Some General Considerations.
It is instructive to compare the public attitude towards insanity with
that adopted in the case of another serious disease, tuberculosis.
There is nowadays a general conviction, not only amongst the medical
profession but also amongst a large proportion of the educated public,
that tuberculosis is a curable disease. It may exist in a mild and
incipient form in many persons regarded as healthy, and, if properly
treated in its early stages, with due regard not only to the actual
disease in the bodily organism, but also to the healthy environment of
the individual, it is almost certainly conquerable. Not many years ago,
however, this happy belief did not obtain. A person “in consumption,”
especially if “consumption was in the family,” was regarded as
being in a very serious and almost hopeless condition. The patient,
shielded from fresh air, inappropriately and insufficiently fed, often
succumbed, supplying one more example to support the unscientific
conception then prevalent of the inheritance of the disease. But such
conditions are passing away. In our medical schools and hospitals
special attention is paid to the diagnosis and treatment of early forms
of tuberculosis; the importance of preventive measures is emphasised;
the influence of the patient’s environment in favouring or combating
the disease is explained; and the future medical practitioner
is afforded frequent opportunities for personal investigation
of tubercular patients. The old ideas about the “inheritance of
consumption” are greatly modified. No longer is a patient’s disease
explained as “in the family” and left at that. Preventive measures,
early treatment, an attempt justly to appreciate the relative influence
of heredity and environment are the watchwords of the modern medical
attack upon tuberculosis.
If, however, we consider the attitude of the general public in this
country towards the malady of insanity we find a mixture of ignorant
superstition and exaggerated fear. From these there springs a tendency
to ignore the painful subject until a case occurring too near home
makes this ostrich-like policy untenable. The sufferer is removed to a
“lunatic” asylum, neither himself nor his relatives being spared the
gratuitous extra wrench to their feelings aroused by this name, which
has long struck terror into the uneducated mind. He is taken away by
the relieving officer of the district, often under the pretence of
being given “a few weeks in a convalescent home at the sea-side,” and
eventually finds himself under lock and key. Here, as is well known, he
is treated with great kindness. Neither public money nor the exertions
of the staff are stinted in the effort to render his lot as pleasant
as possible—“the asylum to-day has become a model of comfort and
orderliness.”[50] But the proportion of doctors to patients is on the
average, one to 400, and it is exceedingly difficult to ensure that
all patients, once inside the “lunatic” asylums, shall be regularly
visited by friends from the outside world.[51] The attitude of the
general public is not deliberately cruel, but it appears to be far
more benevolent than it really is. The community treats the sufferer
well, when, _but not before_, he has become a “lunatic.” It allows
his delusions to become fixed, his eccentricities and undesirable
acts to harden into habits, his moods of depression to permeate and
cement together the whole of his life—and then interns him and treats
him kindly for the rest of his life, but does not give him facilities
for gratuitous treatment while he is still sane. _That is the British
procedure to-day._
Lest we should be accused of exaggeration, or worse, we will quote here
from published articles and reports.
Dr. Bedford Pierce says:—
“Let me state in a few words the defects of our present system. At
present, broadly speaking, no person unable to pay its cost can
receive adequate treatment until he is certified as of unsound mind.
This practically means that no special treatment is possible until he
has utterly broken down, and is so seriously affected as to convince
a magistrate that he is decidedly insane. No general hospital will
receive such a patient; the public asylums are all closed to any
one who begs for protection or treatment, for county asylums cannot
receive voluntary boarders even when the cost of their maintenance is
forthcoming.
Consequently there is no alternative but to apply to the Poor Law
authorities, who, under certain circumstances, provide treatment for
a period of two weeks in the workhouse infirmary. The whole system
is radically wrong. When the wife of an artisan becomes depressed
after confinement, surely it is cruel in the extreme to make her a
pauper and send her to the workhouse infirmary, pending a decision
as to whether she is insane or no. It is obvious in such a case that
this course will not be adopted until the last possible moment, and
consequently much valuable time is lost.
Every practitioner will be able to call to mind patients travelling
steadily towards insanity in unfavourable surroundings. This question
is brought even more prominently before consulting physicians,
especially those interested in nervous and mental diseases.” (_Op.
cit._, p. 42.)
In the words of the report of the Medico-Psychological Association:—
“The present system, which compels all persons, except those able
to pay adequately for their maintenance, to apply to the Poor Law
authorities in order to secure treatment, is unsatisfactory and
unjust. In doubtful and undeveloped cases temporary care can be given
only in workhouses or Poor Law infirmaries, which, with very few
exceptions, lack proper facilities for treatment.
_A system which artificially creates paupers in order to obtain
medical treatment necessarily acts as a deterrent, so that too
frequently there is serious and even disastrous delay._”[52]
This is not exactly locking the stable door after the horse has
gone; it is double-locking him thoroughly, expensively and often
unnecessarily, in someone else’s stable.
Let us, for a moment, compare this state of affairs with that existing
in the case of tuberculosis. Nobody now believes that the scientific
way of treating this disease consists in waiting until the patient has
become a positive danger to others, and then locking him up. This point
needs no elaboration. But another fact in this connection should not be
forgotten. The tubercular patient usually seeks the doctor _of his own
free will_, often obtaining treatment in a relatively early stage of
the disease.
