분석심리학 논문집/Chapter13

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CHAPTER XIII

THE CONTENT OF THE PSYCHOSES[194]


INTRODUCTION[편집]

My short sketch on the Content of the Psychoses which first appeared in the series of "Schriften zur Angewandten Seelenkunde" under Freud's editorship was designed to give the non-professional but interested public some insight into the psychological point of view of recent psychiatry. I chose by way of example a case of the mental disorder known as Dementia Præcox, which Bleuler calls Schizophrenia. Statistically this extensive group contains by far the largest number of cases of psychosis. Many psychiatrists would prefer to limit it, and accordingly make use of other nomenclature and classification. From the psychological standpoint the change of name is unimportant, for it is of less value to know what a thing is called than to know what it is. The cases of mental disorder sketched in this essay belong to well-known and frequently occurring types, familiar to the alienist. The facts will not be altered if these disorders are called by some other name than dementia præcox.

I have presented my view of the psychological basis in a work[195] whose scientific validity has been contested upon all sorts of grounds. For me it is sufficient justification that a psychiatrist of Bleuler's standing has fully accepted, in his great monograph on the disease, all the essential points in my work. The difference between us is as to the question whether, in relation to the anatomical basis, the psychological disorders should be regarded as primary or secondary. The resolution of this weighty question depends upon the general problem as to whether the prevailing dogma in psychiatry--"disorders of the mind are disorders of the brain"--presents a final truth or not. This dogma leads to absolute sterility as soon as universal validity is ascribed to it. There are undoubted psychogenic mental diseases (the so-called hysterical) which are properly regarded as _functional_ in contrast with organic diseases which rest upon demonstrable anatomical changes. Disorders of the brain should only be called organic when the psychic symptoms depend upon an undoubtedly primary disease of the brain. Now in dementia præcox this is by no means a settled question. Definite anatomical changes are present, but we are very far from being able to relate the psychological symptoms to these changes. We have, at least, positive information as to the functional nature of early schizophrenic conditions; moreover the organic character of paranoia and many paranoid forms is still in great uncertainty. This being so it is worth while to inquire whether manifestations of degeneration could not also be provoked by psychological disturbance of function. Such an idea is only incomprehensible to those who smuggle materialistic preconceptions into their scientific theories. This question does not even rest upon some fundamental and arbitrary spiritualism, but upon the following simple reflection. Instead of assuming that some hereditary disposition, or a toxæmia, gives rise directly to organic processes of disease, I incline to the view that upon the basis of predisposition, whose nature is at present unknown to us, there arises a non-adaptable psychological function which can proceed to develop into manifest mental disorder; this may secondarily determine organic degeneration with its own train of symptoms. In favour of this conception is the fact that we have no proof of the primary nature of the organic disorder, but overwhelming proofs exist of a primary psychological fault in function, whose history can be traced back to the patient's childhood. In perfect agreement with this conception is the fact that analytic practice has given us experience of cases where patients on the borderline of dementia præcox have been brought back to normal life.

Even if anatomical lesions or organic symptoms were constantly present, science ought not to imagine the psychological standpoint could advisedly be neglected, or the undoubted psychological relationship be given up as unimportant. If, for instance, carcinoma were to prove an infectious disease the peculiar growth and degenerative process of carcinomatous cells would still be a constant factor requiring investigation on its own account. But, as I have said, the correlation between the anatomical findings and the psychological picture of the disease is so loose that it is extremely desirable to study the psychological side of it thoroughly.


PART I[편집]

Psychiatry is the stepchild of medicine. All the other branches of medicine have one great advantage over it--the scientific methods can be applied; there are things to be seen, and felt, physical and chemical methods of investigation to be followed: the microscope shows the dreaded bacillus, the surgeon's knife halts at no difficulty and gives us glimpses of most inaccessible organs of vital importance. Psychiatry, which engages in the exploration of the mind, stands ever at the door seeking in vain to weigh and measure as in the other departments of science. We have long known that we have to do with a definite organ, the brain; but only beyond the brain, beyond the morphological basis do we reach what is important for us--the mind; as indefinable as it ever was, still eluding any explanation, no matter how ingenious. Former ages, endowing the mind with substance, and personifying every incomprehensible occurrence in nature, regarded mental disorder as the work of evil spirits; the patient was looked upon as one possessed, and the methods of treatment were such as fitted this conception. This mediæval conception occasionally gains credence and expression even to-day. A classical example is the driving out of the devil which the elder Pastor Blumhardt carried out successfully in the famous case of Gottlieb in Deltus.[196] To the honour of the Middle Ages let it also be said that there are to be found early evidences of a sound rationalism. In the sixteenth century at the Julius Hospital in Würzburg mental patients were already treated side by side with others physically ill, and the treatment seems to have been really humane. With the opening of the modern era, and with the dawn of the first scientific ideas, the original barbaric personification of the unknown Great Power gradually disappeared. A change arose in the conception of mental disease in favour of a more philosophic moral attitude. The old view that every misfortune was the revenge of the offended gods returned new-clothed to fit the times. Just as physical diseases can, in many cases, be regarded as self-inflicted on account of negligence, mental diseases were likewise considered to be due to some moral injury, or sin. Behind this conception the angry godhead also stood. Such views played a great _rôle_, right up to the beginning of last century, especially in Germany. In France, however, about the same time a new idea was appearing, destined to sway psychiatry for a hundred years. Pinel, whose statue fittingly stands at the gateway of the Salpetrière in Paris, took away the chains from the insane and thus freed them from the symbol of the criminal. In a very real way he formulated for the world the humane and scientific conception of modern times. A little later Esquirol and Bayle discovered that certain forms of insanity ended in death, after a relatively short time, and that certain constant changes in the brain could be demonstrated _post mortem_. Esquirol had described as an entity general paralysis of the insane, or as it was popularly called "softening of the brain," a disease which is always bound up with chronic inflammatory degeneration of the cerebral matter. Thus was laid the foundation of the dogma which you will find repeated in every text-book of psychiatry, viz. "diseases of the mind are diseases of the brain." Confirmation of this conception was added about the same time by Gall's discoveries which traced partial or complete loss of the power of speech--a psychical capacity--to a lesion in the region of the left lower frontal convolution. Somewhat later this view proved to be of general applicability. Innumerable cases of extreme idiocy or other intense mental disorders were found to be caused by tumours of the brain. Towards the end of the nineteenth century Wernicke (recently deceased) localised the speech centre in the left temporal lobe. This epoch-making discovery raised hopes to the highest pitch. It was expected that at no distant day every characteristic and every psychical activity would be assigned a place in the cortical grey matter. Gradually, increased attempts were made to trace the primary mental changes in the psychoses back to certain parallel changes in the brain. Meynert, the famous Viennese psychiatrist, described a formal scheme in which the alteration in blood-supply in certain regions was to play the chief part in the origin of the psychoses. Wernicke made a similar but far more ingenious attempt at a morphological explanation of psychical disorders. The visible result of this tendency is seen in the fact that even the smallest and least renowned asylum has, to-day, its anatomical laboratory where cerebral sections are cut, stained, and microscoped. Our numerous psychiatric journals are full of morphological contributions, investigations into the structure and distribution of cells in the cortex, and other varying source of disorders in the different mental diseases.

Psychiatry has come into fame as gross materialism. And quite rightly, for it is on the road--or rather reached it long ago--to put the organ, the instrument, above function. Function has become the dependent accessory of its organs, the mind the dependent accessory of the brain. In modern mental therapy the mind has been the loser, whilst great progress has been made in cerebral anatomy; of the mind we know less than nothing. Current psychiatry behaves like a man who thinks he can unriddle the meaning and importance of a building by a mineralogical investigation of its stones. Let us attempt to realise in which mental diseases obvious changes in the brain are found, and what is their proportion.

