A sensible and intelligent man, once the cause of his trouble has been made clear to him, may be competent to continue to cure himself, or, in other words, to re-educate himself, and completely to conquer the cause of his undoing. But the duller and stupider man may need a daily demonstration and renewal of confidence before he begins to make any progress. It is precisely analogous to the experience of every teacher of a class of students; the brilliant man will seize hold of a principle at once and learn to apply it without further help, whereas the dull man needs repeated and concrete demonstrations before it sinks into his understanding.
In dealing with soldiers, and this applies with especial force to the regular army, the conditions in many of the cases differ considerably from those of the civilians. Trifling forgetfulness in the civilian would perhaps not be a serious cause of worry, but in the soldier, inured by years of training to strict discipline, forgetfulness of even trivial instructions, or any difficulty in understanding complex orders, is likely to bring down upon his head condign punishment. Such lapses are regarded by the soldier as extremely serious offences, because years of training and discipline have inculcated this idea. When as the result of shock such soldiers are afflicted by even slight forgetfulness, they become worried by it much more than would the civilian and exaggerate its importance until it becomes a real terror to them. As the result of their training they may regard such phenomena as altogether abnormal; and by a process of rationalising what to them is a novel experience, they are apt to imagine that they are going mad. Such patients often dream about incidents in their army life when they had been forgetful and got into trouble; they become obsessed with the haunting fear that they are likely to get into perpetual difficulties, are worried by the thought that they are incompetent for the duties to which they have been accustomed, and may imagine themselves debarred from all useful work. However, they are easily reassured when the medical attendant explains to them that in ordinary life civilians are frequently subject to such experiences, and that it is only the special circumstances of army life which make such trivial lapses seem serious to them. Not only is the soldier much more scared by such things than the civilian, but it is also a very remarkable phenomenon, and certainly one which came as a surprise, that the neurasthenia of a soldier is apt to be very much more serious than that of the civilian. For when a really brave man is stricken by fear he is more seriously affected by the terror of an experience which to him not only has a larger element of novelty than in the case of the civilian, but also wounds him more deeply by convincing him that he is lacking in that very quality which is most essential for his professional work.
The Therapeutic Value of Work.
It should be unnecessary to emphasise the desirability of preventing the neurasthenic from dwelling upon his subjective troubles by occupying his mind with other things. This end may often be achieved by the provision of suitable occupation, and where possible, for many obvious reasons, this occupation should take the form of useful work. The worker then feels that he is not a mere burden upon the hospital which is treating him: the institution in its turn benefits materially. But it is necessary to sound a note of warning against the indiscriminate prescription of work as a panacea. First of all it should be certain that the work is of such a kind as really to interest the patient and to occupy his mind. There are many varieties of work, especially of manual labour, which can be performed mechanically, and do not succeed in distracting the attention from worries and anxieties. But more important even than this is the consideration that there are some mental troubles from which no form of work will distract the patient. Especially is this the case in many of the psychoneuroses caused by the war. The sufferer is often haunted day and night by memories which torture him not merely by their horror but also by another aspect which is even worse: the ever-increasing moral remorse which they induce. A patient may be troubled not only by the terrible nature of the memory but by the recurring thought, “If I had not done” this or that, “it might never have happened.” The reader will easily see how such a thought may arise in the mind, especially of a nerve-stricken officer or “N.C.O.” after weeks of brooding in private upon the memory of a disaster. Now, such self-reproaches are frequently based upon entirely insufficient evidence, and if the medical officer is given the opportunity of calmly discussing their foundations with the patient, the result is often to reassure him and to enable him to view his past in an entirely new light. It is then, and not before then, that he will be able cheerfully to enter upon useful occupation and to benefit by it. To suppose that the mere physical fatigue induced by a day’s hard work will banish all forms of insomnia betrays an ignorance of one of the most important causes of this malady; viz., mental conflict. It is well known that bodily fatigue in the case of a mentally excited patient may merely increase his unrest at night. Again, anyone who has had a few months’ experience of receiving the confidence of these nerve-stricken soldiers will know that some of their troubles are so poignant that the attractions of the (apparently) most interesting kinds of occupation leave them cold.
To sum up, the physician may confidently prescribe work when, by investigating the history of any particular case, he has satisfied himself that such occupation will be likely successfully and profitably to distract the patient’s mind from his worries. But the prescription of work for the patient must be regarded as a sequel to, not as a substitute for, the performance of work by the doctor.
FOOTNOTES:
[24] Such, for example, as those set forth in the series of articles in Vol. VIII, of Sir Clifford Allbutt’s System of Medicine, 1899, pp. 88-233.
[25] The part played by bodily disease in the causation of mental disturbance has been concisely summarised by Sir G. H. Savage in the introductory chapter on Mental Disease in Vol. VIII, of Allbutt’s System of Medicine, pp. 191-195.
[26] Or in some mild cases, to encourage him to wish to remain an invalid under such pleasant conditions.
[27] In his careful studies of these conditions, C. S. Myers has called attention to the mistaken notion of regarding these troubles as “fundamentally due to disordered volition,” Lancet, Sept. 9th, 1916, p. 467.