_OBSERVATION._
We must bear in mind the fact that all observation is difficult, not
only because of our lack of perception, but because impressions already
received project themselves, so to speak, on to the objects to be
observed, and prevent our seeing these as they really are. Here lies the
true interpretation of the “fixed idea,” and the “subjective” order of
mind. The mind must not only be large enough and elastic enough to
receive new impressions, but must also combine them with the old, so as
to modify the former idea; for that which can only receive a new
impression at the cost of casting out former and equally truthful
impressions is deficient in retentiveness, and must always be wanting in
thoroughness. We see examples of this order of mind in persons who
eagerly take up one subject after another, but who permanently
assimilate nothing. Mental growth is manifestly of little advantage to
us if, while gaining on the one side, we are continually losing on the
other. Again, if we cut ourselves off from outer impressions we lose
mental power, for it is only by use of a part that nutriment can be
attracted to it; and if our impressions are too exclusively of one
particular order, our minds become ill-balanced.
Before we can be of special use as observers, therefore, education must
have meant for us “the harmonious development of all the faculties.” We
need to have our sense perceptions in good order that we may perceive
quickly and accurately; we need the retentive power to enable us to
store the impressions received; and we need the faculty of combining
these impressions in our minds--the lower manifestation of which process
we call imagination, and the higher, reasoning faculty.
Probably, in the cases where we generally attribute erroneous
observations to excess of imagination, the fault really lies in the
defective perceptive power. Either the nervous structure lacks
sufficient sensitiveness to respond readily to the stimulus, or it lacks
the strength to retain the impression. In these respects we commonly
note improvement with the amelioration of the general health. It is a
question, however, whether, if the stimulus were to make an adequate
impression, the impression would not be more effectually retained. Be
that as it may, we find persons who observe isolated facts readily
enough, and who remember them well, but who learn little thereby,
because they lack combining power. Isolated facts are facts to them and
nothing more. The notion of _law_ is a thing beyond them, and each fact
has to be observed separately.
These are just the persons who are unfit to have the charge of nervous
invalids, but for some mysterious reason they are just the persons into
whose hands nervous invalids most often fall. Perhaps the explanation
is, that ready combining power can exist only with a certain amount of
sensitiveness of nervous structure, and that the sieves through which
we pass our nurses may cast out those who would be of the greatest value
in nervous illness, besides tending to lessen the sensitiveness of those
that remain.[6] At all events, I have been disappointed to find that
women from whom I hoped great things as nurses--women of good
organisation, and certainly not of delicate constitution--have broken
down completely in the course of their hospital training; whilst women
whom I consider positively injurious to any kind of invalid have passed
through it triumphantly. The question arises, Are we not unwise so to
shape our sieves as to exclude the very people by whom we ourselves
would most prefer to be tended in sickness? Will any mere knowledge
atone for the loss of that keen intelligence which we recognise in
persons of so-called sympathetic disposition?
On inquiring the reason why so many highly desirable persons have been
cast out from the sieve of their hospital training, I have been told
that the fact causes no concern to the authorities, so numerous are the
women pressing in to take the place of the defeated strugglers for
existence. If this is no answer to the inquiries, it is at least as good
as most of the replies one gets when seeking for information on this
unsatisfactory subject. Supposing it to be true, we may well ask further
whether a too great narrowing of the spaces of the sieve in a particular
direction, combined probably with an extreme elongation in another
direction, does not tend to produce ill-shapen and one-sided nurses? I
say _tend_, because the present system is still new, and though it may
have immediate advantages, we should not blind ourselves to its possible
disadvantages in the future. We need always to remember that a process
of selection which ensures the survival of the toughest does not
necessarily ensure the survival of the fittest. There is such a thing as
evolving backwards, like the cave-fish who have lost their sight during
their long residence in the dark. The best things in life are not
machine-made.
But correct observation being such a complicated performance, we should
be very indulgent to people who make mistakes; especially so if we have
ever made a mistake ourselves. In our plentiful abuse of individuals, we
merely display our inability to recognise the limitations and
imperfections of “the thing called human nature.” We have reached a
certain landing-place in our upward climb by means of paying attention
to our sieves, but we have a long way still to go.
