digestion, weak muscles, poorly The pace set is set, after all, by men for men,
acting hearts and feeble eye-muscles, which and while it is too fast for some it is not certain
are observed so often amongst a certain class of that on the whole it increases faster than the
neurasthenics, belong in this category of physical power of adaptation of the majority. At the
signs. But, important as these conditions are worst the strains of modern living are mostly
and much as they call for local treatment obvious and open enemies, whereas the enemies
(which is too well known to need re-statement which we have most to fear are those which, in our
here), neither their clinical nor their biological ignorance, we do not see. If we could but secure
significance is clear. Their own etiology is all the power of meeting hard conditions that
indeed in doubt. They certainly cannot be belongs to us by birthright we should not have
considered as essential causes of the psycho- to strive so hard to make these conditions casier.
neurotic illnesses, and on the other hand It is not so much overwork as worry and appre-
there is much question whether they are not, to hension that really sap the nervous vigor, and
some extent, products rather than antecedents of while worry and apprehension doubtless accom-
the disordered nervous and mental states. Dis-pany necessary competition and well-founded
orders of the bodily functions do certainly arise anxiety and doubt, yet it is a piece of common
from disordered emotions and may lead in their knowledge that the most harrassing worries
turn to organic changes on a large scale. Indeed, are those which are without external provocation
between the "organic" and the "functional "but which imply internal tumults of the emotions,
it is impossible to draw sharp lines. Bodily the hidden causes of which it now becomes our
processes are a sounding-board for mental duty to study at close range.
processes, and vice versa. On the whole, the What are the influences, brought to bear
effect of thus seeking to shift the resposibility within the lifetime of the individual, that lead
for these nervous illnesses on to the shoulders to these emotional tumults? How can we best
of our ancestors has been to make physicians explain the conversion of the emotions into the
pessimistic as to their power to help toward a symptoms of disease? Where shall we best find
cure. The hereditary tendency is conceived of an adequate treatment? I beg you to take notice
too strongly as "biological" and therefore not of the fact that the actual evolution of our knowl-
to be materially modified in any given individual, edge in respect to these matters has not followed
and too great emphasis laid upon this point has the lines indicated by the questions which
tended to a gross sort of materialism and fatalism. thus ask. On the contrary, the controlling
The belief that a patient's mental sufferings factors in this evolution have been, partly, the
are a reproduction of tendencies which his scientific tendencies obtaining at the particular
father or his mother showed before him is too periods when the various advances were first
often accepted as an excuse for doing nothing to made; partly, the qualifications, temperament
relieve him. Meantime, another set of facts and training of the particular investigators.
has been coming more and more prominently It has long been plain to every one that emotional
forward. The something" that we inherit is, influences were important causes of disease,
in most cases, a" tendency "indeed, but nothing and various modes of combating these influences
more, and as in the instance of tuberculosis have been described, but it is only rather recently
 

"
 

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[JULY 21, 1910
that the origin of these emotions and the mode of servers of which Freud was the leader and is still
production of the symptoms have been measure- the central figure. Janet's work and that of
ably understood. The physicians who have been men following similar lines (Morton Prince,
the leading workers in this great field of study Sidis, etc.) have made a revolution in the field of
may be classified in three groups: (1) The group scientific psychology; Freud's work has extended
of the accurate observers, descriptive analysts, this scientific revolution and has set on foot an
natural historians; (2) the group of the thera- equal revolution in character-study, educational
peutists; (3) the group of the constructive ana-psychology, race-psychology, child-study and
lysts, inductive reasoners, philosophie thinkers. folk-lore.
 