There are, however, many reasons that deter the mental sufferer from
seeking medical help. One of the strongest of these is the wish to cure
himself by his own unaided efforts. This is a laudable desire and one
which is extremely helpful and important in mild and uncomplicated
cases of relatively recent occurrence, but of which, as we have
seen,[53] the gratification is not always possible. Another factor
is the natural disposition which the patient shares with the rest
of conventional humanity, to conceal his worries, not only from his
friends, but perhaps above all from those of his own household. This
tendency to concealment, however, often only aggravates his mental
distress. Particularly is this the case in adolescents. As is well
known, a talk with a kindly, sympathetic and wise person, or even a
confession to such an adviser, frequently means the end of many painful
mental conflicts.
But in addition to these very natural reasons for deferring recourse to
medical help, there are in our own country special causes for delay.
These are due to the prospects imagined by the sufferer to be awaiting
him if he discloses his trouble.[54] The treatment of incipient
mental disorder is often a long and complicated process for which
the average general practitioner has seldom either the time or the
special training. In very few hospitals in this country is out-patient
attendance for such maladies practicable. For the mental sufferer
whose means are not considerable, there exists nothing if the efforts
of the general practitioners fail, but trying to cure himself, or,
if he becomes worse, admission to an asylum. Unfortunately, however,
the average asylum, with its one doctor to 400 patients, does not and
can not meet his needs. The successful treatment of mental disease
usually requires individual care, often lasting over long periods. When
it is remembered that the asylums contain a considerable percentage
of patients whose bodily diseases, apart from their mental troubles,
require the doctor’s attention, and further, that by the time the
patient reaches the asylum, his disorder has usually passed through
its initial stages, it is easily seen that our asylum system in its
present state—to put it mildly—is far from conducive to recovery from
mental disease. Considering that, in spite of these drawbacks, 33 per
cent. of the patients are discharged,[55] we can only gladly recognise
the efforts made by the asylums; we are, however, bound to ask: _What
percentage of the inmates need ever have entered the asylum?_ It may
be objected that it is easy, but unfair, to ask such a question seeing
that no satisfactory answer can be given. To this objection there are
two replies: first that, judging from the present state of affairs,
this question cannot be publicly asked too often; secondly, that
materials for an answer are already forthcoming. It is conclusively
proved by the experience of other countries that a large proportion of
the patients might have been cured without being sent into an asylum.
Thus, for example, in Germany, in the province of Hesse, by reason
of suitable treatment during the early stages of mental illness the
authorities were able to postpone for ten years the erection of a new
asylum.
“The Psychopathic Hospital at Boston, Massachusetts, ... was built by
the State expressly to deal with recent acute cases. No fewer than
1,523 patients were received in its first year, and of these 590 were
received under a temporary care law, which provides for a week’s
detention only; large numbers were also received on a voluntary basis,
so that during the year _48 per cent. of all patients escaped the
usual lunacy procedure_.
On reading the reports of work done, one is struck with the enthusiasm
of the medical staff and the vast field of research undertaken.
During the two years eighteen medical men describe their work
covering almost every department of psychiatry: juvenile crime,
tests for feeble-mindedness, incidence of syphilis, alcoholism,
hydropathy in its influence on red blood cells, treatment of delirium,
prophylaxis, analysis of genetic factors, salvarsan treatment,
tests of cerebro-spinal fluid, and last, but not least, the value
of out-patients’ departments and after-care. There is a special
social service department for the purpose of following up cases in
their homes, and it was found that of every 100 admissions 20 needed
supervision on discharge, 24 needed advice, 3 required assistance in
arranging their discharge, and 10 showed a need for prophylactic work
in their families.
This bald statement of the activities of the Boston State Hospital
shows plainly what an important service it renders in providing
treatment apart from ordinary asylum associations. It shows how it
is possible at such a hospital to organise a medical service which
covers all departments of psychiatry; and further, that when the
mental symptoms clear up, a patient need not be thrown back into old
associations without help or supervision.
This hospital at Boston is but one of many that have been established
in the United States in recent years. Some of the others are due to
private munificence; in particular, reference may be made to the Henry
Phipps Psychiatric Clinic at Baltimore, the medical staff of which
consists of a director, assistant director, a resident physician, two
assistants, and five [resident medical officers]. In addition to these
are the heads of three research laboratories dealing (1) with clinical
pathology and bio-chemical investigation, (2) with neurological
research, and (3) with psychopathology.” (Bedford Pierce, _op. cit._,
p. 42.)
In advocating the establishment of separate pavilions for nervous and
mental disease in direct association with the general hospitals, Dr.
Bedford Pierce says:—
“At La Charité Hospital in Berlin, the visitor enters a small park,
and Dr. Ziehen’s clinic is but one of many detached buildings devoted
to special diseases. It is as easy and simple for the patient
suffering in mind to get advice there as for another with eye and lung
trouble.”
Let it be noted that none of these German patients, on returning to
their relatives and friends, suffer from the stigma of having been
to an asylum. In our country some of those same friends during the
patient’s absence would often have been engaged in “sympathetically”
spreading the news of the sufferer’s absence and his whereabouts
to everybody in the district. To a certain type of mind there is a
ghoulish fascination in gloating over the illnesses and afflictions
of neighbours. Even though people addicted to such habits may salve
their own consciences by exclaiming “poor fellow” at the end of their
narrative, the effect of their conduct is none the less brutal and
offensive. This is not the place for the discussion of so remarkable
and important a phenomenon of social psychology. Nevertheless it plays
a great part in the causation of the prevalent dread of treatment for
mental disorder.
