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Page 21
By the recent advances in scientific knowledge and in methods of
investigation we have been led to see that the conditions under
consideration cannot be understood without a study of the mechanisms on
which mental activity depends and without discovering the psychic and
physical causes, arising from without and from within, which have
disturbed the function of these mechanisms. We have learned that these
illnesses do not arise from one cause alone and that they are the result
of influences to which we all may be subject to some degree.
The originator of these modern methods, Prof. Freud, has stimulated us
to regard the ordinary symptoms of mental illnesses as directing posts
indicating lines to be investigated, and he and others have suggested
various methods which may usefully be employed.
It is essential that we carefully distinguish what are primary from what
are secondary symptoms. Two thousand years ago a physician,
[Transcriber's note: original reads 'physican'] Areteus, pointed out
that mania frequently commenced as melancholia, and he drew attention to
the extreme frequency of an initial depression in cases of mental
illnesses. But he did not offer any explanation of this initial state.
Such an initial state may perhaps be, to a certain extent, understood if
we assume that the first evidences of mental disturbance consist in some
difficulty in carrying out ordinary mental processes, some difficulty in
exercise of the function of perceiving, thinking, feeling, judging, and
acting, and that any disturbance of the harmonious activity of these
functions must give rise to an emotional condition of anxiety and
depression. Some such disharmony will, by adequate investigation, be
found in a large number of cases to exist in the early states of the
illness and will be appreciated by the patient before there occur any
obvious signs, any outward manifestations of disability.
But in any disharmony which may occur it must be recognized that the
mental mechanisms affected are those with which the patient was
originally endowed, which he has gradually trained throughout his past
experience and which he has employed more or less successfully up to the
time the illness commenced. There is no new mechanism introduced to
produce a mental illness, but a putting out of gear of those common to
the race and their disturbance is the result of the action of influences
which may befall any one of us, unbearable ideas with which some intense
emotional state is intimately associated. The normal function of these
mechanisms, simple at first and remaining fundamentally unaltered,
although possibly much modified gradually by added experiences from
within and without, depends on the maintenance of a harmonious balance
between stimuli received and emotional reaction and motor response to
those stimuli so that the feeling of well-being may arise.
If from any cause there occurs a failure to appreciate the stimuli
clearly, if the emotional reactivity be disturbed, if the sense of value
becomes biassed in one direction or another so that the response is
recognized by the patient as abnormal there will result a disharmony and
a feeling of ill-being of the organism. Under these conditions the
processes of facilitation along certain definite lines and inhibition of
all other lines--processes which are essential to clear
consciousness--will become difficult or perhaps impossible and a mental
illness will develop. In the slighter degrees the disharmony may be
known to the patient without there being any outward manifestation to
betray the conflict going on within. In the severe degrees the mental
activity of the patient may be under the control of some dominant
emotional state so that it may be impossible for him to adapt himself to
his surroundings in a normal manner although his behavior may not appear
so irrational when we know the stimuli affecting him. Within these
extremes we discover all degrees of disturbance, and all varieties of
signs and symptoms may be encountered.
But the signs which become obvious to superficial observation are, to a
large extent, secondary products. The primary symptoms are felt by the
patient as a disturbance of the capacity to perceive, to think, to feel,
to judge, and to act, and with these disabilities there will be
associated a certain degree of confusion and anxiety which cannot fail
to appear as the result of such alterations of function.
The obvious signs may represent merely a more intense degree of the
primary affection, disturbed capacity together with some confusion and
anxiety; or they may represent efforts on the part of the patient to
overcome or to escape from the disturbance or to explain it to himself.
And now the total lack of knowledge of the processes on which mental
activity depends, the altered standard of judgment due to some degree of
dissociation, and the necessity of obtaining relief in some way or other
will have much to do with determining the character of the symptoms with
which we are all familiar. So many factors are concerned in the
production of these secondary characters that it is difficult to assign
to the symptoms their true value or to decide whether they possess much
value at all with regard to the fundamental disturbance which
constituted the primary illness. So often they appear to be mere
rationalizations, mere false judgments on the part of the patient; they
thus form subjects for investigation rather than fundamental
constituents of the illness.
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