The psychological study of disease is still, alas! a very young and immature science. We have been held so long in the thrall of the materialistic delusion of having to look for bacilli and other micro-organisms behind all diseases that we have almost wholly neglected the psychic factor in disease. It now seems that these psychic factors play the chief role in the so-called “nervous” diseases, whereas all the other “causes,” namely, the predisposition, heredity, infection, etc., it now turns out, do play a certain role, not an unimportant one, it is true, but yet a secondary one. The influence of emotional disturbance upon these diseases has only recently received careful study.

We have learned that psychic causes may play a great role in the occurrence and the prevention of disease. We may confidently assert that without the presence of a psychic component which invokes the disease hardly a single case of nervous disease could occur. Paradoxical as this may sound it is nearer the truth than the orthodox teachings of our day. For who does not recollect times in his childhood when he longed to be sick that he might not have to go to school, and that he might at the same time be petted and indulged by his parents? A little of this infantilism persists with us throughout life. Hysterics especially are distinguished by the infantilism of their thoughts, their feelings, and their ideas. This being so, we must agree with Bleuler when he asserts that the most common cause of hysteria is the desire to take refuge in disease. It will be of interest here to reproduce Bleuler’s report of one of his cases (from his book on “affectivity, suggestibility, and paranoia,” published by Karl Marhold in 1906).

“A paterfamilias suffers an injury in a railway accident. How terrible it would be if he were so disabled that he could no longer provide for his family and if he had to go through life that way, suffering all the time, and half the time unable to work! How much better it would be if he were dead or wholly disabled. His attorney informs him that his annual earnings equal the interest on 80,000 francs, and that he could bring an action for that amount—a sum which would insure his family against want for the rest of their lives. Are there not indications enough that he will need this sum? Isn’t it a fact that he is already suffering from insomnia? Work fatigues him—his head aches—railway journeys make him apprehensive and even cause attacks of anxiety; how helpful it would be, nay, how absolutely necessary it would be, to prove that he is very sick and to get that 80,000 francs! And now the traumatic neurosis or psychosis is established, and will in all probability not be curable until the lawsuit is satisfactorily settled.” Bleuler does not mince matters but roundly asserts that in this case the wish caused the neurosis. Would it be proper to call these people malingerers? By no means! For, naturally, all these wishes are not clearly known to these individuals; they suffer in good faith. The wish emanates from unconscious levels. Consciousness vehemently resents any imputation of the thought of simulation. Such invalids usually protest vehemently their desire to be well. “How happy would I be if only I had my health! Then I would gladly dispense with damages!”

Here I should like to report two cases from my own experience which serve to illustrate the refuge in disease even better than the case described by the distinguished Swiss psychiatrist. The first was a very sick woman who had been bed-ridden for six years. No organic malady could be discovered. The diagnosis was hysteria. The deeper cause of her malady was as follows: Her husband was a coarse, brutal fellow, continually upbraiding her for something or other and raising fearful rows; but when she was sick his whole nature underwent a change. Then he became amiable, affectionate and attentive. As soon as she was well he became the old, unendurable, domestic tyrant. Finally, there was nothing for this delicate, weak woman to do but to take refuge in disease. Her limbs used to tremble and refuse their function, so that she had to stay in bed or be rolled about in an invalid chair. All the skill of her physicians—and she had the best the metropolis had to offer—proved unavailing. Naturally the cure of such a case is hardly possible unless one can remove the cause for the refuge in disease. In this case this solution was out of the question, and so the woman goes on enjoying the blessed fruits of her invalidism, complainingly but not unhappily, exulting within, but miserable without.

Our everyday life furnishes numerous petty examples of refuge in disease: the nervous wife who breaks out in a hysterical crying spell if her husband reproaches her; the schoolboy who complains of headache when he cannot get his lessons done; the husband who gets pains in the stomach every time his wife makes life unbearable;—they all take refuge in disease as a means of escape from their persecutor. How often is this phenomenon observed among soldiers, for whom a few days of illness means the most delightful change! In these cases even the most experienced military physicians often find it impossible to distinguish between wish and reality.