It is possible to describe the symptoms of a The Freud method (to which the name of
disease and to observe many facts in the natural "psycho-analytic "has been given) does not
history of its development, as a naturalist depend for its therapeutic success upon the
studies the characters of an animal or a species, ability of the physician to hypnotize his patient
without being greatly drawn to see its real place or of the patient to subject himself to the hyp-
in the great scheme of nature; it is eminently notic influence. It is not an effort to spread the
possible for men of practical instincts the healing mantle of any "suggestive" influence
nurturing instincts” perhaps they might be over the painful details of the case. It is an
called to treat patients with great success, up attempt to enable the patient to penetrate with
to a certain point, without having any adequate tireless zeal, increasing skill and fearless honesty,
conception of the causes of their illnesses.
upon the details of his own emotions, life and
Consult your own memories and you will see thought, in the belief that nothing becomes less
the parts which men of these different types have sacred or fails to become less painful, through be-
played. For examples of the observers and de- ing clearly seen. Such being its purpose it is hard
scribers we might go back to Falret and Briquet, to see why this method can justly challenge the
who gave us such excellent accounts of folic de hostility of any conscientious person, though easy
doute and of hysteria, even in the middle of the to see why many physicians should shrink from
last century. The French have always been the difficulties attending its successful applica-
prominent in these lines, and I will next mention tion. "Suggestion," "isolation," improvement
that truly great pioneer in descriptive clinical of the bodily nutrition, persuasion, explanation,
analyses, Pierre Janet, the pupil of the great all of which have their valued place, leave many
Charcot, without pausing to mention those of the great springs of emotion and of motive
who with such brilliant success have followed entirely untouched. They make no adequate
similar lines. Janet's remarkable contributions effort to base themselves on any deep knowledge
marked the beginning of a new era of knowledge, of human nature. Their influence, however im-
and the data which they have furnished will be of portant it may be, is bound to be limited in
enduring value. If they do not represent a move-its scope.
 

ment capable of indefinite expansion it is be- The psycho-analytic method does not indeed
cause they have been of the nature of studies necessarily give us all that we may need for
into this or that special problem of medical spiritual progress, but it prepares the way and
psychology rather than recognitions of typical opens a long path. It does not exclude the other
facts lending themselves readily to great philo-
sophic and sociological generalizations.
 

modes of treatment, but supplements some of
them and often renders all of them unnecessary.
If the slogan of the suggestive psychotherapeu-
tics has been, "You can do better if you try,'
the distinctive slogan of this method is "You
can do better when you know."
 

As examples of the therapeutists, the men of
practical instincts, I need only mention Charcot,
Weir Mitchell and his followers, and such men as
Liébault, Bernheim, Van Eeden, Forel and
Dubois. These names stand only for a few men But when you know what? The answer has
out of hundreds and of course those who bore been already given, "When you know yourself."
and bear them were not exclusively therapeutists. The symptoms of the psychoneuroses,-morbid
Finally, we come to the third group of investi- fears, irresistible impulses to thoughts and acts,
gators, whom I have designated as analysts, distressing doubts, nameless apprehensions,
inductive reasoners and broad thinkers. The and not these symptoms of illness alone, but also
foremost representative of this group, at the their congeners, selfishness, envy, suspicion, and
present day, is unquestionably Sigmund Freud, temptations to cruelty and prejudice such as
a remarkable personage, whose observations have filled the world with misery, have been
and whose method have opened for us avenues largely the outcome of self-ignorance, in the
of inquiry into which men of the best minds are sense that in this ignorance, the deeper sources
pressing forward in ever increasing number. of which have been, until now, imperfectly
No future student of human character and defined and largely unsuspected, lies the secret
motives, whether these be called normal or of the occurrence of these evils. It is the removal
morbid, will ever make studies deserving serious of this ignorance and, the implantation of the
recognition without familiarizing himself with desire as well as the ability to see things as they
the researches of the school of thinkers and ob- are that constitutes the best and only radical
It will of course be understood that I am speaking of leaders in treatment. This treatment, too, has its practical
 

"
 

psychoneurology alone.
 

Each person may be conceived of as representing the community in
Strictly speaking the originator of the psycho-analytic method was microcosm and the social sins of hatred, otc., represent conflicts between
Joseph Breuer, Freud's older colleague and co-worker.
different aspects of our pust and present selves.
 