A few very simple experiments will suffice to show us how hard a thing
it is to see even what lies right under our very noses. We may then
perhaps realise how rash it is to form hasty opinions about the
complicated and invisible nervous systems of our suffering
fellow-creatures. Having got thus far, it may even dawn upon us that to
make our fanciful and erroneous theories (fanciful because founded on
insufficient knowledge, and erroneous because founded on the defective
observations of others) the excuse for ill-treating other people’s
nerves by showing a want of consideration for their sufferings, by
tormenting them with painful and fantastic tricks, and by indulging our
own tyranny and self-righteousness, is to manifest to the world an
extremely primeval species of childishness.
I once drew a character called “Dr. Broadley,” who, excellent man though
he was in some respects, put on a “stalk” when he came in contact with a
nervous patient. Now, three different people thought they recognised Dr.
Broadley, and informed me of the fact. They were all wrong. Not one of
their three supposed models had sat to me for his portrait. I am forced,
against my will, to the conclusion that there are in existence a
superfluous number of persons who make the proximity of an invalid the
excuse for displaying unnecessary airs. Surely it is not by such an
influence, such an example, that the morals of our patients are to be
improved.
I once put together two small prayer-books, so that the coloured edges
of the leaves were divided only by the edge of the thin cover of each
book. The leaves of one were of a bright golden colour; those of the
other had been tinted a dull red. The books were momentarily held up for
observation, with this interesting result. The leaves of the one book
were seen correctly, so far, at least, as their colour was concerned;
for they were unhesitatingly declared to be tinted with bright gold. The
leaves of the other, however, were with equal readiness declared to be
of a _golden_ red colour.
It is easy to understand how this mistake arose. The golden colour was
the first perceived, and the impression made by the dull red was not
strong enough in comparison to be correctly seen and retained in a brief
moment. The bright gold of the one book had so powerfully affected the
retina that the colour was cast, so to speak, on to the leaves of the
other book. These therefore appeared to be golden red in tint, instead
of the dull red they were in reality.
On another occasion a small smooth cake was placed in a dish together
with several large almond-cakes. When attention was attracted to it, it
was mistaken for a cocoanut cake.
Here a rapid inspection had sufficed to show that one cake was smaller
than the others. It had not sufficed to show the great difference in its
construction. The large cakes had been first perceived, and their
roughness was erroneously seen to be shared by the small cake.
Some people go through life with their minds so completely lined by a
series of crystallised impressions, that no aftercomers have the
smallest chance of even combining with them to produce a half-truth, to
say nothing of overcoming them to a sufficient extent to drive out the
errors and replace approximate truths by others still truer.
It may be objected that the above failures in perception of differences
(a much more difficult thing than perception of similarities[7]) was
occasioned solely by the speed with which the observations were made. I
entertained a contrary belief, and my belief was confirmed by the
following example of my own capacity for disgraceful blundering.
Shortly after the publication of “The Massage Case,” a friend asked me
how I could have made such a mistake as to attribute to Elfie during her
convalescence the strength to walk twenty miles in one day. I asked her
to show me the passage wherein I had erred. She did so; and I read that
Elfie really did walk twenty miles in the desert. I was amazed at my own
stupidity, for, considering the length of time required for complete
recovery from severe nervous exhaustion, it is evident that even the
charm of Dr. Risedale’s society could not be expected to inspire her
even temporarily with nerve-power for such a feat. I had looked steadily
at the passage for a few seconds before the idea occurred to me that I
might be seeing wrong. Then I scrutinised each word by the light of this
suspicion, and having hit upon a correct theory, I found out the truth.
It turned out that Elfie walked in the desert for twenty _minutes_, not
_miles_. An erroneous impression had been conveyed to my brain through
the ear; and by its disproportionate tenacity--disproportionate to my
perceptive power at the moment--had prevented my receiving a new and
truer impression through the eye.
