The psychological work of the physician does not begin with his curative
efforts. Therapy is always only the last step. Diagnosis and observation
have to precede, and an inquiry into the causes of the disease is
essential, and in every one of these steps psychology may play its role.
The means of psycho diagnostic are not less manifold than those of
psychotherapy. Moreover there the technique may be more complex and
subtle. The whole equipment of the modern laboratory ought to be put at
its disposal. Perceptions and associations, reactions and expressions
ought to be examined with the same carefulness with which the
conscientious physician examines the blood and the urine.

A particular difficulty of the task more or less foreign to every other
medical inquiry is the intentional or unintentional effort of the
patient to hide the sources of the trouble and to mislead as to their
true character. Too often he is entirely unconscious of the sources of
trouble or else he has social reasons to deceive the world and himself,
and ultimately the physician. And yet no psychical treatment can start
successfully so long as the patient is brooding on secret thoughts at
the bottom of his mind. The desire to hide them may often be itself a
part of the disease. It is surprising how often unsuspected vistas of
thoughts and impulses and emotions are opened by an inquiring analysis
where the direct report of the patient does not awaken the least
suspicion. In the field of insanity, naturally the physician at once
goes to an examination on his own account, but in the borderland regions
of the psychasthenics and hysterics and neurasthenics, the intellectual
clearness of the patient too easily tempts one into trusting the
sincerity of his story; and yet the most important ideas clustering
perhaps about love or ambition, about vice or crime, about business
failure or family secrets, about inherited or acquired diseases may be
cunningly withheld and may frustrate every psychotherapeutic influence.
Where suspicion is awake and mere confidential talk and persuasion seem
insufficient, the physician may feel justified in the interest of his
patient in drawing the thoughts out of their hiding-place by artificial
means. Skill, tact, and experience are needed there.

As a matter of course, in the overwhelming mass of cases the frankness
and the good will of the patient himself will support the physician and
accordingly his examination is not obliged to trap the patient but
simply to guide him to important points. But then begins the most
essential study of diagnostically differentiation. With all the means not
only of psychology but of neurology and internal medicine, he has to
separate the particular case from similar ones and to examine whether
he deals with, for instance, a hysteric or with a paranoiac, with a
neurasthenic or with a case of dementia præcox; and he will not forget
that there exist almost no symptoms of serious diseases which the
nervous system of the hysteric may not imitate for a time. Not ours is
the task of analyzing special methods of neurological and mental
differential diagnosis such as are used in the psychiatric clinic and in
the office of the nerve specialist. There the family history with
reference to nervous and other diseases, the history of the patient
himself, the infectious diseases which he has passed through, his habits
and anomalies, his use of alcohol and of drugs, his experiences in
social life, the demands of his profession, his recent troubles and
their first origin are to be recorded carefully. Then begins the
physical examination, the study of his sense organs and his nerves, of
the motor inabilities, the pains, the local anesthesia and
paræsthesias, the disturbances of the reflexes, of the spasms, tremors,
convulsions, and incoordinations, of the vasomotor and trophic
disorders, and so on. In a similar way the psychical examination tests
the hallucinations and illusions, the variations and defects of memory
and attention, of judgment and reasoning, of orientation and
self-consciousness, of emotions and volitions, of intellectual
capacities and organized actions. But we do not have to enter here into
a discussion of such diagnostic means; our chief interest belongs to the
therapy.

The variety of the psychotherapeutic methods is great and only some
types are to be characterized here. But one rule is common to all of
them: never use psychotherapeutic methods in a schematic way like a
rigid pattern. Schematic treatment is a poor treatment in every
department of medicine, but in psychotherapeutics it is disastrous.
There are no two cases alike and not only the easily recognizable
differences of sex and age, and occupation and education, and financial
means, and temperament and capacity are decisive, but all the subtle
variations of prejudices and beliefs, preferences and dislikes, family
life and social surroundings, ambitions and prospects, memories and
fancies, diet and habits must carefully be considered. Every element of
a man's life history, impressions of early childhood, his love and his
successes, his diseases and his distresses, his acquaintances and his
reading, his talent, his character, his sincerity, his energy, his
intelligence--everything--ought to determine the choice of the
psychotherapeutic steps. As it is entirely impossible to determine all
those factors by any sufficient inquiry, most of the adjustment of
method must be left to the instinct of the physician, in which wide
experience, solid knowledge, tact, and sympathy ought to be blended.
Even the way in which the patient reacts on the method will often guide
the instinct of the well-trained psychotherapist.

It is therefore certainly not enough that the knowledge of the physician
simply decide beforehand on a definite course of psychical treatment and
leave the carrying out to a well-meaning minister or any other medical
amateur who schematically follows the indicated path. The finest
adjustment has to come in during the treatment itself and the response
of the patient often has to suggest entirely new lines of procedure.
More than in any other field of medicine, the physician himself has to
extend his influence far beyond the office hours and the strictly
medical relations. And yet, on the other hand, there is no department of
medicine in which the treatment might not profit by the
psychotherapeutic influence. With a few vague words of encouragement
mechanically uttered, or with a routine of tricks of suggestion by bread
pills and colored water and tuning forks, not much will be gained even
in the ordinary physician's practice. Subtle adjustment to the personal
needs and to the individual conditions is necessary in every case where
the psychical factor is to play an important role. It cannot be denied
that the one great obstacle in the work of the routine physician is the
lack of time and patience which is needed for successful treatment. To
prescribe drugs is always quicker than to influence the mind; to cure a
morphine by hyoscine needs less effort than to cure him by suggestion.