In the last four years we have received 1325 patients at Burgholzi;[197] 331 a year. Of these 9 per cent. suffered from congenital psychic anomalies. By this is understood a certain inborn defect of the psyche. Of these 9 per cent., about a quarter were imbeciles. Here we meet certain changes in the brain such as microcephalus, hydrocephalus, malformations or absence of portions of the brain. The remaining three-quarters of these congenital defects present no typical changes in the brain.

Three per cent. of our patients suffer from epileptic mental troubles. In the course of epilepsy there arises gradually a typical degeneration of the brain. The degeneration is, however, only discoverable in severe cases and when the disease has existed for some time. If the attacks have only existed for a relatively short time, not more than a few years, the brain as a rule shows nothing. Seventeen per cent. of our patients suffer from progressive paralysis and senile dementia. Both diseases present characteristic changes in the brain. In paralysis there is most extensive shrinkage of the brain, so that the cortex is often reduced by one half. The frontal portions of the brain more especially, may be reduced to a third of the normal weight. There is a similar destruction of substance in senile decay.

Fourteen per cent. of the patients annually received are cases of poisoning, at least 13 per cent. of these being due to alcohol. As a rule in slight cases nothing is to be found in the brain; in only a relatively few severe cases is there shrinkage of the cortex, generally of slight degree. The number of these severe cases amounts to less than 1 per cent. of the yearly cases of alcoholism.

Six per cent. of the patients suffer from so-called maniacal depressive insanity which includes the maniacs and the melancholics. The essence of this disease is readily intelligible to the public. Melancholia is a condition of abnormal sadness without disorder of intelligence or memory. Mania is the opposite, the rule being an abnormally excited state with great restlessness; likewise without deep disturbance of intelligence and memory. In this disease there are no demonstrable morphological changes in the brain.

Forty-five per cent. of the patients suffer from the real and common mental disease called dementia præcox. The name is a very unhappy one, for the dementia is not always precocious, nor in all cases is there dementia. Unfortunately the disease is too often incurable; even in the best cases, in those that recover, where the outside public would not observe any abnormality, there is always present some defect in the emotional life. The picture presented by the disease is extraordinarily diverse; generally there is some disorder of feeling, frequently delusions and hallucinations. As a rule there is nothing to be found in the brain. Even in cases of a most severe type, lasting for years, an intact brain is not infrequently found _post mortem_. In a few cases only certain slight changes are present which, however, cannot as yet be reduced to any law.

To sum up: in round figures a quarter of our insane patients show more or less clearly extensive changes and destruction of the brain, while three-fourths have a brain which seems to be generally unimpaired or at most exhibit such changes as give no explanation of the psychological disturbance.

These figures offer the best possible proof that the purely morphological view-point of modern psychiatry leads only very indirectly, if at all, to the understanding of the mental disorder, which is our aim. We must take into account the fact that those mental diseases which show the most marked disturbances of the brain end in death; for this reason the chronic inmates of the asylum form its real population, consisting of some 70 to 80 per cent. of cases of dementia præcox, that is, of patients in whom anatomical changes are practically non-existent. The psychiatry of the future must come to grips with the core of the thing; the path is thus made clear--_it can only be by way of psychology_. Hence in our Zürich clinic we have entirely discarded the anatomical view and turned to the psychological investigation of insanity. As most of our patients suffer from dementia præcox we were naturally concerned with this as our chief problem.

* * * * *

The older asylum physicians paid great attention to the psychological precursors of mental disorder, just as the public still does, following a true instinct. We accepted this hint and carefully investigated the previous psychological history wherever possible. Our trouble was richly rewarded, for we often found, to our surprise, that the disease broke out at a moment of some great emotion which, in its turn, had arisen in a so-called normal way. We found, moreover, that in the mental disease which ensued a number of symptoms occurred which it was quite labour in vain to study from the morphological standpoint. These same symptoms, however, were comprehensible when considered from the standpoint of the individual's previous history. Freud's fundamental investigations into the psychology of hysteria and dreams afforded us the greatest stimulus and help in our work.

A few instances of the latest method in psychiatry will make the subject clearer than mere dry theory. In order to bring home to you the difference in our conception I will first describe the medical history in the older fashion, and subsequently give the solution characteristic of the new departure.

The case to be considered is that of a cook aged 32; she had no hereditary taint, was always industrious and conscientious, and had never been noticeable for eccentric behaviour or the like. Quite recently she became acquainted with a young man whom she wished to marry. From that time on she began to show certain peculiarities. She often spoke of his not liking her much, was frequently out of sorts, ill-tempered, and sat alone brooding; once she ornamented her Sunday hat very strikingly with red and green feathers, another day she bought a pair of pince-nez in order to wear them when she went out walking with her fiancé. One day the sudden idea that her teeth were rather ugly would not let her rest, and she resolved to get a plate, although there was no absolute need. She had all her teeth out under an anæsthetic. The night after the operation she suddenly had a severe anxiety-attack. She cried and moaned that she was damned for ever, for she had committed a great sin; she should not have allowed her teeth to be extracted. People must pray for her, that God might pardon her sin. In vain her friends attempted to talk her out of her fears, to assure her that the extraction of teeth was really no sin; it availed nothing. At day-break she became somewhat quieter; she worked throughout the day. On following nights the attacks were repeated. When consulted by the patient I found her quiet, but she wore a rather vacant expression. I talked to her about the operation, and she assured me it was not so dreadful to have teeth extracted, but still it was a great sin, from which position, despite every persuasion, she could not be moved. She continually repeated in plaintive, pathetic tones, "I should not have allowed my teeth to be extracted; oh yes, that was a great sin which God will never forgive me." She gave the impression of real insanity. A few days later her condition grew worse, and she had to be brought into the asylum. The anxiety-attack had extended and was persistent, and the mental disorder lasted for months.

The history shows a series of entirely unrelated symptoms. Why all the queer story of the hat and pince-nez? Why those anxiety-attacks? Why this delusion that the extraction of her teeth was an unpardonable sin? Nothing here is clear. The morphologically-minded psychiatrist would say: This is just a typical case of dementia præcox; it is the essence of insanity, of madness, to talk of nothing but mysteries; the standpoint of the diseased mind towards the world is displaced, is "mad." What is no sin for the normal, the patient finds a sin. It is a bizarre delusion characteristic of dementia præcox. The extravagant lamentation about this supposed sin is what is known as "inadequate"[198] emotional emphasis. The queer ornamentation of the hat, the pince-nez, are bizarre notions such as are very common in these patients. Somewhere in the brain certain cells have fallen into disorder, and manufacture illogical, senseless ideas of one kind and another which are quite without psychological meaning. The patient is obviously a hereditary degenerate with a weak brain, having a kink which is the origin of the disorder. For some reason or other the disease has suddenly broken out. It could just as easily have broken out at any other time. Perhaps we should have had to capitulate to these arguments had real psychological analysis not come to our aid. In filling up the certificate required for her removal to the asylum, it transpired that many years ago she had had an affair which terminated; her lover left her with an illegitimate child. Nobody had been told of this. When she was again in love a dilemma arose, and she asked herself, What will this new lover say about it? At first she postponed the marriage, becoming more and more worried, and then the eccentricities began. To understand these we must immerse ourselves in the psychology of a naïve soul. If we have to disclose some painful secret to a beloved person we try first to strengthen his love in order to obtain beforehand a guarantee of his forgiveness. We do it by flattery or by caresses, or we try to impress the value of our own personality in order to raise it in the eyes of the other. Our patient decked herself out with beautiful feathers, which to her simple taste seemed precious. The wearing of "pince-nez" increases the respect of children even of a mature age. And who does not know people who will have their teeth extracted, out of pure vanity, in order that they may wear a plate to improve their appearance?

After such an operation most people have a slight, nervous reaction, and then everything becomes more difficult to bear. This was, as a matter of fact, just the moment when the catastrophe did occur, in her terror lest her fiancé should break with her when he heard of her previous life. That was the first anxiety-attack. Just as the patient had not acknowledged her secret in all these years, so she now sought to guard it, and shifted the fear in her guilty conscience on to the extraction of the teeth; she thus followed a method well known to us, for when we dare not acknowledge some great sin we deplore some small sin with the greater emphasis.