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limitations, but these are rather incidental to which had been repressed and rejected from
the difficulties of application of the method than the light of conscious knowledge.
inherent in its nature. It is a necessary condition We say we cannot bear to think of "-and
for the therapeutic success of this method of so strive not to think of one or another matter,
radical re-education that the patients should when in fact it is self-interest, or laziness, or
be reasonably intelligent, not too old and inclas-blind obedience to an artificial code of social
tic, absolutely honest, absolutely unreserved in rules that really impels our choice.
dealing with their physician, ready to join him Magna Charta, the abolition of slavery, the
in the inquiry, prepared to confide absolutely change of sentiment as to promiscuous alms-
in his reliability and good faith. It is necessary, giving, every true reform,—were all wrung from
likewise, that the physician should be confident persons possessed of a certain power to maintain
in his own motives and that he should have had their views against the Cromwells and Washing-
a special training and special interest in this tons and Wilberforces that rose up vigorously
sort of psychological research. In other words, against them. The Cromwells are often narrow,
this kind of investigation, which seeks at once to too; they also are but partial knowers of them-
discover the causes of the disorder and by that selves. But one great reason for their success is
very fact to apply the remedy, implies a high that they represent arguments the truth of
degree of skill and training, or of natural aptitude. which upholders of the established order already
It is not, therefore, well adapted for the general have divined but will not formulate to themselves
practitioner or for the run of hospital patients, or listen to when adduced by others.
and no one should enter on such a course of And so it is with our own conscious attention
treatment in any given case without being pre-in its dealing with rejected thoughts. We prefer
pared to carry it to the end. If he does so he may to accept the established, traditional opinion
find himself standing aghast at the task before rather than to investigate and think; we prefer,
him, as Faust stood before the Earth Spirit if need be, to show anger and bigotry rather than
which his magic arts had summonetl. But even
though the general practitioner does not use this
method, every physician should understand its
scope and meaning, just as every physician should
know the principles of many bacteriological
procedures which he can never use.
 

investigate and think; and yet we, too, divine the
truth. For, be it clearly understood, the experi-
ences, thoughts and emotions which we reject
because they do not fit into the scheme of life
which we select are not so far out of our minds as
we suppose. We do not like to think of them,
we do not dare perhaps to think of them, we say
we do not think of them. But they are in our
memories and in our minds, and they influence
our acts; and it is the half-consciousness of their
presence, and the fact that they represent deep
instinctive cravings of our natures, in spite of our
assumed hatred of them and our shrinking from
them, that induce such emotions in us as anger
I spoke a few moments ago of the "tumults of and depression and envy and prejudice and
conflicting emotions" and also of "self-ignorance" jealousy and fear, and the impulse to adopt
as being the causes of the psychoneurotic symp-ceremonies and observances which are practically
toms. Both of these terms need amplification analogous to pagan ceremonies of propitiation
and explanation.
 

It is important to note that the generalizations
of which I shall now speak were worked out
laboriously through the direct and prolonged
questioning of many patients and the combined
observations of many men, partly pupils and
followers of Freud, partly independent workers
in a much-neglected field. (Havelock Ellis,
Krafft-Ebing, Moll, Fliess, etc.
 

and expiation. Indeed, the whole fabric of
mythology is built on the projection outward
of the sense of war and tumult and revolt
and victory going on within ourselves between
the thoughts and emotions which we clearly
formulate and those which we only half or a
quarter formulate and those which we do not
formulate at all and affect not to know, yet
which in reality influence our acts and thoughts.
 

