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.