For many reasons the psychiatric clinic is not regarded by the public
as a “lunatic” asylum. In the Giessen clinic in Germany, for instance,
both nervous and mental diseases are treated. The patient afflicted
with tremor or a paralysed finger visits this institution as well as
the sufferer whose troubles if neglected might develop into mental
disease. Difficult medico-legal cases resulting from such incidents as
those arising from the claims by workmen and others for compensation
after accident are sent to this clinic for observation and opinion.
“Rest-Cures” and similar treatment are also carried out there. The
official title of the institution, displayed at the entrance, is
“Clinic for Mental and Nervous Diseases.” The institution is therefore
regarded by most people in quite a different light from the asylum, and
it is not spoken of by the general public with bated breath. One of us,
while working in the laboratory of a German psychiatric clinic, was
introduced to a visitor who made some remark about “when I was here.”
To the question, “Were you on the staff, then?” the visitor answered
quite naturally, “Oh no, I was here as a patient.”
With this experience may be contrasted another incident, this time
from our own country. Delegates from a certain Board of Guardians paid
a visit to the county asylum to inspect the arrangements made for the
comfort of the inmates from their own district. In the next week’s
local newspaper a report of the visit appeared in the form of the
chief delegate’s speech at the subsequent board meeting. This report
consisted of “funny” stories of the eccentricities of the patients the
visitors had seen, and of the delusions from which some of the victims
were suffering, with sufficient detail to enable many of the relatives,
and possibly some of the friends, of these “lunatics” to identify the
afflicted ones. The newspaper account of this humorous effort was
punctuated at suitable intervals with “laughter.”
It is obviously not claimed that these two accounts are typical either
of Germany or of England. But what is claimed is that of these two
public attitudes the clinic system promotes the one, the “lunatic”
asylum the other.
Before leaving the comparison of insanity with tuberculosis we must
remind the reader of some other facts that are important in this
connection. We have seen[56] that the scientific study of tuberculosis
has materially modified the earlier views concerning its hereditary
transmission. It is now held that tuberculosis is not inherited as
such; but that a child of tuberculous parentage may begin life with
a subnormal power of resistance to the disease and perhaps greater
risk of exposure to infection. If later he develops the disease, it is
traceable directly to his environment. The corollary is that if his
environment be improved, and his body’s power of resistance increased
meanwhile by all the means in our power, he has a considerable chance
of living a life free from the disease. Thus the old pessimistic view
is replaced by a distinctly optimistic one.
In the mental disorders that are indubitably traceable to organic
disease of the central nervous system, heredity doubtless plays a great
role. But two points should be remembered in this connection. First,
among asylum patients the number of mental disorders which cannot,
_post-mortem_, be traced to organic causes is very great as compared
with those that can be so related. For example, of 1,325 patients
received at the Burgholzi Central Asylum and University Psychiatric
Clinic, Zürich, Dr. C. G. Jung states:—
“... in round figures a quarter of our insane patients show more or
less clearly extensive changes and destruction of the brain, while
three-fourths have a brain which seems to be generally unimpaired
or at most exhibits such changes as give no explanation of the
psychological disturbance.... We must take into account the fact that
those mental diseases which show the most marked disturbances of the
brain end in death; for this reason the chronic inmates of the asylum
form its real population, and among them are some 70 to 80 per cent.
of cases of dementia præcox, that is of patients in whom anatomical
changes are practically non-existent.”[57]
In a great number of mental disorders our present knowledge of
anatomy, physiology and pathology is of little help as a means of
throwing any light upon the patient’s condition. While in no way
attempting to belittle the magnificent work in these subjects during
the past century, it should be pointed out that its very success has
brought about, especially in this country, an unfortunate tendency
to regard these methods as the only ones suitable for attacking the
problems of insanity. But nothing is more certain than that in the
psychoneuroses: hysteria, neurasthenia, psychasthenia and the rest,
anatomical and physiological knowledge has not yet passed beyond
the theoretical stage[58]. But it is equally indisputable—and the
statistics of shell-shock cases have strengthened the evidence for
this assertion—that the psychological mode of attack, the treatment
of mental disorder by mental means, is now firmly established as a
practical method.
It appears, therefore, that precisely in those cases of psychoneurosis
which yield to psychical treatment, there is no anatomical,
pathological or chemical evidence of inheritance.
But while the contributions of anatomy, physiology and pathology to
the treatment of psychoneuroses have not yet gone beyond theoretical
and mutually conflicting suggestions, the psychological method of
investigation and treatment on the other hand has proved itself of
practical use in restoring patients to a normal state of mental health.
What scientific justification therefore have we, when considering
the action of heredity, for lumping together the organic and the
functional mental disorders? The psychoneurosis is often simply a
progressive state of mal-adaptation to environment; a mental twist
which can be corrected if treated suitably at a sufficiently early
stage. Its specific nature is frequently explicable almost entirely
in terms of the peculiar educational, family or social relations of
the patient’s environment. The war has shown us one indisputable fact,
that a psychoneurosis may be produced in almost anyone if only his
environment be made “difficult” enough for him.[59] It has warned us
that the pessimistic, helpless appeal to heredity, so common in the
case of insanity, must go the same way as its lugubrious homologue
which formerly did duty in the case of tuberculosis. In the causation
of the psychoneuroses, heredity undoubtedly counts, but social and
material environment count infinitely more.
To some readers the above argument may seem so obvious as to be
superfluous. To ascribe a patient’s entangled state of mind to heredity
without attempting to discover how far his own personal experiences
have tended to bring about that mental condition, would seem as
fatuous as attributing to heredity the financial muddles of a son who
has inherited from his unbusinesslike father a badly managed estate.
