The Modern Treatment of Mental and Nervous Disorders

by Bernard Hart

T HE MODERN TREAT-
MENT OF MENTAL &
NERVOUS DISORDERS

A LECTURE DELIVERED AT THE UNIVERSITY OF
MANCHESTER, ON 25th MARCH 1918

BY

BERNARD HART, M.D.

Fellow of University College, London; Physician for Mental
Diseases, University College Hospital; Lecturer in
Psychiatry, University College Hospital
Medical School

MANCHESTER:
AT THE UNIVERSITY PRESS
12 LIME GROVE, OXFORD ROAD
LONGMANS, GREEN & CO.
London, New York, Bombay, etc.
1918

The Modern Treatment of Mental and Nervous Disorders

"The modern treatment of mental and nervous disorders " is a title which covers a very wide field, a field so wide that to deal with it in any comprehensive and detailed manner within the limits of a single lecture is obviously impracticable. It is, moreover, a highly technical field, requiring for its adequate understanding a theoretical and practical knowledge of medicine which I cannot assume my present audience to possess. The goal which I hope to achieve is, however, a comparatively modest one, and I shall only endeavour to set forth certain aspects of the subject which are of general and not merely of medical interest. In particular I propose to call attention to certain problems which are of importance to the lay public, because their solution vitally concerns the public health.

"Mental and nervous disorder" is a popular rather than a technical term, and, like all such terms, its meaning is somewhat loose and indefinite, but, with the help of a few additional words of explanation, it will be sufficiently precise for our present purpose. By "mental disorder" is meant actual insanity, and those minor mental disturbances which are stages on the road to insanity. By "nervous disorder" is meant only those conditions which are technically called "functional" as opposed to "organic"— that is to say, those not due to any demonstrable disease or injury of the nervous system. These conditions are covered by a multitude of popular names: "neurasthenia," "hysteria," "nervous breakdown" and just "nerves." The war has added yet another to this list, for the now familiar "shell shock" is merely a general term under which are grouped a large number of the cases of nervous disorder due to the stress of active service.

Defined in this way, "mental and nervous disorder" constitutes a heterogeneous group of affections, many of which are very different one from another, but we are justified in considering them together, because in every case mental phenomena play a part either in the symptoms or in the causation. So far as the mental group is concerned this fact is obvious, and we shall see that we now have reason to believe that the statement is equally true in the case of the so-called nervous group.

The treatment of these disorders forms a fascinating chapter in the history of medicine, and it will be worth while to spend a few moments in perusing that chapter, because our understanding of the present will be materially helped by some knowledge of the views and practices of the past. Treatment has naturally depended always on the current opinion with regard to causation, and the extraordinary diversity of practice throughout history in dealing with these cases has been the logical result of the constant change of view as to the causes responsible for them.

In the Middle Ages the phenomena which we now ascribe to mental or nervous disorder were thought to be due to evil spirits which inhabited the body of their victim, and the patient was said to be "possessed by devils." It followed that the only treatment practised in those times was the employment of exorcism, ceremonials and incantations. This was also the age of witchcraft, and it seems clear that the greater number of those accused of witchcraft were persons whom we should now class as neurotic or insane, and who then suffered death for the crime of being merely ill. The procedures of the famous witch trials were often based on the detection of symptoms which are commonplaces in the modern nerve hospital. One such symptom, for example, was the existence of a patch of insensitive skin somewhere on the body of the alleged witch, a symptom known then as the "devil's claw," and now by the less lurid name of "hysterical anæsthesia."

These ancient superstitions have more than a merely historical interest, because their effect has lasted through the centuries, and is to be seen to-day in the stigma which still attaches to mental disease. The fear, the feeling of something uncanny and mysterious, the desire for concealment from the eyes of our neighbour, which continue to characterise the general attitude towards insanity, have at least one of their roots in these old conceptions which regarded insanity as a manifestation of the supernatural and demoniacal.