The problem seemed insoluble to the weak and sensitive mind of the patient, hence the affect became insurmountably great; this is the mental desire as presented from the psychological side. The series of apparently meaningless events, the so-called madness, have now a meaning; a significance appertains to the delusions, making the patient more human to us. Here is a person like ourselves, beset by universal human problems, no longer merely a cerebral machine thrown out of gear. Hitherto we thought that the insane patient revealed nothing to us by symptoms, save the senseless products of his disordered cerebral cells, but that was academic wisdom reeking of the study. When we penetrate into the human secrets of our patients, we recognise mental disease to be an unusual reaction to emotional problems which are in no wise foreign to ourselves, and the delusion discloses the psychological system upon which it is based.

The light which shines forth from this conception seems to us so enormously powerful because it forces us into the innermost depths of that tremendous disorder which is most common in our asylums, and hitherto least understood; by reason of the craziness of the symptoms it is the type that strikes the public as madness _in excelsis_.

The case which I have just sketched is a simple one. It is transparent. My second example is somewhat more complicated. It is the case of a man between 30 and 40 years of age; he is a foreign archæologist of great learning and most unusual intelligence. He was a precocious boy of quite excellent character, great sensitiveness and rare gifts. Physically he was small, always weakly, and a stammerer. He grew up and was educated abroad, and afterwards studied for several terms at B----. So far there had been no disorder of any kind. On the completion of his university career he became zealously absorbed in his archæological work, which gradually engulfed him to such an extent that he was dead to the world and all its pleasures. He worked incessantly, and buried himself entirely in his books. He became quite unsociable; before, awkward and shy in society, he now fled from it altogether, and saw no one beyond a few friends. He thus led the life of a hermit devoted entirely to science. A few years later, on a holiday tour, he revisited B----, where he remained a few days. He walked a great deal in the environs of the town. His few acquaintances now found him somewhat strange, taciturn, and nervous. After a somewhat protracted walk he seemed tired, and said that he did not feel very well. He then remarked he must get himself hypnotised, he felt his nerves unsteady. On top of this he was attacked by physical illness, viz. inflammation of the lungs. Very soon a peculiar state of excitement supervened which led to suicidal ideas. He was brought to the asylum, where for weeks he remained in an extremely excited state. He was completely deranged, and did not know where he was; he spoke in broken sentences which no one could understand. He was often so excited and aggressive that it took several attendants to hold him. He gradually became quieter, and one day came to himself, as if waking out of a long, confused dream. He soon completely regained his health, and was discharged as cured. He returned to his home and again immersed himself in books. In the following years he published several remarkable works, but, as before, his life was that of a hermit living entirely in his books and dead to the world. He then gradually acquired the name of a dried-up misanthrope, lost to all meaning of the beauty of life. A few years after his first illness a brief holiday brought him again to B----. As before he took his solitary walks in the environs. One day he was suddenly overcome by a faint feeling, and lay down in the street. He was carried into a neighbouring house where he immediately became extremely excited. He began to perform gymnastics, jumped over the rails of the bed, turned somersaults in the room, began to declaim in a loud, voice, sang his own improvisations, etc. He was again brought to the asylum. The excitement continued. He extolled his wonderful muscles, his beautiful figure, his enormous strength. He believed that he had discovered a natural law by which a wonderful voice could be developed. He regarded himself as a great singer, and a marvellous reciter, and at the same time he was a great inspired poet and composer to whom verse and melody came spontaneously.

All this was in pitiable and very remarkable contrast to reality. He is a small weakly man of unimposing build, with poorly developed muscles betraying at the first glance the atrophying effect of his studious life. He is unmusical, his voice is weak and he sings out of tune; he is a bad speaker, because of his stutter. For weeks he occupied himself in the asylum with peculiar jumping, and contortions of the body which he called gymnastics, he sang and declaimed. Then he became more quiet and dreamy, often stared thoughtfully in front of him for a long time, now and then sang a love song which, despite its want of musical expression, betrayed a pretty feeling for love's aspirations. This also was in complete contrast with the dryness and isolation of his normal life. He gradually became accessible for lengthy conversations.

We will break off the history of the disease here, and sum up what is furnished so far by observation of the patient.

In the first illness the delirium broke out unexpectedly, and was followed by a mental disorder with confused ideas and violence which lasted for several weeks. Complete recovery appeared to have taken place. Six years later there was a sudden outbreak of mania, grandiose delusions, bizarre actions, followed by a twilight-stage gradually leading to recovery. Here we again see a typical case of dementia præcox, of the katatonic variety, especially characterised by peculiar movements and actions. In psychiatry the views obtaining at present would regard this as localised cellular disease of some part of the cortex, exhibiting confusional states, delusions of grandeur, peculiar contortions of the muscles, or twilight-states, which taken all together have as little psychological meaning as the bizarre shapes of a drop of lead thrown into water.

This is not my view. It was certainly no accidental freak of the brain-cells that created the dramatic contrasts shown in the second illness. We can see that these contrasts, the so-called grandiose delusions, were very subtly determined by the deficiencies in the patient's personality. Without doubt, any one of us would naturally regard these deficiencies seriously in ourselves. Who would not have the desire to find compensation for the aridness of his profession and of his life in the joys of poetry and music and to restore to his body the natural power and beauty stolen from it by the study's atmosphere? Do we not recall with envy the energy of a Demosthenes who, despite his stammering, became a great orator? If our patient thus fulfilled the obvious gaps in his physical and mental life by delusional wishes, the supposition is warranted that the whispered love-song which he sang from time to time filled up a painful blank in his being, which became more painful the more it was concealed. The explanation is not far to seek. It is simply the old story, born anew in every human soul, in a guise befitting the destined creature's highest sensibilities.

When our patient was a student he learnt to know and love a girl-student. Together they made many excursions in the environs of the town, but his exceeding timidity and bashfulness (the lot of the stammerer) never permitted him an opportunity of getting out the appropriate words. Moreover, he was poor and had nothing to offer her but hopes. The time came for the termination of his studies; she went away, and he also, and they never saw one another again. And not long afterwards he heard she had married some one else. Then he relinquished his hopes, but he did not know that Eros never emancipates his slaves.

He buried himself in abstract learning, not to forget, but to work for her in his thoughts. He wanted to keep the love in his heart quite secret, and never to betray that secret. He would dedicate his works to her without her ever knowing it. The compromise succeeded, but not for long. Once he travelled through the town where he heard she lived--it seems to have been an accident that he travelled through that town. He did not leave the train, which only made a short halt there. From the window he saw standing in the distance a young woman with a little child, and thought it was she. Impossible to say whether it was really so or not. He does not think he felt any peculiar feeling at that moment; anyway he gave himself no trouble to ascertain whether it was she, which makes the presumption strong that it was not really she. The unconscious wanted to be left in peace with its illusion. Shortly afterwards he again came to B----, the place of old memories. Then he felt something strange stir in his soul, an uneasy feeling, akin to Nietzsche's--

"Not for long shalt thou thirst, O burning heart!
There is promise in the air,
Winds come to me from unknown mouths--
The healing coolness comes."

Civilised man no longer believes in demons, he calls in the doctor. Our patient wanted to be hypnotised. Then madness overcame him. What was going on in him?

He answered this question in broken sentences, with long pauses, in that twilight-stage that heralds convalescence. I give as faithfully as may be his own words. When he fell ill he suddenly lost the well-regulated world and found himself in the chaos of an overmastering dream, a sea of blood and fire; the world was out of joint; everywhere conflagration, volcanic outbreaks, earthquakes, mountains fell in, followed by enormous battles where the peoples fell upon one another; he became involved more and more in the battle of nature, he was right in the midst of those fighting, wrestling, defending himself, enduring unutterable misery and pain; gradually he was exalted and strengthened by a strange calming feeling that some one was watching his struggles, that his loved one saw all from afar. That was the time when he showed real violence to the attendants. He felt his strength increasing and saw himself at the head of great armies which he would lead to victory. Then more great battles and at length victory. He would try to get his loved one as prize of victory. As he drew near her the illness ceased, and he awoke from a long dream.