The trade-adviser called in to help might for a moment consider the
possibility that the son may have inherited his father’s unpractical
character, but surely his first serious efforts would be to discover
where the business methods were wrong or antiquated and to improve
on them. So it is with the mental patient; his own history is the
important desideratum. That of his parents may cast valuable light
upon his trouble, but even then it is often just because their own
difficulties have contributed to the making of his environment.
One of the most dangerous and misleading terms in our language is the
word “neuropathic;” for it is made to signify so many things that it
ends by meaning nothing. Etymologically, it should mean “afflicted with
disease of the nerves,” a conception the precision of which we shall
discuss below. Yet on the return from the front of patients afflicted
with “shock” one heard the opinion at first that the cases were those
of “neuropathic” men: that the soldiers who became affected by shock
were weaklings or were descended from mentally afflicted or nervous
parents. It is, of course, unquestionable that in a large army there
must be many soldiers with tainted family histories; and it is probably
equally certain that such factors play some part in determining the
greater susceptibility of certain men to shock. But it would be a gross
misrepresentation of the facts to label all the soldiers who suffer
from mental troubles as weaklings. The strongest man when exposed to
sufficiently intense and frequent stimuli may become subject to mental
derangement. It is quite common to find among the patients suffering
from shock senior non-commissioned officers who have been in the army
fifteen or twenty years (much of which time has been spent in foreign
service under trying circumstances, such, for example, as the South
African War), and have stood this severe strain. Such men can hardly be
called weaklings or “neuropathic.”
Even in those cases where there is a definite history of a neurotic
parent, it would be a mistake hastily to conclude that when the son
of such a man or woman becomes a victim of shell-shock it is due to
heredity. For when the detailed history of such patients is obtained
the fact comes out quite clearly that the social disturbances in the
household of such a nervous person may be amply sufficient to inflict
severe psychical injuries upon young children.
Further, in many cases the histories themselves clearly and definitely
reveal the real etiology of the mental condition, and point to
emotional disturbances in children, due to the cruelty of drunken
parents, a rankling sense of injustice, a terrifying experience, which
may have been an accident or deliberate maltreatment by some human
being, or again, to the appalling conditions created in some of these
homes by nervous and irritable parents, as the real trauma which the
“shock” has served to re-awaken.
But when we come to ask _what_ disease of the nerves, or, more
strictly, of the nervous system, is implied in speaking of the
“neuropathic” we find no satisfactory answer. Certainly no one disease
is regarded as being the causal factor. And the list of theories is
overwhelming. Disturbances of the genital, vaso-motor, or digestive
systems, demineralisation, chemical disturbances of nutrition of
hepatic or cholæmic origin, visceral ptosis, cerebellar disturbance,
thyroid disorder, complex disturbances in functioning of the blood
vessels, intoxication, exhaustion[60]: these are some of the numerous
theoretical suggestions proposed to account for neurasthenia only.
Whether the unfortunate neuropath is supposed to be afflicted by one
or all of these is a matter which we certainly cannot decide; for the
theories proceed from many different sources.
But we must not lose sight of another important fact in this
connection. The neuropathic person’s mental troubles, or those at
least for which he seeks relief from the physician are by no means in
the clouds of theory. They are real enough, and as a rule not to the
patient only, but also to his relatives and friends, with whom he finds
it difficult to live amicably. Those troubles are based upon fear,
anxiety, anger, and excessive curiosity concerning matters about which
the normal person would not bother his head. They find expression in
outbursts of pugnacity or of unusual self-assertion with its emotion of
elation, often followed by self-abasement and subjection, inordinate
desires either to be alone or never to be alone, floods of tender
emotion, possibly following close on the heels of a mood of blatant
self-assertion with no regard for the feelings of others. These
relatively simple processes of mind, occurring sometimes in comparative
isolation, sometimes inextricably blended or kaleidoscopically
transient, are the real marks of the so-called neuropath or neurotic.
Bodily troubles may, and often are, added to these. But as every
physician knows to his cost (and sometimes to the patient’s), and
as faith-healers know to their advantage, these bodily diseases are
usually exaggerated by the neurotic sufferer, and frequently prove to
have but a slight material basis. In other words, the real marks of the
“neurotic” are mental.[61] And one need not be a technical psychologist
to see that the above list is nothing but an enumeration of the
instincts and emotions possessed in common by all men.[62]
If then, the neuropath is merely displaying instincts which are common
to all mankind, what is the difference between him and the normal
human being? The difference is psychologically slight, sociologically
immense. While his normal brother reacts instinctively and emotionally
to his physical and social environment in such a way and to such a
degree as to promote his own welfare and that of others, the neuropath
does not. Nobody calls the townsman a neuropath who before crossing
the street waits on the pavement until the stream of traffic has
thinned. If he did not wait we should rather call him a fool. But the
instinct of fear is largely at the bottom of his so-called intelligent
caution—especially if he has ever witnessed a distressing street
accident. But what do we say of the man who waits and waits until
finally he is too afraid to advance, eventually stealing down to
another place so that he may cross in safety? He is very likely to be
called a neuropath. Or what shall we say of the unfortunate man whose
caution has gone so far that he cannot cross _any_ open space whatever,
and is said to be suffering from agoraphobia?