I was overdone at the time, and took the warning; that is to say, I
rested. But many of our doctors and nurses, whose observations are of
the extremest importance, are supposed to do their work in a fatigued
condition, and are considered fit objects of abuse if they do it badly.
Why then do they overwork themselves? The answer to this question is
that they are underpaid. The butcher and the baker must always receive
the reward of their labours; the doctor and the nurse must often toil
for nothing, though we are aware that, in order to obtain efficiency in
any profession, it is essential that that profession should be well
paid. The community may object that it cannot afford to pay more than it
pays at present. Can it then afford to be kept ill or made ill by
ignorant interference or by erroneous notions? It would surely be
cheaper in the long-run to pay to get well or to learn how not to get
ill.
To be dogmatic about that which is least known would appear to be an
ineradicable characteristic of human nature in its present imperfect
state. “Fools rush in where angels fear to tread” is still a true
saying. In the treatment of nervous disease it is amply exemplified.
Where we are most ignorant, there we are most uncompromising in our
dealings. When we understood absolutely nothing of insanity, seeing
little connection between madness and disease, we resorted to the whip
and the chain. On waking to some conception of nervous disorder, we
perceive similarities more readily than differences, and proceed to lump
together all diseases of the nerves in the earlier stages under the name
of “hysteria.” Having already some vague foolish fixed idea in our heads
about “hysteria” being synonymous with idleness and general depravity,
we drag our patients about, beat them with wet towels, give them
frightful shocks, galvanic or otherwise, and then get rid of them as
quickly as possible, so as not to have the burden of remote
consequences.
But when more serious mischief is set up, what then? Why, then comes
tardily a perception of differences, and we divide nervous disorders
into hard and fast diseases, concluding that all had been different from
the very first. The later perception of underlying similarity has as yet
scarcely dawned. Some of these maladies are considered curable; others,
without rhyme or reason, are considered incurable.
With regard to the curability of nervous disease, let us consider what
happens when we travel by train from Eastbourne to London, and again
from Eastbourne to Brighton. In each case we pass through Willingdon and
Polegate, and stop at Lewes. We can get out at Lewes or at either of the
previous stations and return to Eastbourne, but if we proceed as far as
Lewes, our return journey will be longer than if we had got out at
Polegate. In the same way nervous disease is more quickly cured in the
early stages than in the later stages. Now, suppose that we are in a
train which does not stop between Lewes and London. It is evident in
this case that, if we have missed our chance of alighting at Lewes, we
must go on to the final goal; no return being possible. Thus, there is a
point in certain nervous diseases beyond which recovery is impossible.
On the other hand, in travelling from Eastbourne to Brighton, we have
several chances of retracing our steps even after leaving Lewes, where
the ways diverge; and so we find that, in some cases of nervous disease,
incurability is reached sooner than in others. And just as we must be
content to take longer to return from Lewes than from Polegate, so we
must be content with a slow cure in advanced nervous disorders, and
remember that, in administering nerve-tonics, the weaker the patient,
the weaker should be the dose; all attempts to hurry the cure being
fatal to success. Moreover, just as, in journeying from Eastbourne to
London, and from Eastbourne to Brighton, we travel along the same road
as far as Lewes, so all nervous diseases have a common origin in
nerve-deterioration which may be repaired.
Defective powers of observation bring with them this great evil,--we not
only fail to reduce a terrible malady to a minimum, but we mete out
unjust censure to those who seem to be responsible for the failure.
Whereas the really responsible party is the community at large--in
short, ourselves. We blame the doctor; but doctors are after all a small
minority, and the minority can only expand and take shape in the
direction in which the least pressure is put upon it by the majority.
The grotesque modes of treatment resorted to in past times evidently
gave satisfaction to all but the enlightened few, just as bad
Governments have been tolerated in the countries fitted only to be
governed badly.
But to be dissatisfied, to mete out blame, to expect a cure, are
healthier symptoms than a passive acceptance of the evil and a lazy
belief in incurability.
Medical science is unlimited. The law of our universe is progress.
_PART II._
The Causes of Neurasthenia.
“Whoever degrades another degrades me,
And whatever is done or said returns at last to me.”
--WALT WHITMAN.