His daily life again began to follow the regular routine. He shut himself up in his work and forgot the abyss within himself. A few years later he is again at B---- Demon or Destiny? Again he followed the old trail and again was overborne by old memories. But this time he was not immersed in the depths of confusion. He remained orientated and _en rapport_ with his surroundings. The struggle was considerably milder, but he did gymnastics, practised the arts, and made good his deficiencies; then followed the dreamy stage with the love-songs, corresponding to the period of victory in the first psychosis. In this state, according to his own words, he had a dreamlike feeling as if he stood upon the borders of two worlds and knew not whether truth stood on the right or on the left. He told me, "It is said she is married, but I believe she is not, but is still waiting for me; I feel that it must be so. It is ever to me as if she were not married, and as if success were yet attainable."

Our patient here portrayed but a pale copy of the scene in the first attack of psychosis, when he, the victor, stood before his mistress. In the course of a few weeks after this conversation the scientific interests of the patient again began to predominate. He spoke with obvious unwillingness about his intimate life, he repressed it more and more, and finally turned away from it as if it did not belong to himself. Thus gradually the gate of the under-world became closed. There remained nothing but a certain tense expression, and a look which, though fixed on the outer world, was turned inwards at the same time; and this alone hinted at the silent activity of the unconscious, preparing new solutions for his insoluble problem. This is the so-called cure in dementia præcox.

Hitherto we psychiatrists used not to be able to suppress a laugh when we read an artist's attempts to portray a psychosis. These attempts have been generally regarded as quite useless, for the writer introduces into his conception of the psychosis psychological relationships quite foreign to the clinical picture of the disease. But the artist has not simply proceeded to copy a case out of a psychiatric text-book; he knows as a rule better than the psychiatrist.

The case which I have sketched is not unique, it is typical of a whole class for which the artist Spitteler has created a model of universal validity; the model is _Imago_. I may take for granted that you know his book of that name. The psychological gulf, however, between the creation of the artist and the insane person is great. The world of the artist is one of solved problems; the world of reality, that of unsolved problems. The mental patient is a faithful image of this reality. His solutions are unsatisfying illusions, his cure a temporary giving up of the problem, which yet goes on working in the depths of the unconscious, and at the appointed time again rises to the surface and creates new illusions with new scenery; part of the history of mankind is here seen abridged.

Psychological analysis is far from being able to explain in complete and illuminating fashion all cases of the disease with which we are here concerned. On the contrary, the majority remain obscure and difficult to understand, and chiefly because only a certain proportion of patients recover. Our last patient is noteworthy because his return to a normal state afforded us a survey of the period of his illness. Unfortunately the advantage of this standpoint is not always possible to us, for a great number of persons never find their way back from their dreams. They are lost in the maze of a magic garden where the same old story is repeated again and again in a timeless present. For patients the hands of the clock of the world remain stationary; there is no time, no further development. It makes no difference to them whether they dream for two days or thirty years. I had a patient in my ward who was five years without uttering a word, in bed, and entirely buried in himself. For years I visited him twice daily, and as I reached his bedside I could see at once that there was no change. One day I was just about to leave the room when a voice I did not recognise called out--"Who are you? What do you want here?" I saw with astonishment that it was the dumb patient who had suddenly regained his voice, and obviously his senses also. I told him I was his doctor, whereupon he asked angrily, why was he kept a prisoner here, and why did no one ever speak to him? He said this in an injured voice just like a normal person whom one had neglected for a couple of days. I informed him that he had been in bed quite speechless for five years and had responded to nothing, whereat he looked at me fixedly and without understanding. Naturally I tried to discover what had gone on in him during these five years, but could learn nothing. Another patient with a similar symptom, when asked why he had remained silent for years, maintained, "Because I wanted to spare the German language."[199] These examples show that it is often impossible to lift the veil of the secret, for the patients themselves have neither interest nor pleasure in explaining their strange experiences, in which as a rule they realise nothing peculiar.

Occasionally the symptoms themselves are a sign-post to the understanding of the psychology of the disease.

We had a patient who was for thirty-five years an inmate at Burghölzli. For decades she lay in bed, she never spoke or reacted to anything, her head was always bowed, her back bent and the knees somewhat drawn up. She was always making peculiar rubbing movements with her hands, so as to give rise during the course of years to thick horny patches on her hands. She kept the thumb and index finger of her right hand together as in the movement of sewing. When she died I tried to discover what she had been formerly. Nobody in the asylum recalled ever having seen her out of bed. Only our chief attendant had a memory of having seen her sitting in the same attitude as that she afterwards took up in bed, at which time she was making rapid movements of extension of the arm across the right knee; it was said of her that she was sewing shoes, later that she was polishing shoes. As time went on the movements became more limited till finally there remained but a slight rubbing movement, and only the finger and thumb retained the sewing position. In vain I consulted our old attendant, she knew nothing about the patient's previous history. When the seventy-year-old brother came to the funeral I asked him what had been the cause of his sister's illness; he told me that she had had a love-affair, but for various reasons it had come to nothing. The girl had taken this so to heart that she became low-spirited. In answer to a query about her lover it was found that he was a _shoemaker_.

Unless you see here some strange play of accident, you must agree that the patient had kept the memory-picture of her lover unaltered in her heart for thirty-five years.

One might easily think that these patients who give an impression of imbecility are only burnt-out ruins of humanity. But such is probably not the case. One can often prove directly that such patients register everything going on around them even with a certain curiosity, and have an excellent memory for it all. This is the reason why many patients become for a time pretty sensible again, and develop mental powers which one believed they had long since lost. Such intervals occur occasionally during serious physical disease, or just before death. We had a patient with whom it was impossible to carry on a sane conversation; he only produced a mad medley of delusions and words. He once fell seriously ill physically, and I expected it would be very difficult to treat him. Not at all. He was quite changed, he became friendly and amiable, and carried out all his doctor's orders patiently and gratefully. His eyes lost their evil darting looks, and shone quietly and understandingly. One morning I came to his room with the usual greeting: "Good morning. How are you getting on?" The patient answered me in the well-known way: "There again comes one of the dog and monkey troupe wanting to play the Saviour." Then I knew his physical trouble was over. From that moment the whole of his reason was as if "blown away" again.

From these observations we see that reason still survives, but is pushed away into some corner by the complete preoccupation of the mind with diseased thoughts.

Why is the mind compelled to exhaust itself in the elaboration of diseased nonsense? On this difficult question our new insight throws considerable light. To-day we can say that the pathological images dominate the interests of the patient so completely, because they are simply derivatives of the most important questions that used to occupy the person when normal--what in insanity is now an incomprehensible maze of symptoms used to be fields of vital interest to the former personality.

I will cite as an example a patient who was twenty years in the asylum. She was always a puzzle to the physicians, for the absurdity of her delusions exceeded anything that the boldest imagination could create.

She was a dressmaker by trade, born in 1845, of very poor family. Her sister early went wrong and was finally lost in the swamp of prostitution. The patient herself led an industrious, respectable, reserved life. She fell ill in 1886 in her 39th year--at the threshold of the age when so many a dream is brought to naught. Her illness consisted in delusions and hallucinations which increased rapidly, and soon became so absurd that no one could understand her wishes and complaints. In 1887 she came to the asylum. In 1888 her statements, so far as the delusions were concerned, were not intelligible. She maintained such monstrous things as that: "At night her spinal marrow had been torn out; pains in the back had been caused by substances that went through the walls and were covered with magnetism." "The monopoly fixed the sorrows which are not in the body and do not fly about in the air." "Excursions are made by breathing in chemistry, and by suffocation regions are destroyed."

In 1892 the patient styled herself the "Bank Note Monopoly, Queen of the Orphans, Proprietress of the Burghölzli Asylum;" she said: "Naples and I must provide the world with macaroni" (Nudel).