Or again, take the case of a man whose personality, family or country,
is grossly and publicly insulted. If he strikes at the aggressor, do
we call him neuropathic? But we seldom hesitate to apply this term to
the man who is inordinately touchy, ever on the watch for the least
suspicion of insult towards himself or anything even remotely connected
with him. The emotion of fear underlies both the attitude of caution
and of “funk,” that of anger, the righteous indignation of the stalwart
and the querulous, peevish irritability of the neurasthenic. The
difference between the behaviour of the normal man and the neuropath
lies primarily in the circumstances that provoke emotion in them, and
secondly in the violence and duration of the emotion itself.
We should remember also that many varieties of animals display the
kind of behaviour we have described, and regard as so unusual, if not
utterly eccentric, in our friends. Professor William James reminds us
of the chronic agoraphobia of our domestic cats; and the tamer of wild
animals has good reasons to respect the incessant touchiness of some
species of the genus _Felis_. Do we invoke theories of visceral ptosis,
intoxication and the rest to explain the behaviour of the average cat
or mule? Scarcely. We say that these animals are actuated by instinct.
Our arrogance makes it difficult for us to suppose that our suffering
human brothers are also acting instinctively. Yet this is undoubtedly
the case.
It has been said of the neurasthenic with aptness and truth that he
behaves like a child. But if a child, normal in its behaviour up to
a certain day, suddenly manifests fear of being left alone for a
moment in a room with closed doors, or in a street, do we rush for our
“Liddell and Scott” and forthwith proceed to babble of claustrophobia
or agoraphobia?[63] Do we follow this up by solemnly invoking
complicated physico-chemical theories concerning the state of his blood
or other bodily fluids? Finally, do we brand him as “insane” or at
least “neuropathic?” What we do in this case, if we have any sense, is
carefully to investigate the causes of the emotional outbreak. We try
sympathetically to understand and re-educate the child to meet such
situations without fear. In other words, we use a method precisely
similar to that which proves to be of such great use in treating the
psychoneuroses.
The analogy—if it be an analogy and not perhaps an identity—between
the two cases goes still farther. The child who manifests extreme fear
at “inadequate” causes, such as we have described, not infrequently
agonises his mother—perhaps soon after his outburst of fright—by an
exhibition of foolhardiness which, if we did not know of the previous
sign of weakness, would cause one to look upon him as fearless. In
short, the child’s fear is restricted to one or two special situations.
So it is with many neurasthenics. Some, for example, may be driven
through traffic in a fast motor car without experiencing the slightest
fear, though they cannot bring themselves to enter an ordinary slow
suburban train; others may surprise us not only by their exhibition
of anger at what we should consider an absurdly slight provocation,
but by their tolerance and self-control in other (to us) much more
annoying situations. Their exaggerated emotional reactions are excited
not by general but by specific stimuli; and a little tact, insight
and patience on the part of the physician often reveals in their
past experience, psychological factors which explain the tremendous
personal importance and overweighting of these stimuli. If for
neuropathic we write: “unduly hampered by instinct and emotion”—and
this is all we have the right to do[64]—we represent the matter more
truthfully.
Among the laity, before the war, the justification of an attitude of
inertia towards the treatment of mental disorder (more particularly
of the psychoneuroses) was often based upon two statements. The first
was that many of the phenomena reported were not real, but were the
imaginings of hysterical women. If to this it was objected that men
were not immune to hysteria[65] one was met by the retort: “But
they are ‘neuropaths.’” This war has, however, removed from honest
people’s minds the possibility of regarding these phenomena in such
a shamelessly unscientific light. In the military hospitals there
have been hundreds of patients suffering from psychoneuroses, who are
demonstrably neither women nor neuropaths, in any of the legitimate
senses of these terms. And many of these men have suffered intensely.
Their fears and other emotional troubles are such as they usually
conceal as long as possible, until further endurance is intolerable.
Their troubles are real enough to them. “But they are unreasonable,”
the healthy philistine may object. Some (by no means all) of the fears
_are_ unreasonable, if by that is meant that the actual danger (as
the healthy man estimates it) and the emotion which it evokes in the
patient are entirely disproportionate. But who among us has “sized
up” life’s dangers so accurately that he can say he knows the precise
degree of fear which each one _ought_ to evoke?
In some country places the inhabitants to-day are more afraid of the
presence in their houses of peacock’s feathers or of hawthorn blossom
than of scarlet fever. Their fears are unreasonable. But we do not call
these people neurasthenics. As a matter of fact, neurasthenia is one
of the last diseases likely to attack these rustics. If they vouchsafe
any reason for their fear, it is safe to assert that it will be a
rationalisation, for its real sources are hidden from them. And if we
really wish to discover the cause of their fear we turn for help to
the records of folk-lore and ethnology. In other words, we investigate
the history of the fear. This history may go back many centuries and
the process of recovering it from a series of clues will prove a task
of infinite fascination. Now the history of the neurasthenic’s fear is
likewise obtainable and much more easily, for it is of much more recent
date. Its discovery often means the freeing of a mind from torment,
the restoration of a useful member to society, and the enrichment of
the science whereby other similar liberations may become possible. But
how few investigators, as yet, have been attracted by this tremendous
unfilled field of knowledge!