The first method to bring back the psychophysical equilibrium is of
course the one which is also demanded by common-sense, namely, to remove
the external sources of the disturbance. External indicates there not
only the outer world but also the own body outside the conscious parts
of the brain. If we take it in the widest meaning, this would evidently
include every possible medical task from filling a painful tooth to
operating on a painful appendix, as in every case where pain results,
the mental equilibrium is disturbed by it and the normal mental life of
the patient reduced in its efficiency. But in the narrower sense of the
word, we shall rather think of those sources of trouble in the organism
itself which interfere directly with the mental functions. The
examination of any public school quickly leads to the discovery that
much which is taken for impaired mental activity, for lack of attention,
for stupidity, or laziness may be the result of defective hearing or
sight or abnormal growth of the adenoids. Growths in the nose may be
operated upon, the astigmatic or the short-sighted eye may be corrected
by glasses, the child who is hard of hearing may at least be seated near
the teacher; and the backward children quickly reach the average level.
No doubt in the life of the adult as well, often almost insignificant
and from a strictly physical point of view unimportant abnormities in
the bodily system, especially in the digestive and sexual spheres, are
sources of irritation which slowly influence the whole personality. To
be sure, the brain disturbance may have reached a point where the mere
removal of the original affliction is not sufficient to reinstate the
normal balance of mental energies, but wherever such a bodily irritation
goes on, it is never too late to abolish it in the interests of
psychotherapy.

The less evident and yet even more important source of the painful
intrusions may lie outside of the organism in the social surroundings
and conditions of life. Most of that has to be accepted. The physician
cannot bring back the friend who died or the fortune which was lost in
speculation or the man who married another girl. He will even avoid
suggesting far-reaching social changes in the private life of the
patient, changes like divorce in an unhappy marriage or the breaking of
the home ties, however often he may get the impression that such a
liberation would stop the source of the mental trouble. He will be the
more careful not to overstep his medical rights as he seldom has the
possibility to judge fairly on the basis of the one-sided complaint, and
the probability is great that the character and temperament of the
complainant may be a more essential factor of the ailment than the
personalities which surround him. Yet even the conservative physician
will find abundant opportunities for advice which will remove disturbing
energies from the social surroundings of the sufferer. Even a short
release from the burdening duties, a short vacation from the incessant
needs of the nursery, a break in the monotony of the office, may often
do wonders with a neurasthenic. Often within a surprisingly short time
the brain gathers the energies to overcome the frictions with
unavoidable surroundings.

Yet here the physician has to adjust the prescribed dose of outing very
carefully to the special case. We may be guided by the psychological
experiments which have been made in the interest of testing the fatigue
induced by mental work. If perhaps four hours of concentrated work are
done without pauses, experiment shows that the quality of the work
deteriorates, measured for instance by the number of mistakes in quick
calculation. If certain relatively long pauses are introduced, the
standard of work can be kept high all through. But if frequent pauses
are made, and each short, the result is with many individuals the
opposite. The experiment indicates that these frequent pauses are
working as interruptions which hinder the perfect adjustment to the work
in hand. That is suggestive. Our neurasthenic may complain about the
life which he has to live and yet after all he is frequently so
completely adjusted to it that it may not be in his interest to remove
him far away from the conditions which cannot ultimately be changed but
to which he has to return. The instinct of the physician has to find the
middle way between a temporary removal of irritation which really allows
a development of new energies and a mere interruption which simply
damages the acquired relative adjustment. Every cause of friction which
can be permanently annihilated for the patient certainly should be
removed.

This negative remedy demands its positive supplement. The patient must
be brought under conditions and influences which give fair chances for
the recuperation of his energies. Too often from the standpoint of the
psychologist, the prescription is simply rest. As far as rest involves
sleep, it is certainly the ideal prescription. There is no other
influence which builds up the injured central nervous system as safely
as sound natural sleep, and loss of sleep is certainly one of the most
pernicious conditions for the brain. Again rest is a great factor in
those systematic rest cures which for a long while were almost the
fashion with the neurologist. Experience has shown that their
stereotyped use is often unsuccessful, and moreover that the advantage
gained by those months spent in bed completely isolated and overfed is
perhaps due to the separation and changed nutrition more than to the
overlong absolute rest. Yet used with discrimination, the physiological
and the psychical effect of lying in bed for a few weeks has certainly
often been a marked improvement, especially with young women. But more
often the idea of rest in bed during daytime is not meant at all when
the nerve specialist recommends rest to his over-strained patient. It is
simply meant that he give up his fatiguing daily work, even if that work
is made up of a round of entertainments and calls and social
engagements. The neurasthenic and all similar varieties are sent away
from the noise of the city, away from the rush of their busy life, away
from telephones and street cars, away from the hustling business and
politics.