In 1896 she became "Germania and Helvetia from exclusively pure butter"; she also said, "I am Noah's Ark, the boat of salvation and respect."

Since then the disease has greatly increased; her last creation is the delusion that she is the "lily red sea monster and the blue one."

These instances will show you how far the incomprehensibility of such pathological formations go. Our patient was for years the classic example of meaningless delusional ideas in dementia præcox; and many hundreds of medical students have received from the demonstration of this case a permanent impression of the sinister power of insanity. But even this case has not withstood the newer technique of psychoanalysis. What the patient says is not at all meaningless; it is full of significance, so that he who has the key can understand without overmuch difficulty.

Time does not allow me to describe the technique by means of which I succeeded in lifting the veil of her secret. I must content myself by giving a few examples to make the strange changes of thought and of speech in this patient clear to you.

She said of herself that _she was Socrates_. The analysis of this delusion presented the following ideas: Socrates was the wisest man, the man of greatest learning; he was infamously accused, and had to die in prison at the hands of strange men. She was the best dressmaker, but "never unnecessarily cut a thread, and never allowed a piece of material to lie about on the floor." She worked ceaselessly, and now she has been falsely accused, wicked men have shut her up, and she will have to die in the asylum.

Therefore she is Socrates; this is, as you see, simple metaphor, based upon obvious analogy. Take another example: "_I am the finest professor and the finest artist in the world._"

The analysis furnishes the remarks that she is the best dressmaker and chooses the most beautiful models which show up well and waste little material; she puts on the trimming only where it can be seen. She is a professor, and an artist in her work. She makes the best clothes and calls them absurdly "The Schnecke Museum-clothes." Her customers are only such persons as frequent the Schnecke House and the Museum (the Schnecke House is the aristocratic club. It is near the Museum and the Library, another rendezvous of the aristocratic set of Zürich), for she is the best dressmaker and makes only Schnecke Museum[200] clothing.

The patient also _calls herself Mary Stuart_. Analysis showed the same analogy as with Socrates: innocent suffering and death of a heroine.

"_I am the Lorelei._" Analysis: This is an old and well-known song: "I know not what it means," etc. Whenever she wants to speak about her affairs people do not understand her, and say they don't know what it means; hence she is the Lorelei.

"_I am Switzerland._" Analysis: Switzerland is free, no one can rob Switzerland of her freedom. The patient does not belong to the asylum, she would be free like Switzerland, hence she is Switzerland.

"_I am a crane._" Analysis: In the "Cranes of Ibykus" it is said: "Whosoever is free of sin and fault shall preserve the pure soul of a child." She has been brought innocent to the asylum and has never committed a crime--hence she is a crane.

"_I am Schiller's Bell._" Analysis: Schiller's Bell is the greatest work of the great master. She is the best and most industrious dressmaker, and has achieved the highest rung in the art of dressmaking--hence she is Schiller's Bell.

"_I am Hufeland._" Analysis: Hufeland was the best doctor. She suffers intolerably in the asylum and is moreover treated by the worst doctors. She is, however, so prominent a personality that she had a claim to the best doctors, that is to a doctor like Hufeland--hence she is Hufeland.

The patient used the expression "I am" in a very arbitrary way. Sometimes it meant "it belongs to me" or "it is proper for me"; sometimes it means "I should have." This is seen from the following analysis:

"_I am the master-key._" Analysis: The master-key is the key that opens all the doors of the asylum. Properly, according to all rights, the patient should long since have obtained this key for she has been for many years "the proprietress of the Burghölzli Asylum." She expresses this reflection very much simplified in the sentence, "I am the master-key."

The chief content of her delusions is concentrated in the following words:--

"_I am the monopoly._" Analysis: The patient means the banknote monopoly, which has belonged to her for some time. She believes that she possesses the monopoly of the entire bank notes of the world, thus creating enormous riches for herself, in compensation for the poverty and lowliness of her lot. Her parents died early; hence she is the Queen of the Orphans. Her parents lived and died in great poverty. Her blessings are extended to them also, the dreamlike delusions of the patient benefit them in many ways. She says textually: "My parents are clothed by me, my sorely-tried mother, full of sorrow--I sat with her at table--covered in white with superfluity."

This is another of these malleable hallucinations which the patient had daily. It is one of those scenes of wish-fulfilment, with poverty on one side and riches on the other, recalling Hauptmann's Hannele; more especially that scene where Gottwald says: "She was clothed in rags--now she is bedeckt in silken robes; and she ran about barefoot--now she has shoes of glass to her feet. Soon she will live in a golden castle and eat each day of baked meats. Here has she lived on cold potatoes...."

The wish-fulfilments of our patient go even further. Switzerland has to furnish her with an income of 150,000 francs. The Director of the Burghölzli owes her 80,000 francs damages for wrongful incarceration. She is the proprietress of a distant island with silver mines, the "mightiest silver island in the world." Therefore she is also the greatest orator, possesses the most wonderful eloquence, for, as she says, "Speech is _silver_, silence gold." To her all the beautiful landed estates belong--all the rich quarters, towns and lands, she is the proprietress of a world, even a "threefold proprietress of the world." Whilst poor Hannele was only elevated to the side of the Heavenly Bridegroom, our patient has the "Key of Heaven," she is not only the honoured earthly queens Mary Stuart and Queen Louise of Prussia, but she is also the Queen of Heaven, the Mother of God as well as the Godhead. Even in this earthly world where she was but a poor, ill-regarded homely dressmaker she attained fulfilments of her human wishes, for she had taken three husbands from the best families in the town and her fourth was the Emperor Francis. From these marriages there were two phantom children--a little boy and a little girl. Just as she clothed, fed and feasted her parents, so she provided for the future of her children. To her son she bequeathed the great bazaar of Zürich, therefore her son is a "Zur," for the proprietor of a _Bazaar_ is a "Zur." The daughter resembles her mother; hence she becomes the proprietress of the asylum and takes her mother's place so that the mother is released from captivity. The daughter therefore receives the title of "Agency of Socrates," for she replaces Socrates in captivity.

These instances by no means exhaust the delusional fancies of the patient. But they will give you some idea, I hope, of the richness of her inner life although she was apparently so dull and apathetic, or, as was said _imbecile_, and sat for twenty years in her workroom, where she mechanically repaired her linen, occasionally uttering a complex of meaningless fragments which no one had hitherto been able to understand. Her odd lack of words can now be seen in another light; they are fragments of enigmatical inscriptions, of fairy-story phantasies, which have escaped from the hard world to found a world of their own. Here the tables are ever laden, and a thousand feasts are celebrated in golden palaces. The patient can only spare a few mysterious symbols for the gloomy dim shores of reality; they need not be understood, for our understanding has not been necessary for her for this long time.

Nor is this patient at all unique. She is one of a type. Similar phantasies are always found in patients of this kind, though not always in such profusion.

The parallels with Hauptmann's Hannele show that here likewise the artist has shown us the way with the free creation of his own phantasy. From this coincidence, which is not accidental, we may conclude that there is something common both to the artist and the insane and not to them alone. Every human being has also within himself that restless creative phantasy which is ever engaged in assuaging the harshness of reality. Whoever gives himself unsparingly and carefully to self-observation, will realise that there dwells within him something which would gladly hide and cover up all that is difficult and questionable in life, and thus procure an easy and free path. Insanity grants the upper hand to this something. When once it is uppermost, reality is more or less quickly driven out. It becomes a distant dream, and the dream which enchains the patient wholly or in part, and often for life, has now the attributes of reality. We normal persons, who have to do entirely with reality, see only the products of disordered fancy, but not the wealth of that side of the mind which is turned away from us. Unfortunately only too often no further knowledge reaches us of the things which are transpiring on that other side, because all the bridges are broken down which unite this side with that.