Before any one could be said to really know
himself it would be necessary for him to know
all the experiences, thoughts and emotions
which he had had since birth. Of course this is
impossible, but he might at least know them,
or be able to summon them into the focus of
his consciousness, by groups and samples, and
every one would admit that a person did not
know himself even tolerably well who had, either Now, the leaders of the psycho-analytic move-
deliberately or in obedience to some blind im- ment have shown that these attempts to conceal
pulse, selected certain groups of experiences, ourselves from ourselves lead to mental conflicts
thoughts and emotions which he chose to take and to illness and to false standards of civiliza-
as standing for himself, and turned his eyes tion. They are insisting that those who wish
away from other groups, in spite of the fact not to be invalids shall not be encouraged
that the rejected knowledge was of obvious to hedge themselves behind their lack of knowl-
importance. And yet this species of selection edge or their unwillingness to think or the
and rejection is continually going on with every divine right of some conventional code of
one of us. It takes place also, and on a large morals, without its being made clear to them that
scale, with communities and nations, and one these artificial rights are waging war within
of the chief functions of education and civili- their minds with instincts older than morals and
zation is to obtain their rights for important standing in no necessary antagonism to morals.
groups of experiences, thoughts and emotions | There is a sacredness in traditional customs,
 

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the filtered wisdom of the ages, but there is who helps to make this scrutiny soon comes to
also a sacred right to revolt against them and realize that no symptom or trait of character can
a sacred obligation in either case not to act or be adequately understood except on the basis of a
think without a reasonable knowledge of the relatively complete knowledge of the patient's
facts. The typical signs and symptoms of nervous whole environmental and emotional life since
invalidism of the type that is now before us are infancy. As this knowledge grows gradually
really covers and substitutes instinctively adopted wider and more accurate the element of time seems
for the purpose of putting aside (concealing) gradually to be eliminated from the history;
thoughts, emotions, cravings and longings of infancy and age become approximated; the cause
forbidden sorts, or of sorts that it hurts one's and the result are seen at one glance and as if
sense of pride to face. They are all symbolisms, coalescing; the present act, which one might have
analogous to the symbolisms of dreams, and like felt tempted to characterize roughly as selfish
them they point, for those who can read their or cowardly or criminal, is seen as the logical
hieroglyphic language, at the desires and repres- expression of a repressed but natural instinct or
sions which are the real facts at stake. These of a misconception, formed in childhood but
thoughts and desires, half-formulated or unfor- witnessed as if now living and active.
mulated, cause a sense of deep distress, for which The immense significance of that rapid but hidden
the patient instinctively seeks reasons to account. transition from babyhood with its animal instincts
Led by this instinct he adopts the figment of a fear and emotions to the later periods with their
of bridges or open windows or of railroad trains or artificial morals and conventions is now for the
of an impulsion to do injury to some one. In these first time clearly recognizable, through this process
symptoms, distressing though they are, the patient of rendering the whole life transparent, and its
expresses in a rough fashion the cravings in which intensely dramatic features are susceptible of being
they had their birth; and for that reason he clings clearly understood.
to his fears as to something which has the sacred Then, as the research goes further, several
fascination of a relic, though not realizing that he other principles gradually get developed. The
does so. If he would get well he must learn to see occasions on which these intolerable mental
this, and for this purpose his entire life, and not conflicts arose for which the fears were substituted
merely the latest phase of it, must be made as are found to have been not one or two alone, but
transparent as glass, so that he may be able to see many and of various sorts. The recognition of this
the whole of it at one glance. It will then appear multiplicity of emotional traumata is an important
that it is his own thoughts of which he is afraid and supplement to the commonly accepted principle.
that his present fear has been preceded by other A patient has a railroad accident, for example, or
fears, the outcome of the same and other sets of some severe emotional excitement, and these
mental conflicts, dating back, many of them, to events (which in themselves involve considerable
days of childhood. To state the facts again in mental conflict) are considered as the sole and
other words, his present fear represents a state of sufficient cause of the symptoms that result.
mental distress which arose as an expression of the But when his history is well analyzed many other
fact that his thoughts or emotions relating to events are found, different in appearance from the
some important subject or subjects had become in- last, but psychologically of like import. "To
tolerable to him, and the open window, the bridge, fall," "to be overpowered," to "suffer loss,"
the railroad train serve simply as so many molds to be in danger" are terms which apply to many
into which the patient instinctively seeks to com- emotional as well as physical situations of the
press his vague and apparently causeless distress most varied sorts, and such as every one has been
and so to explain it, even though erroneously, to exposed to not once alone, but many times, and
himself. Every one recognizes that a bridge is a the unconscious memories of these rush in, im-
place from which people sometimes jump or fall, pelled by the force of mental association, to lend a
that a train journey is a common cause of acci-new fulness of meaning to the railroad accident
dents, that to be "shut in," whether actually or and to receive a new fulness of meaning for them-
morally, has a certain element of the unpleasant. selves from it.
For reasons such as these, and perhaps many more, But is there no difference in significance and
the situations indicated are really seized upon as standing between these various related and associ-
excuses for the fears, simply because some excuse ated memories? Are there not some that have more
must be found. The patient, recognizing that he power for harm as centers of emotional stress?
must find some way of accounting for his distress, The inevitable answer is (however gradually it
instinctively grasps at causes which his neighbors may come to the surface in a given case) that those
would recognize as reasonable. This method of emotional conflicts have the greatest power to
explaining the genesis of morbid fears is not a piece give a tone or color to the rest into which we
of a priori argument, but a mode of reasoning originally put the deepest essence of ourselves,
arrived at by questioning the patient's own experi- our strongest hopes, our most personal and secret
ence and emotions. At first the patients do not see
its logic, but gradually the truth enforces itself
upon them and makes them able and willing to
see themselves in a new light and to learn to
substitute an intelligent scrutiny for an endless
chain of morbid introspection. The physician
 