So far as cultivated thought was concerned, however, these conceptions were swept away by the growth of science, and by the nineteenth century the belief had established itself that mental and nervous disorders were due to deranged bodily processes, and in particular to diseases of the brain. Investigation was then naturally directed to determining precisely what bodily processes were at fault, and treatment to remedies by which these processes could once more be made normal. This "physiological conception," as we may call it, still holds its place, but its sway is no longer undisputed, because during the past fifty years yet another conception has come into being. In this period psychology has freed itself from the metaphysics, ethics and other alien companions which formerly hampered its progress, and has developed into a positive science. As a result of this development we have learnt, not that events may have mental causes, because that we always knew, but that these mental causes are capable of exact scientific estimation, that they act according to precise scientific laws, and that they are capable of being influenced or removed by scientific methods of treatment. With this recognition of the fact that mental events follow one another in a rigidly determined chain of cause and effect there has come a new "psychological conception" of mental and nervous disorders, which holds that some at least of their phenomena are due to mental causes, capable of determination by psychological investigation, and of removal by psychological methods of treatment.

It will perhaps be helpful to make clear by some simple examples precisely what is meant by "mental" and "physical" causes. Weeping may be produced by the explosion of a tear-shell, and is then due to the irritative action of certain gases liberated by the bursting of the shell. It may also be produced by the loss of a loved relative, and is then due to the presence in the mind of certain ideas, and the emotions associated with those ideas. In the first case we should say that the cause of the weeping was physical, in the second that it was mental. Or again, irritability may result from noxious substances in the blood arising as a result of dyspepsia, or it may be due to the patient being absorbed in anxious consideration as to which of two conflicting lines of conduct he should adopt. In the first case the irritability is of physical, in the second of mental origin.

As a result of this brief historical investigation we find, therefore, that there are two conceptions of the origin of mental and nervous disorders which at present hold the field, the "physiological" and the "psychological" According to the first, the phenomena are to be interpreted as the effect of a chain of physical or physiological causes, diseases of the brain and other organs, or the presence in the body of poisonous substances. According to the second, they are to be interpreted as the effect of a chain of mental causes, worries, anxieties, emotions and so forth. Hence the question arises: Which of these conceptions is to be accepted in the light of modern knowledge? Are we to embrace the doctrine that mental and nervous disorders result from such causes as brain diseases and poisons in the blood, or the rival doctrine that they are due to such things as worries, anxieties and emotions? This is no mere academic question, because upon the answer given to it is absolutely dependent the line of treatment we shall be called upon to adopt. Treatment consists in discovering and removing causes, and our procedure will be totally different according as we believe those causes to be of physiological or psychological order. For example, we should treat weeping due to the explosion of a tear-shell by administering substances which eliminate the poisonous gas, while we should strive to comfort the patient weeping for the loss of a loved relative. Merely to comfort the first patient would be as useless as to administer lotions to the second. Take another example. Insomnia is a symptom which may be due to many different causes. It may be due to kidney disease, and is then best combated by remedies directed to the organs which are at fault. Or it may be due, as it often is in shell-shock patients, to the existence of tormenting thoughts and fears, which crowd into the patient's mind as he lies in bed, and make absolutely impossible the mental composure necessary for sleep. Treatment here will endeavour to remove the thoughts and fears which are responsible for the condition, and this can only be done by the employment of psychological methods.

It must be observed that in this last instance the cause immediately responsible for the insomnia is probably the same in both cases, some particular condition of the brain or blood vessels. But, so far as treatment is concerned, we are not mainly interested in this immediate cause, but in those ultimate causes whose removal will lead to the disappearance of the symptom. The symptom may be regarded as the final result of a chain of causes, and treatment must be directed to the removal of those links which are the most important, and upon which the chain is mainly dependent.