However, our philistine, while agreeing to this, may, and often does,
change his ground. He may add: “When I said that the phenomena were not
real I had in mind rather the pains and the paralyses from which the
hysteric and neurasthenic suffer—or say they suffer.” To this we may
answer in the words of Dr. Purves Stewart:—
“... we must recognise that the neuroses are real diseases, as real
as small-pox or cancer. A sharp distinction must be drawn between a
hysterical or neurasthenic patient and a person who is deliberately
shamming or malingering.... The hysterical or neurasthenic patient
usually has no knowledge of the disease which he or she may
unconsciously simulate. The various paralyses and pains from which
hysterics and neurasthenics suffer are as real to the patient as if
they were due to gross organic disease.”[66]
There is a view which, while eminently useful and sensible in so far as
it concerns neurology alone, is apt, by virtue of these good qualities,
to retard the progress of psychical treatment of the neuroses. For it
tends to focus the attention of the medical world on their physical
basis alone. Such a view is expressed by Dr. Purves Stewart in the
manual from which we have just quoted. In his chapter on the neuroses
he says:—
“The old definition of a neurosis as a nervous disease devoid of
anatomical changes is inadequate. _Disease is inconceivable without
some underlying physical basis._[67] The lesion need not be visible
microscopically: it may be molecular or bio-chemical.”[68]
Now from the purely material standpoint such a statement is above
reproach. But some important reflections occur as one thinks over the
paragraph, and especially the statement: “Disease is inconceivable
without some underlying physical basis”—as applied for example,
to neurasthenia. What are the important signs of disease in the
neurasthenic, or what unusual phenomena are there which cause him to
seek the doctor? Chiefly, as we have seen on p. 91, the undue dominance
in his mental happenings of instinct and emotion. But we cannot say
that this by itself is a sign of disease. Otherwise we shall arrive at
the paradoxical conclusion that wild animals, savages and children
form the diseased class _par excellence_.
The behaviour of the neurasthenic differs from that of the normal
person only in degree, and some sane men might be unhesitatingly
regarded as neurasthenic by one class of society, normal by another.[69]
Moreover, it is perfectly clear that if we adopt any of the usual
views as to the relation between body and mind, not only disease, but
health too is “inconceivable without some underlying physical basis.”
Yet of the molecular or bio-chemical aspects of that basis we know
practically nothing which would help us to understand even ordinary
mental occurrences. So when a normal, physically healthy mother bursts
into tears of joy on her son’s return from the front, is sleepless
when she knows he is in the trenches, forgets some of her daily
duties in perpetually thinking of him, is “on edge” and irritable
when she has had no letter from France—though we may be perfectly
justified in believing that there are molecular or bio-chemical nervous
changes underlying her behaviour, we do not dream of invoking these
as explanations of her condition, for of them we know little. Neither
do we call her neurasthenic. We understand her condition in that we
correctly refer it to the action of instinct and emotion. Its cause is
clear to us, and if we attempted to treat it we should know beforehand
that the best cure would be the restoration of her loved one, the next
best, sympathetic help in facing her worries, the removal of unfounded
fears and the production of a serener outlook on the future. In other
words, the diagnosis, the tracing of causes, and the treatment would be
entirely mental, with no reference whatever to the physical basis, the
existence of which we obviously should not deny. Similarly, if a man is
troubled by a great moral conflict which produces in him sleeplessness,
irritability, abstraction and the rest, the physical basis of his
emotional condition may be “materially” treated. His sleeplessness may
be reduced by bromides, his irritability and depression by alcohol;
but who, if he knew of the great mental conflict, would dare merely to
prescribe these?
And this, in the case of many of the psychoneuroses is the crux of the
whole matter. The root of the trouble is mental conflict, the complete
details of which can seldom be found on the surface of the complex of
symptoms. To palliate them one by one is often to provoke new ones.
The conflict is sometimes clearly apprehended by the patient, but
even then is often jealously guarded from everyone else. Sometimes,
however, it is not clearly conscious in all its details, even to him.
This is especially the case, if as so often happens, he habitually
shuns the thought of it. Faced with an inability to adapt himself to
his circumstances, he instinctively relapses into a more childish way
of meeting the situation—hence the tears, the irritability, the mental
distraction and the rest. This phenomenon, we repeat, is not new. We
all acknowledge its existence when we say that the “nervy patient
behaves childishly,” though perhaps we do not realise what a true
conception of the matter we are expressing.
To sum up, while it is indisputable that the psychoneuroses, like all
mental phenomena, have a material basis, we should clearly distinguish
between fact and theory in our existing knowledge. Every doctor will
naturally seek to make the fullest use of his learning in building up
the bodily health of the neurasthenic. But to sit with folded hands
and wait for the advancement of our knowledge of microscopic anatomy,
physiology or bio-chemistry would be fatuous when there are other and
more direct means of treating the numerous and often pathetic cases,
which urgently call for cure. The view that “disease, like health, is
inconceivable without some underlying physical basis” is sound and
useful, but must not be allowed to blind us to the vital significance
of the mental factor and its corresponding importance in the diagnosis
and treatment of “functional” disease.
It is an indisputable fact that many modern physicians are apt to
concentrate their attention almost exclusively upon the bodily ills of
their patients. Yet the majority of doctors, especially those who in
general practice get to know their patients intimately, admit readily,
even eagerly, that not a small number of the maladies which come under
their notice are seriously complicated, if not dominated, by mental
factors. To take a simple and obvious example, insomnia may be caused
by distressing mental conflicts quite as often as by physical disease.
The doctor, however, even if he suspects this fact, often hesitates to
proceed further in the light of such knowledge.
For this there are several reasons. In the first place, his arduous,
lengthy and expensive medical course has usually never vouchsafed him
five minutes’ specific training concerning the manifold ways in which
human nature may succeed or fail in adapting itself to the complex
environment which we call civilisation. Any wisdom of this kind that he
has picked up is due to his own interest and insight in social matters.
