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.