A physician who does not know of the phenomenon we have designated as “refuge in disease” will be helpless in the handling of most cases of hysteria. A blooming young girl had for two years consulted specialists of the highest repute about the raging headaches with which she was afflicted. All the usual remedies, such as antipyrin, phenacetin, pyramidon, and even morphine, failed to give her even slight temporary relief. The experts thought of a tumor in the brain and of other dangerous maladies as the possible cause of these obstinate headaches. But it turned out that this headache, too, was only a refuge in disease. A casual remark of the father’s betrayed the true nature of the trouble: “My daughter is about to be married; she has been engaged for two years, and the young man is anxiously waiting for the wedding; but I can’t let her marry while she is suffering from such a severe disease.”

The headache was obviously the means of getting out of a hateful marriage. Of course one who would have been content with her first story would never have discovered the truth. What stories she told about her wonderful love! How ardently she loved her betrothed! There was nothing she longed for more than the wedding-day! How unhappy she would be if she lost him! But a careful psychoanalysis brought forth ample and convincing confirmation of the above-mentioned suspicion. The girl had been engaged once before; in fact she had not yet completely broken off her relations with her former lover. In addition thereto there were confessions about the death of all erotic feelings during the second engagement, as to which we cannot go into details. It was quite clear that her malady was a refuge in invalidism. I advised breaking the engagement. The advice was not followed. On the contrary, the family hoped that a speedy marriage might bring about a cure of the hysterical condition. But the young woman is still going about, complaining and whimpering, with her malady (from which her husband, notwithstanding his inexhaustible patience, suffers more than she). Will she ever be well? If she ever learns to love her husband she may recover her health. But where such powerful, unconscious counter-impulses, such powerful instincts, contend against an inclination, it is scarcely possible that this inclination will develop into full sovereignty of the soul.

What we have just said of the neurosis is also true of the delusions of insanity. A delusion also is a fleeing from this world into another one in which some particular overvalued idea represses all other ideas and dominates the mind. It will not be long ere this conception will be an accepted doctrine of all psychiatrists. For the time being it is the common property of creative literary artists, who, because of their intuitive insight into human nature, have frequently given expression to this idea. It is perhaps most beautifully expressed by Georges Rodenbach, the Flemish artist, unfortunately too early deceased, who says in one of his fine posthumous novels (“Die ErfÜllung,” Dresden, 1905):—

“The insane have nothing to complain of. Often they achieve their purposes only in this way. They become what they have longed for and what they would otherwise never have become. They obtain the coveted goal and their plans are fulfilled. They live what once they dreamed. Their delusion is, to all intents and purposes, their inner fruition, inasmuch as it corresponds to their most ardent desires and their most secret yearnings. Thus the ambitious one ascends in his delusions the heights that have beckoned to him; he possesses endless treasures, orders the destinies of great nations, and moves only among the great rulers of the earth. Religious delusion brings its victim to the throne of God and makes life in Paradise a tangible reality. So that delusion always realises the goal that each has longed for. It gratifies our desires to the utmost limit. Sympathetically it takes a hand in our affairs and completes the altogether too pretentious destiny of those upon whom fulfillment never smiles.”

What a beautiful idea! Delusion is a wish-fulfilment exactly as the dream is. The madhouse is the paradise of thoughts, the heaven in which wishes meet with unlimited fulfilment. And human beings sicken so often, and madness increases with such uncanny rapidity, because our most secret wishes are never gratified, because in these dull times the miraculous has died, and because life demands so much renunciation and yields so little happiness.

Let us draw these lessons from the foregoing remarks: to keep one’s desires within bounds means to assure one’s spiritual health. Inordinate ambition, which foolish parents kindle in their children’s hearts, is often the cause of an early breakdown. We must school ourselves and our children to wish only for the attainable and to attain our desires. Our ideals must live in our breasts, not in the outer world. Then we may find in ourselves what the world denies us. They who can find refuge in their health will escape having to take refuge in disease.