James Walsh - Psychotherapy

"Prefaces are a great waste of time," said Francis Bacon, "and, though they seem to proceed of modesty, they are bravery." In spite of this deterring expression of the Lord Chancellor, the author ventures to write a short apologia pro libro suo . Five years ago he began at Fordham University School of Medicine a series of lectures on Psychotherapy. This book consists of material gathered for these lectures. It will be found in many ways to partake more of the nature of a course of lectures than a true text-book. In this it follows French rather than English or American precedent. Its relation to lectures makes it more diffuse than the author would have wished, but this is offered as an explanation, not an excuse. Addressed to medical students and not specialists the language employed is as untechnical as possible, and, indeed, was meant as a rule to be such as young physicians might use to their patients for suggestion purposes.

The historical portion is probably longer than some may deem necessary. The place of psychotherapy in the past seemed so important, however, and psychotherapeutics masqueraded under so many forms that an historical résumé of its many phases appeared the best kind of an introduction to a book which pleads for more extensive and more deliberate use of psychotherapy in our time. The historical portion was developed for the lectures on the history of medicine at Fordham and perhaps that fact helps to account for the space allotted to this section of the book.

So far as the author knows, this is the first time in the history of medicine that an attempt has been made to write a text-book of the whole subject of psychotherapy. We have had many applications of psychotherapeutics to functional and organic nervous and mental disease and also indirectly to nutritional diseases; but no one apparently has attempted to systematize the application of psychotherapeutic principles, not only to functional diseases, but specifically to all the organic diseases. A chapter on the use of mental influence in anesthesia was, during the course of the preparation of this volume, written for Dr. Taylor Gwathmey's text-book on Anesthesia, which is to appear shortly (Appletons).

No one knows better than the author how difficult is the subject and how liable to misunderstanding and abuse. He appreciates well, too, how almost hopeless it would be to make a perfectly satisfactory text-book of so large a subject at the first attempt. The present volume is founded, however, on considerable experience, on wide reading in the subject, and on much reflection on its problems. It is offered to those who are interested in the old new department of psychotherapy until a better one is available. The author's principal idea in the book has been to help students and practitioners of {viii} medicine to care for ( curare ) suffering men and women and not cases, to treat individual human beings, not compounds in which various chemical, physical and biological qualities have been observed, diligently enough and with noteworthy success, but incompletely as yet, and quite without the satisfying adequacy which it is to be hoped will result from future investigations.

James J. Walsh.

110 West Seventy-fourth Street,

New York City.

To physicians who are students not alone of the manifestations of disease but also of the workings of human nature, there are few chapters in the history of medicine more interesting than those which record the welcome by each generation of the supposed advances in the treatment of disease. Each generation announced its cures for diseases, provided its remedies to relieve symptoms, and invented methods of treatment that seemed to put off the inevitable tendency toward dissolution. Yet few of these inventions and discoveries maintain their early reputations, and succeeding generations invariably abandon most of this supposed medical progress in favor of ideas of their own, which later suffer a like fate. Plausible theories have not been lacking to support the successive remedies and methods of treatment, but the general acceptance of them was always founded far less upon theory than upon actual observation of their supposed efficacy. Certain remedies were given and the patients began to improve. Patients who did not have the remedies continued to suffer, and sometimes the course of their disease led to a fatal termination. Even with the best remedies death sometimes took place, but that was easily accounted for on the ground that the disease had secured so firm a hold that it could not be dislodged, even by a good remedy. The connection of cause and effect between the administration of the remedy and the improvement and eventual cure of the patient seemed to be demonstrated.

The archives of old-time medicine disprove the notion that clinical learning and teaching—that is, observation and demonstration at the bedside—were not part of medical education until quite modern times. The medical books of the thirteenth, fourteenth and fifteenth centuries are full of descriptions of actual cases, while, over a millenium before, one of Martial's epigrams tells of a patient who dreaded the coming of his physician because he brought with him so many students, whose cold hands gave chills to the poor victim.

Coincidence and Consequence.—In spite of the opportunities for careful observation thus afforded and the facilities for training clinical observers in medicine, many remedies came into vogue, were enthusiastically applied, and then, after a time, went out of use and were heard of no more. Sometimes they were subsequently revived and had even a greater vogue than when originally brought out. But most of these remedies eventually went forever into the lumber room of disused treatments. Of the many thousands of remedies which had the approval and the praise of past generations, two score at most hold a place in the pharmacopeia of to-day.

There are many reasons for this initial success and eventual failure; but the most important explanation lies not so much in reason as in coincidence. In the majority of human ills there is a definite tendency to get better, and almost anything that is given to the patient will be followed by relief and improvement. The recovery is not, however, on account of the remedy, but occurs only after a definite succession of events that would have taken place either with or without the remedy.

Mental Influence.—What the old physicians did not, as a rule, appreciate, or at least failed to value at its true significance, was the effect upon the patient's mind of the taking of a remedy. Because of the confidence with which it was given, the patient, having full faith in the physician who gave it, became impressed with the idea that now he must get well. The very presence of the physician and his assurance that the illness was not serious and that many symptoms that were sources of dread to the patient were only concomitant conditions of the ailment, naturally to be expected under the circumstances, relieved the patient from worry, and so gave his nervous energy a chance to exert itself in bringing about improvement. In other words, the suggestive elements of the presence of the physician and the taking of his remedy were important therapeutic factors which enabled what was an absolutely inefficient remedy, as the event proved when closer observations of it had been made, to relieve even serious symptoms, or helped a weak remedy to accomplish good results by strengthening the patient's resistive vitality.