University of Virginia Library

THE PSYCHONEUROSES AND THEIR TREATMENT BY PSYCHO-THERAPY. By Professor J. Déjérine and Dr. E. Gauckler. Authorized Translation by Smith Ely Jelliffe, M. D. Ph. D. J. B. Lippincott Co., Philadelphia, Pa.

This book is another instance of the lack of a common nomenclature in psychopathology. Psychological mechanisms are penetratingly discussed; and important syntheses are made regarding categories which many American psychopathologists name differently not to speak of the nomenclature of the repressionist of Vienna. It seems to the reviewer indeed, that what the authors call neurasthenia is merely a somewhat complex elaboration of the psychosis by induction to which Babinski has restricted the name hysteria. It is true that certain manifestations of this, especially a false gastropathy, may lead to an increased fatigue, and to this the name neurasthenic might appropriately be given. But still more often one sees the appearance of increased fatigue on account of the patient's faulty notion; and to this the name neurasthenic should certainly not be given.

To place in the same rubric a simple somatic hysteria like a paralysis and the complications of what are comprised in psychological neurasthenia as so lucidly described in this book, seems at first sight irrational; but so at first appeared the placing together of clinical pictures as unlike as cervical struma, phthisis pulmonalis and ossious caries under the rubric of tuberculosis, and in a nearer field the synthesis of catatonia, hebephrenia and cementing paranoia into the rubric of dementia precox. So, recognizing

the accuracy of the beautiful analysis of Professor Déjérine of what he calls neurasthenia, we venture to assimilate it with the equally true analysis which Babinski has made of the immediate mechanism of what he wishes to call pithiatism. It is the condition which we personally term hysteria, and the mechanism of which we have more especially studied in the traumatic neuroses and the occupational dyskinesias and some other disorders incident to the exercise of trade or profession. Indeed, the authors say:—"One can see that the helmet headache, the pain in the nape of the neck, and the pain in the spine are frequent among cultivated people and educated neurasthenics, but much rarer among the others" and he explains this by saying that these disturbances "are due to the diffusion of the attention towards obsessions or preoccupations;" and he gives as an example the reply of a patient "I think of my illness or such vicissitude by which it was brought about." Indeed, in one place, Professor Déjérine goes so far as to permit himself to say that the hypochondriac preoccupation itself constitutes originally a purely intellectual conception, a propos of which, but secondarily to it the patient really may work up an emotion, but which is really not of emotional origin, a position first taken and long insisted upon by the reviewer.

What is this when traced to its source but the mechanism of suggestion? The portion of the book describing the functional manifestations of the digestive system is charged with most illuminating instances of associational mechanism typifying the induction of morbid reactions by suggestion. No one perusing them can fail to perceive that the psychological process at work does not differ in principle from that found in the somatic hysterias, from which therefore their separation seems unjustifiable, and at the hands of so eminent an author is likely to maintain rather than diminish present psychological misunderstanding.

The dissimilarity of terms and resemblances of ideas has another illustration in the reference to energy and the will; here it is clearly pointed out that the apparent aboulia of the "neurasthenic" is not a lack, but an unfruitful directing of the will while the Viennese school imply the same idea in their doctrine of sublimation.

The authors believe that neurasthenia differs from the psychasthenia of Janet in that the latter is constitutional, and that the obsessions are secondary, when analysed profoundly, to some pain-bearing contingency which by the mechanism of association has pervaded the mind and which henceforth distorts it with subsequent realities. And yet when Déjérine lays stress upon the fact that badly organized moral hygiene conduces to the emotional preoccupations which lead to obsessions and which he regards as the essential characteristics of the neurasthenic constitution, he leaves no apparent distinction from the psychasthenia of Janet.

"The fundamental distinction of neurasthenia is causation by emotion," but the authors have not extricated this factor from the

role played by induction either of idea or its secondary emotion. In such a fundamental matter as anaesthesia for instance, they say: "In our opinion there exist three classes of hysterical anesthesia. In the first series of facts one may place the cases due to simulation. In the second group of cases we shall range the patients in whom the disturbances of sensibility are directly due to suggestion. Finally there remains a third class of patients in whom the disturbances of sensibility seem to us to be residual emotional phenomena."

"Emotion is able to suppress sensibility entirely by producing absolute side-tracking, and that under such circumstances it was really a question of total anesthesia and not purely psychoanesthesia. When the state has passed and the emotional cause has disappeared the sensibility may return, but anesthesia which is preserved may also persist, either by auto-suggestion or as in the case of the individual who remarks that he felt none of the various injuries which he has experienced, or it is a question of simple residual phenomenon independent of all suggestion." And yet, further on, the authors say that the phenomena of auto-suggestion cannot be separated from the emotion. All this lacks clarity; and except in the instances of failure of perception or of auto-suggestion, the mechanism is not intelligibly set forth.

The authors, however, although under the deplorable classification of neurasthenia or hysteria, depart from the usual therapeutic methods and seek the cause of the patient's disease outside of the objective symptoms and declare that the "element of diagnosis lies chiefly in the origin of the symptoms."

They make much of the assertion that Dr. Weir Mitchell's method of treatment is based practically upon isolation, rest in bed, over-feeding, douches, massage and electricity, in fact on purely physical measures and Professor Déjérine adds: "I was not long in discovering that unless the patient's state of mind improved, the therapeutic results were far from satisfactory;" and he gives examples.

But in spite of the objections to the nosology and psychopathological theory of the authors, there remains nothing but the highest praise for the presentation of the clinical facts and of the sound advice regarding the therapy of various functional manifestations, and concerning the role of the physician in the prophylaxis of the psychogenic neuroses. It is most desirable that every physician should be aware of the clinical facts which Professor Déjérine has accumulated in his vast experience. In gynaecology, gastroenterology, cardiology. and genitounary disease the psychogenetic affections are ignored by most physicians.

This book will give a better understanding of what every practitioner of those specialities should be familiar with.

TOM A. WILLIAMS.