The university’s contribution to his psychological knowledge usually
consists in showing him a handful of comparatively hopeless caricatures
of mentality in his short series of visits to the asylum.[70] It is as
if one tried to teach electrical engineering by a few exhibitions of
broken-down dynamos, navigation by half-a-dozen cursory inspections of
wrecks, finance by a short series of visits to the bankruptcy courts.
The result of this strange conception of medical education is different
according to the mental make-up of the particular physician. There are
many whose insight and sympathy enable them to penetrate successfully
for some distance into the Cimmerian darkness of the patient’s mental
troubles. But do we believe that insight and sympathy alone are
sufficient for the successful diagnosis of disorder or disease of the
heart or lungs? Mental disorder is subtler, more varied than these,
but like them it proceeds along definite lines in definite situations,
and it is capable of description even as they are. It is therefore
insufficient even for the talented doctor to rely entirely upon his
natural gifts. But in what other branch of science would it enter his
head to do so?
But not all doctors happen to be of the type we have described.
There exist many excellent practitioners who are temperamentally
so constituted that to them these unaided excursions into the
investigation of mental trouble would never suggest themselves.
Predominantly objectively-minded,[71] “without a nerve in their
bodies,” calm and confident, practical and quick to apply their
knowledge in the physical sphere, they have no natural inclination
towards the study of such disorders as we have mentioned; and their
teachers have too seldom done anything to supplement the exclusively
materialistic studies[72] of their medical course. When, as not seldom
happens, he is faced by a case of hysteria or neurasthenia, such a
practitioner is inclined to regard the malady, if it does not prove
tractable by rest, change, drugs and diet, massage, electricity, etc.,
either as “fanciful” and requiring firmness unveiled or veiled,[73]
or as the beginning of a lamentable and grave attack of mental
disorder. Unfortunately the number of cases yielding to firmness is
not gratifyingly large. The hysterical patient, too, has a will of his
own, and frequently proves this fact in a disconcerting manner. The
neurasthenic, knowing long before the doctor tells him, that he ought
not to worry, that he ought to “buck up,” frequently becomes acutely
critical of his physician, and his powers of judgment are all the
keener for their frequent whetting upon his own deficiencies. Not that
he should not worry, but _why and how_ he should not worry is what he
wants to know.
This criticism of the brusque, cheery way in which such a physician may
treat mental troubles is not meant to be one-sided or unfair. For some
patients, the “firmness” treatment is the right one; others may be so
impressed by the doctor’s cheery personality that they recover. But it
is safe to say that these are seldom serious cases. The intelligent,
highly moral, over-worked business man must not be given the same
treatment as the society lady suffering from lack of honest labour—and
nobody knows this better than the patient.
This objective way of regarding cases of neurasthenia readily tends on
the one hand to make the physician underrate their importance (as when
he expects to cure them with “firmness”) and on the other, when they
prove impregnable to such attacks, to cause him to exaggerate their
seriousness. For, he may argue to himself, if they are beyond cure in
this way, what is to be the future of the patients except permanent
eccentricity or even insanity? Only a deeper knowledge of the subject
can save him from this top-heavy oscillation from unfounded optimism to
equally baseless pessimism.
We have noted two of the common obstacles which obstruct the path
of the physician anxious to treat mental disorder: his own lack of
training and, in not a few cases, his temperamental inclination to look
exclusively for visible and tangible material evidence of disease.
There is, moreover, at present another serious obstacle consisting in a
widespread social convention. This is the unwritten law which commands
a person to hide any troubles of a mental nature not only from his
friends, but even from his doctor, though he may speak of his physical
disabilities to everybody with unblushing frankness. Much could be
written on this subject, but the inconsistency of the current attitude
has been satirised with inimitable wit and humour by Samuel Butler.
His whimsical fancy has created a civilised country in which this
convention does not exist; in which, in fact, the opposite belief
obtains. In that land, while a man’s bodily ills are counted a
disgrace, and not to be mentioned, his mental troubles are regarded as
physical illness is with us. The name of that country is _Erewhon_.
In _Erewhon_, we are told, physical illness is not only considered
shameful but is punishable by imprisonment. Mental trouble, on the
other hand, even irritability or bad temper, is regarded as illness
requiring the attention of physicians, known as “straighteners.” And
the consequences of this are that a man will dissimulate the existence
of indigestion, giving out that he is being treated for dipsomania,
while in answer to questions about his general condition another will
quite freely and truthfully say that he is suffering from snappishness.
We in England, says the explorer,
“never shrink from telling a doctor what is the matter with us merely
through the fear that he will hurt us. We let him do his worst upon us
and stand it without a murmur, because we are not scouted for being
ill, and because we know that the doctor is doing his best to cure
us and that he can judge our case better than we can; but we should
conceal all illness if we were treated as the Erewhonians are when
they have anything the matter with them; we should do the same as with
moral and intellectual diseases—we should feign health with the most
consummate art till we were found out....”