We do not know to-day whether these new views are of universal or only of limited validity; the more carefully and perseveringly we examine our patients, the more we shall meet cases, which, despite apparent total imbecility, will yet afford us at least some fragmentary insight into the obscurities of the psychical life. This life is far removed from that mental poverty which the prevailing theories were compelled to accept.

However far we are from being able to understand fully the concatenations of that obscure world, at least we may maintain, with complete assurance, that in dementia præcox there is no symptom which can be described as psychologically baseless and meaningless. The most absurd things are in reality symbols of ideas which are not only generally understandable, but also universally operative in the human heart. In insanity we do not discover anything new and unknown, but we look at the foundation of our own being, the source of those life-problems in which we are all engaged.


PART II[편집]

[201]

The number of psychoanalytic investigations into the psychology of dementia præcox has considerably increased since the publication of my book upon the subject.[202] When, in 1903, I made the first analysis of a case of dementia præcox, there dawned on me a premonition of the possibilities of future discoveries in this sphere. This has been confirmed.

Freud first submitted a case of paranoid dementia to closer psychological investigation.[203] This he was enabled to do by means of an analytic technique perfected through his rich experiences with neurotics. He selected the famous autobiography of P. Schreber, "Denkwürdigkeiten eines Nervenkranken." The patient could not be analysed personally, but having published his most interesting autobiography all the material wanted for an analysis was to be found in it.

In this study Freud shows out of what infantile forms of thought and instincts the delusional system was built up. The peculiar delusions which the patient had about his doctor whom he identified with God or with a god-like being, and certain other surprising and really blasphemous ideas, Freud was able to reduce most ingeniously to his infantile relationship to his father. This case also presented similar bizarre and grotesque concatenations of ideas to the one I have described. As the author himself says, his work confines itself to the task of pointing out those universally existent and undifferentiated foundations out of which we may say every psychological formation is historically developed.[204] This reductive analytical process did not, however, furnish such enlightening results in regard to the rich and surprising symbolism in patients of this kind as we had been accustomed to expect from the same method in the realm of the psychology of hysteria. In reading certain works of the Zürich school, for example, Maeder,[205] Spielrein,[206] Nelken,[207] Grebelskaja,[208] Itten,[209] one is powerfully impressed by the enormous symbol-formation in dementia præcox.

Some of the authors still proceed essentially by the method of analytic reduction, tracing back the complicated delusional formation into its simpler and more universal components, as I have done in the preceding pages. One cannot, however, resist the feeling that this method hardly does justice to the fulness and the almost overpowering wealth of phantastic symbol-formation, although it does undoubtedly throw a light upon the subject in certain directions.

Let me illustrate with an example. We should be thankful for a commentary upon "Faust" which traced back all the diverse material of Part II. to its historical sources, or for a psychological analysis of Part I. which pointed out how the dramatic conflict corresponds to a personal conflict in the soul of the poet; we should be glad of an exposition which pointed out how this subjective conflict is itself based upon those ultimate and universal human things which are nowise foreign to us since we all carry the seeds of them in our hearts. Nevertheless we should be a little disappointed. We do not read "Faust" just in order to discover that also we are, in all things, "human, all too human." Alas, we know that but too well already. Let any one who has not yet learnt it go for a little while out into the world and look at it without preconceptions and with open eyes. He will turn back from the might and power of the "too human," hungrily he will pick up his "Faust," not to find again what he has just left, but to learn how a man like Goethe shakes off these elemental human things and finds freedom for his soul. When we once know who was the "Proktophantasmist," to what chronological events the mass of symbols in Part II. relates, how it is all intimately bound up with the poet's own soul and conditioned by it, we come to regard this determination as less important than the problem itself--what does the poet mean by his symbolic creation? Proceeding purely reductively, one discovers the final meaning in these universal human things; and demands nothing further from an explanation than that the unknown and complicated shall be reduced to the known and simple. I should like to designate this kind of understanding as _retrospective understanding_. But there is another kind of understanding, which is not analytic reduction, but is of a _synthetic_ or _constructive_ nature. I would designate this _prospective understanding_, and the corresponding method as the _Constructive method_.

It is common knowledge that present-day scientific explanation rests upon the basis of the causal principle. Scientific explanation is causal explanation. We are therefore naturally inclined, whenever we think scientifically, to explain causally, to understand a thing and to regard it as explained whenever it is reduced analytically to its cause and general principle. In so far Freud's psychological method of interpretation is strictly scientific.

If we apply this method to "Faust" it must become clear that something more is required for a true understanding. It will even seem to us that we have not gathered the poet's deepest meaning if we only see in it universal foregone human conclusions. What we really want to find out is how this man has redeemed himself as an individual, and when we arrive at this comprehension then we shall also understand the symbol given by Goethe. It is true we may then fall into the error that we understand Goethe himself. But let us be cautious and modest, simply saying we have thereby arrived at an understanding of ourselves. I am thinking here of Kant's thought-compelling definition of comprehension, as "the realisation of a thing to the extent which is sufficient for our purpose."

This understanding is, it is true, subjective, and therefore not scientific for those to whom science and explanation by the causal principle are identical. But the validity of this identification is open to question. In the sphere of psychology I must emphasise my doubt on this point.

We speak of "objective" understanding when we have given a causal explanation. But at bottom, understanding is a subjective process upon which we confer the quality "objective" really only to differentiate it from another kind of understanding which is also a psychological and subjective process, but upon which, without further ado, we bestow the quality "subjective." The attitude of to-day only grants scientific value to "objective" understanding on account of its universal validity. This standpoint is incontestably correct wherever it is not a question of the psychological process itself, and hence it is valid in all sciences apart from pure psychology.

To interpret Faust objectively, _i.e._ from the causal standpoint, is as though a man were to consider a sculpture from the historical, technical and--last but not least--from the mineralogical standpoint. But where lurks the _real meaning_ of the wondrous work? Where is the answer to that most important question: what aim had the artist in mind, and how are we ourselves to understand his work subjectively? To the scientific spirit this seems an idle question which anyhow has nothing to do with science. It comes furthermore into collision with the causal principle, for it is a purely speculative constructive view. And the modern world has overthrown this spirit of scholasticism.

But if we would approach to an understanding of psychological things we must remember the fact of the subjective conditioning of all knowledge. The world is _as we see it_ and not simply objective; this holds true even more of the mind. Of course it is possible to look at the mind objectively, just as at Faust, or a Gothic Cathedral. In this objective conception there is comprised the whole worth and worthlessness of current experimental psychology and psychoanalysis. The scientific mind, thinking causally, is incapable of understanding what is ahead; it only understands what is past, that is, retrospective. Like Ahriman, the Persian devil, it has the gift of After-Knowledge. But this spirit is only one half of a complete comprehension. The other more important half is prospective or constructive; if we are not able to understand what lies ahead, then nothing is understood. If psychoanalysis, following Freud's orientation, should succeed in presenting an uninterrupted and conclusive connection between Goethe's infantile sexual development and his work, or, following Adler, between the infantile struggle for power and the adult Goethe and his work, an interesting proposition would have been solved--we should have learnt how a masterpiece can be reduced to the simplest thinkable elements, which are universal, and to be found working within the depths of everything and everybody. But did Goethe construct his work to _this_ end? Was it his intention that it should be thus conceived?

It must be sufficiently clear that such an understanding, though undoubtedly scientific, would be entirely, utterly, beside the mark. This statement is valid for psychology in general. To understand the psyche causally, means to understand but half of it. The causal understanding of Faust enlightens us as to how it became a finished work of art, but reveals nothing of the living meaning of the poet. That meaning only lives if we experience it, in and through ourselves. In so far as our actual present life is for us something essentially new and not a repetition of all that has gone before, the great value of such a work is to be seen, not in its causal development, but in its living reality for our own lives. We should be indeed depreciating a work like Faust if we were only to regard it as something that has been perfected and finished; it is only understood when conceived as a becoming and as an ever new-experiencing.

Thus we must regard the human psyche. Only on one side is the mind a Has Been, and as such subordinate to the causal principle. On the other side the mind is a Becoming that can only be grasped synthetically or constructively. The causal standpoint asks how it is this actual mind has become what it appears to-day? The constructive standpoint asks how a bridge can be built from this actual psyche to its own future?