and, therefore, most strongly repressed longings,
 

This transition from the non-social period of infuney to the more
 

and more social states of normal childhood and adult life, a transition
in which the moral sonse is first developed and when, therefore, an
many antecedent acts and feelings, is of great importance for the whole
likewise, at a sort of biological basis for the doctrine of "original sin."
 

unfavorable judgment must be passed (of course unconsciously) on
theory of character formation und symptom-production. It hints,
 

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BOSTON MEDICAL AND SURGICAL JOURNAL
 

Von. CLX111, No. 3]
 

the feelings in which not only the prudent wishes a remarkable degree. It is interesting to recall, in
of adult life, but the deep, uncensored cravings of this connection, that young children when passing
infancy and youth could find expression. In other through the period of transition from their "sex-
words, it is the emotions related to the great less" state to that of girlhood and boyhood, and,
functions of reproduction, the sexual functions, still more, when impelled by vague memory of
that hold this position of prominence as giving that period, sometimes dream of themselves as of
color to the rest. It is in the conflicting tides of the opposite sex or as uncertain to which sex they
feelings of sexual origin, at which all romances, now belong.
almost all imaginative and dramatic literature, Two questions naturally present themselves
love to hint, some prompting to intense expres to one who hears the merits of this psycho-analytic
sion, others to equally intense repression, all of method described for the first time; first, Does not
which meet in fierce antagonisin around the all this questioning about past matters lead to
sexual instinct, that the real cause of nervous morbid introspection? then, supposing all these
symptoms should be sought. But this should hidden facts have been obtained, What next?
be understood with reference to the principle | Where does the therapeutic influence come in?
just stated, namely, that a vast number of To one who has become practically familiar
emotions take their tone and value from the with the working of this method these questions
strongest or most fundamental one among them, present no great difficulty. So far from morbid in-
just as a large school of artists may get its trospection being caused by this treatment it is pre-
name from that of their greatest representative. vented by it. Every patient is forced by the very
It is only when this point is grasped that we can terms of his illness to dwell upon his symptoms;
meet the objection of those who urge a host of he rolls them continually over in his mind like the
other motives and emotions as of equal rank with tunes of a barrel-organ and without ever arriving at
those of sexual nature. So far as our conscious a satisfactory conclusion. The method of investi-
awareness is concerned, they may be of even higher |gation which is here described substitutes an
rank. For the time when the sexual craving was so interested search, an intellectual inquiry, for this
strong may have been in the forgotten period of emotional treadmill of false reasoning.
infancy, and even then these cravings may not have As regards the therapeutic value of the method,
been recognized as sexual at all. It may be only much the same answer will suffice. The mental
through our reasoning that their true nature is conflict to which I have referred, and which results
revealed. And yet they may have been intense in all the morbid symptoms, goes on without the
enough to have founded the emotional traits patient's knowledge although half-divined. The
of character which came, later, to be represented cure consists in bringing these unconscious
in the mental struggles from which, first the processes to the light of reason. In their own
distress, later the specific fears and illnesses nature they are imps of darkness and lose their
emerged.
power for harm when brought into the light. To
 