This convention inevitably influences the “straightener’s” attitude
towards his patients, as we are told by the traveller in a description
of an interview between his host and an Erewhonian doctor:—
“I was struck with the delicacy with which he avoided even the
remotest semblance of inquiry after the physical well-being of his
patient, though there was a certain yellowness about my host’s eyes
which argued a bilious habit of body. To have taken notice of this
would have been a gross breach of professional etiquette. I was told,
however, that a straightener sometimes thinks it right to glance
at the possibility of some slight physical disorder if he finds it
important in order to assist him in his diagnosis; but the answers
which he gets are generally untrue or evasive, and he forms his own
conclusions upon the matter as well as he can. Sensible men have been
known to say that the straightener should in strict confidence be told
of every physical ailment that is likely to bear upon the case, but
people are naturally shy of doing this, for they do not like lowering
themselves in the opinion of the straightener, and his ignorance of
medical science is supreme. I heard of one lady, indeed, who had
the hardihood to confess that a furious outbreak of ill-humour and
extravagant fancies for which she was seeking advice was possibly
the result of indisposition. ‘You should resist that,’ said the
straightener, in a kind, yet grave voice, ‘we can do nothing for the
bodies of our patients; such matters are beyond our province, and I
desire that I may hear no further particulars.’ The lady burst into
tears and promised faithfully that she would never be unwell again.”
FOOTNOTES:
[50] Hart, _op. cit._, p. 7.
[51] _Cf._ Dr. Bedford Pierce’s statement, (_op. cit._, p. 43), “I have
met persons otherwise level-headed who cannot be persuaded to enter the
grounds of an asylum. Not infrequently all sorts of excuses are made
to escape the duty of visiting a relative who is under care, and so
real is the danger of neglect that the State has decreed that no order
for reception shall be granted without an undertaking that the patient
shall be visited at least every six months.”
[52] p. 5. The italics are ours.
[53] pp. 77 and 78.
[54] We have in mind throughout the discussion, not the richer members
of the community, for whom a relatively expensive holiday or period
spent in the nursing home is easily possible, but the great majority of
the public, to whom even the ordinary doctor’s bill may be a source of
financial embarrassment for months or years.
[55] R. G. Rows, _Journal of Mental Science_, January, 1912.
[56] pp. 77 and 78.
[57] _Analytic Psychology_, London, 1916, p. 318.
[58] “Everybody agrees,” say Déjerine and Gauckler (_op. cit._,
p. 214_f_), “that neurasthenia is a neurosis, _i.e._, a nervous
disease without any known lesions.... Neurasthenia is due wholly
to psychological factors which are essentially, if not exclusively
determined by emotion.” They then proceed to compare the
“materialistic” theories of neurasthenia, showing that they are all
still merely speculative.
[59] _Cf._ pp. 19 _et seq._
[60] _Cf._ Déjerine and Gauckler, _op. cit._, p. 214_f._
[61] As Professor Kraepelin says, “Nervenkranker sind Geisteskranker”
(“Those ‘suffering from nerves’ are _sick in spirit_.”).
[62] The reader should consult Mr. W. McDougall’s excellent treatment
of this subject in his _Introduction to Social Psychology_—especially
pp. 45-89.
[63] The remarks of Mr. George Bernard Shaw on Max Nordau’s
“Degeneration” (_The Sanity of Art_, especially p. 88) might be
consulted in this connection.
[64] _Cf._ E. Régis, “Les Troubles Psychiques et Neuro-Psychiques de la
Guerre,” _Presse Médicale_, 23, p. 177, May 27th, 1915.
[65] This term is derived from the Greek word for the womb. Hysteria
was once thought to be due to the wanderings of the uterus about the
body. The term well deserves its place beside that other ornament of
psychological medicine—the word “lunacy.”
[66] _The Diagnosis of Nervous Diseases_, 3rd Edition, London, 1911, p.
355.
[67] Italics ours.
[68] p. 355.
[69] This was seen repeatedly in the treatment of the relatively
uneducated soldiers who had become slightly neurasthenic as a result
of the war, especially of those whose life had been spent in open-air
manual work, or in the strict and healthy routine of the regular army.
They complained of emotional irritability, minor lapses of memory
such as the forgetting of relatively unimportant names or of errands,
disturbed sleep, soon “getting fed up” with their amusements (_e.g._,
“jig-saws,” or billiards for hours every day, month after month in
a converted schoolroom or outhouse!). Not only did these phenomena
disturb them, but in a great many cases they seemed to prove to these
unfortunate men that they were insane, or rapidly becoming so. They
would anxiously ask such questions as, “What is it that makes me so
irritable at a slight noise, or at being brushed against by another
patient? I used not to be like that.” Their conduct was also regarded
as unusual by their companions. Now would not the head of a business
firm, an over-worked medical man, a university professor or an army
officer in a position of responsibility, confidently expect to be
allowed _ex-officio_ a certain number of these eccentricities without
being called “diseased?” But let him drop the privileges and shelter of
his rank, live for a few weeks as a private in a barracks with a number
of high-spirited and thoroughly healthy soldiers and his behaviour
might certainly be considered by them to be queer, if nothing worse.
[70] Reform of this state of affairs is urgently needed. The matter is
of such fundamental and far-reaching importance that we have devoted
part of the next chapter to the further consideration of its bearings.
[71] “Tough-minded,” “matter-mongers,” modern writers have called this
type, contrasting it with that of the “tender-minded,” “reason-mongers.”
[72] Of a brilliant teacher of physiology, one who was himself
intensely interested in the sciences bordering on his own subject, it
was related that when, in lecturing upon the functions of the nervous
system in man, he approached difficult problems, he used to say, “But
that is a matter for the psychologist.” Whereupon the class heaved a
sigh of relief and prepared to take notes upon the next subject.
[73] “... strong electric shocks, cold douches, and other decorous
substitutes for a sound birching.” W. McDougall, _Psychology_, London,
1912.