Just as the causal method finally reaches the general principles of human psychology by the analysis and reduction of individual events, so does the constructive standpoint reach aims that are general by the synthesis of individual tendencies. The mind is a point of passage and thus necessarily determined from two sides. On the one side it offers a picture of the precipitate of the past, and on the other side a picture of the germinating knowledge of all that is to come, in so far as the psyche creates its own future.

What has been is, on the one hand, the result and apex of all that was--as such it appears to the causal standpoint; on the other hand, it is an expression of all that is to be. The future is only _apparently_ like the past, but in its essence always new and unique, (the causal standpoint would like to invert this sentence) thus the actual formula is incomplete, germlike so to say, in relation to what is to be.

To get any conception of this expression of what is to be we are forced to apply a constructive interest to it. I almost felt myself tempted to say, "a scientific interest." But modern science is identical with the causal principle. So long as we consider the actual mind causally, that is scientifically, we elude the mind as a Becoming. This other side of the psyche can never be grasped by the exclusive use of the causal principle, but only by means of the constructive standpoint. The causal standpoint reduces things to their elements, the constructive standpoint elaborates them into something higher and more complicated. This latter standpoint is necessarily a speculative one.

Constructive understanding is, however, differentiated from scholastic speculation because it imposes no general validity, but only subjective validity. When the speculative philosopher believes he has comprehended the world once for all by his System, he deceives himself; he has only comprehended himself and then naïvely projected that view upon the world. In reaction against this, the scientific method of the modern world has almost put an end to speculation and gone to the other extreme. It would create an "objective" psychology. In opposition to such efforts, the stress which Freud has placed upon individual psychology is of immortal merit. The extraordinary importance of the subjective in the development of the objective mental process was thus first brought adequately into prominence.

Subjective speculation lays no claim to universal validity, it is identical with constructive understanding. It is a subjective creation, which, looked at externally, easily seems to be a so-called infantile phantasy, or at least an unmistakable derivative of it; from an objective standpoint it must be judged as such, in so far as objective is regarded as identical with scientific or causal. Looked at from within, however, constructive understanding means redemption.

"Creation--that is the great redemption from suffering and easiness of living."[210]

* * * * *

Starting from these considerations as to the psychology of those mental patients to whom the Schreber case belongs, we must, from the "objective-scientific" standpoint, reduce the structural phantasy of the patient to its simple and most generally valid elements. This Freud had done. But that is only half of the work to be done. The other half is the constructive understanding of Schreber's system. The question is: What end, what freedom, did the patient hope to achieve by the creation of his system?

The scientific thinker of to-day will regard this question as inappropriate. The psychiatrist will certainly smile at it, for he is thoroughly assured of the universal validity of his causalism, he knows the psyche merely as something that is made, descendent, reactive. Not uncommonly there lurks the unconscious prejudice that the psyche is a brain-secretion.

Looking at such a morbid system without preconception, and asking ourselves what goal this delusional system is aiming at, we see, in fact, firstly, that it _is_ endeavouring to get at something, and secondly, that the patient also devotes all his will-power to the service of the system. There are patients who develop their delusions with scientific thoroughness, often dragging in an immense material of comparison and proof. Schreber certainly belongs to this class. Others do not proceed so thoroughly and learnedly, but content themselves with heaping up synonymous expressions for that at which they are aiming. The case of the patient I have described, who assumes all kinds of titles, is a good instance of this.

The patient's unmistakable striving to express something through and by means of his delusion Freud conceives retrospectively, as the satisfaction of his infantile wishes by means of imagination. Adler reduces it to the desire for power.

For him the delusion-formation is a "manly protest," a means of gaining security for himself against his menaced superiority. Thus characterised, this struggle is likewise infantile and the means employed--the delusional creation--is infantile because insufficient for its purpose; one can therefore understand why Freud declines to accept Adler's point of view. Freud, rightly on the whole, subsumes this infantile struggle for power under the concept of the infantile wish.

The constructive standpoint is different. Here the delusional system is neither infantile nor, upon the whole, _eo ipso_ pathological but _subjective_, and hence justified within the scope of the subjective. The constructive standpoint absolutely denies the conception that the subjective phantasy-creation is merely an infantile wish, symbolically veiled; or that it is merely that in a higher degree; it denies that it is a convulsive and egoistic adhesion to the fiction of its own superiority, in so far as these are to be regarded as finalistic explanations. The subjective activity of the mind can be judged from without, just as one can, in the end, so judge everything. But this judgment is inadequate, because it is the very essence of the subjective that it cannot be judged objectively. We cannot measure distance in pints. The subjective can be only understood and judged subjectively, that is, constructively. Any other judgment is unfair and does not meet the question.

The absolute credit which the constructive standpoint confers upon the subjective, naturally seems to the "scientific" spirit as an utter violation of reason. But this scientific spirit can only take up arms against it so long as the constructive is not avowedly _subjective_. The constructive comprehension also _analyses_, but it does not _reduce_. It decomposes the delusion into _typical_ components. What is to be regarded as the type at a given time is shown from the attainment of experience and knowledge reached at that time.

Even the most individual delusional systems are not absolutely unique, occurring only once, for they offer striking and obvious analogies with other systems. From the comparative analysis of many systems the typical formations are drawn. If one can speak of reduction at all, it is only a question of reduction to general type, but not to some universal principle obtained inductively or deductively, such as "Sexuality" or "Struggle for Power." This paralleling with other typical formations only serves for a widening of the basis upon which the construction is to be built. If one were to proceed entirely subjectively one would go on constructing in the language of the patient and in his mental range. One would arrive at some structure which was illuminating to the patient and to the investigator of the case but not to the outer scientific public. The public would be unable to enter into the peculiarities of the speech and thought of the individual case in question without further help.

The works of the Zürich school referred to contain careful and detailed expositions of individual material. In these materials there are very many typical formations which are unmistakably _analogies_ with _mythological formations_[211]. There arose from the perception of this relationship a new and valuable source for comparative study. The acceptance of the possibility of such a comparison will not be granted immediately, but the question is only whether the materials to be compared really are similar or not. It will also be contended that pathological and mythological formations are not immediately comparable. But this objection must not be raised _a priori_, for only a conscientious comparison can determine whether any true parallelism exists or not. At the present moment all we know is that they are both structures of the imagination which, like all such products, rest essentially upon the activity of the unconscious. Experience must teach us whether such a comparison is valid. The results hitherto obtained are so encouraging that further work along these lines seems to me most hopeful and important. I made practical use of the constructive method in a case which Flournoy published in the _Archives de Psychologie_, although he offered no opinion as to its nature at that time.

The case dealt with a rather neurotic young lady who, in Flournoy's publication, described how surprised she was at the connected phantasy-formations which penetrated from the unconscious into the conscious. I subjected these phantasies, which the lady herself reproduced in some detail, to my constructive methods and gave the results of these investigations in my book, "The Psychology of the Unconscious."

This book has, I regret to say, met with many perhaps inevitable misunderstandings. But I have had one precious consolation, for my book received the approval of Flournoy himself, who published the original case which he knew personally. It is to be hoped that later works will make the standpoint of the Zürich school intelligible to a wider public. Whoever, by the help of this work, has taken the trouble to grasp the essence of the constructive method, will readily imagine how great are the difficulties of investigation, and how much greater still are the difficulties of objective presentation of such investigations.