It is not, then, necessary that every nervous be sure, it is not enough that this knowledge
invalid should accuse himself of having been should be mere lip and ear information. Even
"sexually inclined" in any objectionable sense, this is something, but for the best result the
although it ought to be interjected here that the knowledge of the truth should soak into the mind
germs of the sexual perversions and inversions and express itself in the acts and become an
which when developed into an exaggerated form integral portion of a new and reformed personality.
we characterize as criminal or morbid, are found In proportion as this is accomplished, the person
in normal infancy and even in normal adult in question approaches towards the desired knowl-
life. All these psychoneurotic illnesses, it cannot edge of himself. He may still feel, and should still
too often be repeated, are caricatures of normal feel a craving for some further self-expression, a
tendencies. It is this which justifies the designa- desire to take others, in increasing number, into
tion of them as "functional." This point is not the circle of his thoughts and interests and affec-
brought forward as a mere bit of academic tions. But this craving will no longer tend so
quibbling, but as a matter of the most practical strongly to clothe itself in infantile, utterly
importance. The infant is at first sexless, or, personal and sensuous forms, which excite a
rather, both sexes are equally represented in his
emotional life. It is often as natural to him to
love and love intensely persons of his own sex as
those of the opposite sex, his parents as those not
standing in this relationship to him. Such intense
love may reappear later in an exaggerated form
and may lead to exaggerated expression of various
morbid sorts. Children often exhibit a passion of
objectionable intensity for teachers of their own
sex, or for older children, and teachers for their It is, of course, clear, and clearer far to me than
pupils, and the exaggerated passion of children for you, that this address is anything but complete.
parents may lead to relations of dependence, of in- For one thing, I should have been glad to discuss
stinctive imitation, of "identification," which further the important fact that much of the
dwarfs and limits their own development, or helps explanation for our mental conflicts, in which the
to foster the seeds of nervous invalidism in them, to symptoms of these maladies originate, takes place
 

feeling of mortification and the need of repression
and suppression and expiation. The obsession of
killing some person whom one really loves, of
throwing oneself dramatically from an open win-
dow, are pretty certain to be recognized as ludi-
crously caricatured survivals from the days and
phantasies of childhood; a railroad train takes
its proper shape as a convenient means of locomo-
tion.
 

[JULY 21, 1910
 

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BOSTON MEDICAL AND SURGICAL JOURNAL
 

wholly or partly within the bounds of that limbo social codes and customs, not only of the middle
which we call our unconscious mental life. Vol-ages, but of the present day, which are of the same
umes might be written, also, with reference to the origin with these private prejudices, sins and symp-
great struggle between instinct and social culture toms. To labor against both sets of ills and for
which, while it is responsible for civilization and a better private and public status, is a worthy
progress, is responsible also for repression, bigotry, aim, and if the method of investigation here advo-
illness, misunderstanding and misjudgment of cated can contribute towards this end it should
others and ourselves. Our cultural life with all be warmly welcomed and the labor which its
its virtues is far narrower and more narrowing application involves in any given case should be
than most of us conceive. To broaden some of considered well-rewarded.
its tendencies should be our earnest effort, and Furthermore, what applies to the neurologist,
to this great aim the art of psycho-analysis applies almost equally to the patient. Nervous
is partly consecrated. We should learn to deal invalids should regard themselves not solely as
less in moral judgments and more in knowledge. persons in misfortune, but also as persons in
Moral judgments are, to be sure, needful for position of opportunity and trust; they should
the rough exigencies of social life, as precursors feel themselves members of a band of investi-
of the jail and as affording protection against gators working in a great field, and as in a position
obvious practical evils. But for the scientific | to utilize their individual experiences, even though
thinker they are out of place. The phrase "tout painful, as data towards the solution of a problem
comprendre est tout pardonner" is not indeed of universal interest.
 

applicable to the whole situation, especially in the
 

case of the person mainly concerned. No one
 

should wish to deny moral responsibility for his A CONTRIBUTION TO THE ETIOLOGY OF
acts and thoughts. But it is nevertheless true
that to “know all " is often justly to modify our
judgment and our means of progress.
 

