It is customary to think that functional nervous disease is something unusual, and that is because it is associated in people's minds with palsies and convulsive seizures and other dramatic forms. But that is only a small part of the picture. It is one extreme ; and the other extreme is illustrated by those quiet, undramatic disorders known as neurasthenia, or psychasthenia, or nervous exhaustion. Between these two extremes we find an immense number of people who, while not incapacitated, are distinct variations from the normal. They do not call themselves neurotic, and quite rightly so, because it has become almost a term of abuse. People think that if no cause can be found in the body to account for a man's illness, then he is playing some elaborate trick. They call him a neurotic.
But if a keen and hard-working young surgeon gradually begins to have an unreasonable fear of sharp instruments, if the idea grows in his mind that he might do something silly, or worse, with a knife, what are we to think of his malady ? He is certainly 'a neurotic. He suffers from a psycho-neurosis.* Prom the physical point of view he may be perfectly sound. And yet he is tormented by these strange ideas to an extent which is difficult for the outsider to realize.
Now if we regard his neurosis with a shade of contempt, we are guilty of a singular lack of insight. For his neurosis clearly comes between him and his ambition. He does not desire his neurosis. There is nothing pleasing about it. One cannot imagine that King James willingly endured his torments when he had to knight one of his subjects with the naked sword. His feeling that he might stick it into the kneeling figure was not a pleasure to him, for he had to close his eyes and have his hand guided. And if we say that these ideas are silly, that they are absurd, grotesque, fantastic, can we for a moment suppose that we are helping the patient ? He knows that they are silly—fortunately —but yet he cannot escape from them. However impressively we tell him that the whole business is pure imagination, and however large our fee may be for this advice, we do not cure him. He merely gives up seeking any help and fights a silent battle.
* It was recognized in Charcot's time that neurotic symptoms have their origin in the psyche, and Janet showed that all the symptoms that occur in hysteria can bereproduced by suggestion. Therefore all neuroses—that is, physical disabilities that arise from causes in the psyche—are psycho- neuroses. However, it has become the custom to speak of a psycho-neurosis where the symptoms are chiefly in the psychical field, as in cases of phobia and obsession.
Now when a man has an eruption on his body we do not necessarily seek for the cause in the eruption itself. We go beyond the rash and seek for the cause in the blood-stream, or elsewhere in physical background. If a man has an eruption of grotesque ideas in consciousness, then we might consider that the causes are not to be found in consciousness but in mental background. It is not only abstract theory. The attitude of the neurotic himself supports it.
When a neurotic patient sits down and relates as exactly as he can what is the matter with him, he experiences a difficulty. The difficulty varies in proportion to the definition of the neurosis in the physical field. It may be totally unde-finable in physical terms. Or it may be easily definable in physical terms, but, when described, demands various additions that are non-physical.
He may say that he fears to cross open spaces and that rather than walk across a square he will go round its margins. He may say he is unworthy to associate with his fellow-men ; or, that he has an idea that he carries infection about with him which will cause the death of other people. He may describe some ritual of elaborate washing and disinfection ; or of some ceremonial bowing and gestures which he is compelled to carry out in order to relieve his mind of some intolerable tension. But whatever form the neurosis may take, after describing it, he shows a tendency to proceed further.
The tendency produces the impression that there is always something left unsaid, although the patient may have nothing clearly conscious in his mind at the time. When a man has pneumonia, or cancer, or a broken leg, whatever he says is final. It is as full a statement of the case as he can give. There is no impression of something being kept back, or something shadowy that seeks expression for which no words can be found. But what the neurotic says of his neurosis is never final, nor does it produce that impression. It sounds like an introduction to something.
To what is it an introduction ? It is possible to ignore the sense of the unfinished, and straightway begin to prescribe and advise. But if this course is not followed, and an attempt is made to explore the situation and find out why the impression of something unfinished is left in the mind, it leads inevitably to a personal encounter. This cannot be otherwise, for there is only one path left open, and that is the non-physical or mental. Every physician knows the sharp dividing line between questions that deal with the body and those that deal with the mind. It is easy enough to ask how long pain has lasted or when it is worst. But immediately the question implicates personality, a tension arises suddenly. The physician feels it before he puts the question. Some bracing of self precedes it. It is easier sometimes not to ask it. It is less exhausting.
If you proceed with the case, you find yourself asking questions that have nothing to do with the etiology of recognized organic disease. You find that you are beginning to gaze into the personality of the neurotic, though you may have no clear idea of what you are looking for. If this course is persisted in, a check is soon reached. The patient gives no further information. To your questions he begins to give contradictory answers, and the closer he is pressed, the more unsatisfactory are his replies. It seems impossible to proceed any further. How else, save through the conscious mind of the patient, can his personality be probed ? At first sight it would seem that an impenetrable barrier has been met. And yet the sense of something unfinished remains ; the sense that there is something still there, but out of reach—in the background of the mind.