Among the many difficulties and opportunities for misunderstanding I should like to adduce one difficulty which is especially characteristic. In an intensive study of Schreber's or any similar case, it will be discovered that these patients are consumed by the desire for a new world-philosophy which may be of the most bizarre kind. Their aim is obviously to create a system such as will help them in the assimilation of unknown psychical phenomena, _i.e._ enable them to adapt their own unconscious to the world. This arrangement produces a subjective system which must be considered as a necessary transition-stage on the path to the adaptation of their personality in regard to the world in general. But the patient remains stationary at this transitory stage and assumes his subjective view is the world's, hence he remains ill. He cannot free himself from his subjectivism and does not find the link to objective thinking, _i.e._ to society. He does not reach the real summit of self-understanding, for he remains with a merely subjective understanding of himself. But a _mere_ subjective understanding is not real and adequate. As Feuerbach says: _Understanding is only real when it is in accord with that of some other rational beings_. Then it becomes objective[212] and the link with life is reached.

I am convinced that not a few will raise the objection that in the first place the psychological process of adaptation does not proceed by the method of first creating a world-philosophy; secondly, that it is in itself a sign of unhealthy mental disposition even to make the attempt to adapt oneself by way of a "world-philosophy."

Undoubtedly there are innumerable persons who are capable of adaptation without creating any preliminary philosophy. If they ever arrive at any general theory of the world it is always subsequently. But, on the other hand, there are just as many who are only able to adapt themselves by means of a preliminary intellectual formulation. To everything which they do not understand they are unable to adapt themselves. Generally it comes about that they do adapt themselves just in so far as they can grasp the situation intellectually. To this latter group seem to belong all those patients to whom we have been giving our consideration.

Medical experience has taught us that there are two large groups of functional nervous disorders. The one embraces all those forms of disease which are designated _hysterical_, the other all those forms which the French school has designated _psychasthenic_. Although the line of demarcation is rather uncertain, one can mark off two psychological types which are obviously different; their psychology is diametrically opposed. I have called these--the _Introverted_ and _Extroverted_ types. The hysteric belongs to the type of _Extroversion_, the psychasthenic to the type of _Introversion_, as does dementia præcox, in so far as we know it to-day. This terminology, _Introversion_ and _Extroversion_, is bound up with my way of regarding mental phenomena as forms of energy. I postulate a hypothetical fundamental striving which I designate _libido_.[213] In the classical use of the word, _libido_ never had an exclusively sexual connotation as it has in medicine. The word _interest_, as Claparède once suggested to me, could be used in this special sense, if this expression had to-day a less extensive application. Bergson's concept, _élan vital_, would also serve if this expression were less biological and more psychological. Libido is intended to be an energising expression for _psychological values_. The psychological value is something active and determining; hence it can be regarded from the energic standpoint without any pretence of exact measurement.

The introverted type is characterised by the fact that his libido is turned towards his own personality to a certain extent--he finds within himself the unconditioned value. The extroverted type has his libido to a certain extent externally; he finds the unconditioned value outside himself. The introvert regards everything from the aspect of his own personality; the extrovert is dependent upon the value of his object. I must emphasise the statement that this question of types is _the_ question of our psychology, and that every further advance must probably proceed by way of this question. The difference between these types is almost alarming in extent. So far there is only one small preliminary communication by myself[214] on this theory of type, which is particularly important for the conception of dementia præcox. On the psychiatric side Gross[215] has called attention to the existence of two psychological types. His two types are (1) those with limited but deep consciousness, and (2) those with broad but superficial consciousness. The former correspond to my introverted and the latter to my extroverted type. In my article I have collected some other instances among which I would especially call attention to the striking description of the two types given by William James in his book on "Pragmatism." Fr. Th. Vischer has differentiated the two types very wittily by her division of the learned into "reason-mongers," and "matter-mongers." In the sphere of psychoanalysis Freud follows the psychology of Extraversion, Adler that of Introversion. The irreconcilable opposition between the views of Freud and those of Adler (see especially his book "Über den nervösen Charakter") is readily explained by the existence of two diametrically opposed psychological types which view the same things from entirely different aspects. An Extrovert can hardly, or only with great difficulty, come to any understanding with an Introvert, on any delicate psychological question.

An Extrovert can hardly conceive the necessity which compels the Introvert to conquer the world by means of a system. And yet this necessity exists, otherwise we should have no philosophical systems and dogmas, presumed to be universally valid. Civilised humanity would be only empiricists and the sciences only the experimental sciences. Causalism and empiricism are undoubtedly mighty forces in our present-day mental life but it may come to be otherwise.

This difference in type is the first great obstacle which stands in the way of an understanding concerning fundamental conceptions of our psychology. A second objection arises from the circumstance that the constructive method, faithful to itself, must adapt itself to the lines of the delusion. The direction along which the patient develops his morbid thoughts has to be accepted seriously, and followed out to its end; the investigator thus places himself at the standpoint of the psychosis. This procedure may expose him to the suspicion of being deranged himself; or at least risks a misunderstanding which is considered terribly disgraceful--he may himself have some world-philosophy! The confirmation of such a possibility is as bad as being "unscientific." But every one has a world-philosophy though not every one knows he has. And those who do not know it have simply an unconscious and therefore inadequate and archaic philosophy. But everything psychological that is allowed to remain in the mind neglected and not developed, remains in a primitive state. A striking instance of how universal theories are influenced by unconscious archaic points of view has been furnished by a famous German historian whose name matters to us not at all. This historian took it for granted that once upon a time people propagated themselves through incest, for in the first human families the brother was assigned to the sister. This theory is wholly based upon his still unconscious belief in Adam and Eve as the first and only parents of mankind. It is on the whole better to discover for oneself a modern world-philosophy, or at least to make use of some decent system which will prevent any errors of that kind.

One could put up with being despised as the possessor of a world-philosophy; but there is a greater danger. The public may come to believe the philosophy, beaten out by the constructive method, is to be regarded as a theoretical and objectively valid insight into the meaning of the world in general.

I must now again point out that it is an obstinate, scholastic misunderstanding not to be able to distinguish between a world-philosophy which is only psychological, and an extra-psychological theory, which concerns the objective thing. It is absolutely essential that the student of the results of the constructive method should be able to draw this distinction. In its first results the constructive method does not produce anything that could be called a scientific theory; it furnishes the _psychological lines of development_, a _path_ so to say. I must here refer the reader to my book, "Psychology of the Unconscious."

The analytic reductive method has the advantage of being much simpler than the constructive method. The former reduces to well-known universal elements of an extremely simple nature. The latter has, with extremely complicated material, to construct the further path to some often unknown end. This obliges the psychologist to take full account of all those forces which are at work in the human mind. The reductive method strives to replace the religious and philosophical needs of man, by their more elementary components, following the principle of the "nothing but," as James so aptly calls it. But to _construct_ aright, we must accept the developed aspirations as indispensable components, essential elements, of spiritual growth. Such work extends far beyond empirical concepts but that is in accordance with the nature of the human soul which has never hitherto rested content with experience alone. Everything new in the human mind proceeds from speculation. Mental development proceeds by way of speculation, never by way of limitation to mere experience. I realise that my views are parallel with those of Bergson, and that in my book the concept of the libido which I have given, is a concept parallel to that of "élan vital"; my constructive method corresponds to Bergson's "intuitive method." I, however, confine myself to the psychological side and to practical work. When I first read Bergson a year and a half ago I discovered to my great pleasure everything which I had worked out practically, but expressed by him in consummate language and in a wonderfully clear philosophic style.

Working speculatively with psychological material there is a risk of being sacrificed to the general misunderstanding which bestows the value of an objective theory upon the line of psychological evolution thus elaborated. So many people feel themselves in this way at pains to find grounds whether such a theory is correct or not. Those who are particularly brilliant even discover that the fundamental concepts can be traced back to Heraclitus or some one even earlier. Let me confide to these knowing folk that the fundamental ideas employed in the constructive method stretch back even beyond any historical philosophy, viz. to the dynamic "views" of primitive peoples. If the result of the constructive method were scientific theory, it would go very ill with it, for then it would be a falling back to the deepest superstition. But since the constructive method results in something far removed from scientific theory the great antiquity of the basic concepts therein must speak in favour of its extreme correctness. Not until the constructive method has presented us with much practical experience can we come to the construction of a _scientific theory, a theory of the psychological lines of development_. But we must first of all content ourselves with confirming these lines individually.

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