ACTINOMYCOSIS. THE EXPERIMENTAL
PRODUCTION OF ACTINOMYCOSIS IN
GUINEA PIGS INOCULATED WITH THE
CONTENTS OF CARIOUS TEETH.
 

The familiar sins of "incontinence, violence
and malice" which Dante punishes in his Inferno
as attacks upon social stability and progress
might justly be described in medical terms as
equivalent to psychoneurotic symptoms; and in
the sufferings and joys of those whom this great
student of human nature sets toiling up the hill of
J. ISRAEL 'noted the presence of carious teeth
Purgatory it is possible to read the symbolized in three of five cases with actinomycosis. In one of
history of that typical and desirable sort of con- the three he succeeded in demonstrating the para-
valescence from the miseries of nervous illness site of the disease not only in the pus of a sub-
which leads not only to a better personal health, periosteal abscess of the lower jaw, but also in
but to a wider sense of social opportunity and the root canal of an extracted, neighboring and
obligation. The community is the individual
written large, and the so-called normal individual carious molar tooth. He inferred that the parasite
resembles the psychoneurotic invalid, but with made in his publication of the presence of the
the difference that he has learned, either instine- organism in the teeth of any of his other patients
tively or consciously, in infancy or in childhood or or in individuals without the lesions of actinomy-
in later years, to establish a harmonious co-cosis.
operation amongst the dominant tendencies of
 

HY FREDERICK 1. LORD M.D., BONTON, MANN.,
Instructor in Clinical Medicine, and Visiting Physician to the Clinic in
the Harvard Medical School; Physician to Out-Patients, Mussachu-
netts General Hospital.
 

1. SUGGESTIVE PREVIOUS WORK.
 

was harbored in carious teeth. No mention is
 

The first extensive studies on the biology of the
his mental life, or what is the same thing micro-organism of the disease were made by
transferred to another field of action to adjust Bostroem and by Wolff and Israel.³ Their
himself to some workable conception of community widely different views are responsible for much of
The invalid is he who is roughly studying the confusion which has since prevailed.
this important lesson and within whose mind the Bostroem's opinion that both man and animals
struggle is still going on between native instincts, are infected from sources without the body by
on the one side, and the forces arrayed to estab- the implantation within the tissues of grains,
lish and maintain a series of moral and social especially barley grains or their fragments, has
standards imposed by the traditions of a con- received general acceptance. It is now known,
ventional community, upon the other side. however, through the masterly work of J. H.
If this thesis is correct, the physician's task Wright that Bostroem and many subsequent
broadens into that of reviewing these moral and
social standards themselves and studying into the
question of their justice, their desirability, their
real origin. The sociological significance of the
physician's task, as he studies nervous invalidism,
is seen to take on a new importance in view of
these considerations. The mischief which may
be done by the ill-regulated emotions and preju-
dices of a "normal" person is always painful to
contemplate. But there are many narrow and cruel Med. Research, vol. xiii, May, 1905.
 

life.
 

investigators, beginning their experiments with
material containing true actinomyces, have in
many instances cultivated therefrom a group of
organisms properly classed among the Nocardia.
Organisms of this group are widely distributed
 

*This investigation was undertaken under a grant from the Proctor
 

Fund of the Harvard Medical School,
 

Virchow's Arch., 1878, 74, p. 15.
 

Beitr. 2. path. Anat. u. z. ilg. Path., ix, 1890, pp. 1–240.
Virchow's Arch., 1801, exxvi, pp. 11-50.
 

The Biology of the Micro-organism of Actinomycosis. Jour.