The decision at issue, therefore, the question whether the chain of causes responsible for mental and nervous disorders is made up of entirely physiological or physical links, as the physiological conceptions of the nineteenth century would have us believe, or made up of mental links, as the newer psychological conception maintains, is one fraught with consequences of the utmost practical importance. The answer which seems to fit best the facts known to modern science is that neither of these one-sided conceptions is wholly correct, but that the causal chain contains both mental and physical factors in every case, although the relative importance of these factors differs greatly in the different types of disorder.^[1] We find a chain comprising such factors as constitutional peculiarities, including the original structure and "make-up" of the brain and nervous system, affections of brain or other organs, mental causes such as worries, anxieties and conflicting emotions, the secondary bodily effects produced by these mental causes, the mental effects produced by the bodily conditions, and so forth. Each and every one of these factors plays its part in the chain, and helps to mould the final link, the symptom, to the shape in which we see it in our patient. We may picture the processes involved, of course in purely diagrammatic fashion, and without making any attempt to indicate the actual subtleties of action and reaction, by the aid of the following figure:—

To cure our patient we must break this chain somewhere, and the fundamental problem of treatment is: "Which link shall be attacked?" The method of treatment selected depends entirely on the solution of this problem, because if we decide to attack a "bodily" link we must proceed by physiological means, if a "mental" link, by psychological means. Now it will surely be clear that we must direct our attack in the first place against the most important link, because unless this is broken no complete cure can be hoped for. In the second place, if the most important link is inaccessible to the weapons at present in our possession, we must attack one of the minor links with the object of altering, to some extent at least, the end result of the chain. In other words, we shall hope to achieve thereby an amelioration of the symptoms.

We are thus led to a further question: "Which is the most important link in the chain of causes responsible for mental and nervous disorder?" There is no one answer to this question, because "mental and nervous disorder " includes a number of very different conditions, and the relative importance of the constituent links varies greatly as we pass from one to another. This will be made clear by a brief consideration of a few of the principal types of disorder which are encountered in our patients.

In one type the constitutional element is vastly the most important, and the condition of the patient is determined in the main by the original structure of his brain and nervous system. The chain here will be represented by the following figure, where the relative importance of the various links is indicated roughly by the size of the corresponding circle^[2]:—

This is the type to which "mental deficiency" belongs. The patient has a cramped and undeveloped mind because he has been born with a stunted brain, which is incapable of development. Here the chief link is inaccessible to the weapons we at present possess, and we know of no means by which the defect can be remedied. Treatment must be limited to influencing, so far as lies in our power, the minor links of the chain with the object of ameliorating the patient's symptoms. This is the treatment always adopted in dealing with cases of this type, and forms the basis of the well-known methods of "training" now in use for the mentally deficient. In another type bodily changes, especially disease of the brain, constitute the most important factor, and a chain of causes exists which may be represented as follows:

In this type, to which certain forms of insanity such as general paralysis belong, the brain disease is vastly the most important causal element, and it is to this that our attempts at treatment must be directed. In the symptoms shown by the patient mental changes may bulk largely, but in the chain of cause and effect they are links of only secondary importance, and it is the constitution of this chain which is of vital concern to the problem of treatment.

In a third type both physiological and mental factors seem to play an active part, and we are uncertain in the present state of our knowledge as to their relative importance. The chain here may be represented as in the accompanying diagram, where the dotted circles indicate that we do not yet know the relative size which should be assigned to them:

A very large group of the insanities conforms to this type. When we endeavour to unravel the causes which have produced the disorder, we find on the one hand a series of mental stresses which are clearly responsible at least for the particular shape the patient's symptoms have assumed. On the other hand we find a series of constitutional peculiarities and physiological disturbances whose importance is so obvious that we may be tempted to ascribe to them the chief part in the causation of the symptoms, and to regard the mental causes as minor agents which have merely provided the symptoms with their surface colouring. For example, to revert to an illustration already given, the irritability of the dyspeptic may show itself mainly in the patient's relations with a certain person, because it is directed into that channel by the existence of certain ideas and emotions. But the prime cause of the irritability is the dyspepsia; the ideas and emotions have merely provided the particular colouring in which it manifests itself. In this example the matter is, of course, simple enough, but in the group of insanities now under consideration the physiological and mental causes are so intricately woven and interwoven that their unravelling is a problem of extreme difficulty, and one to which science has not yet furnished a satisfactory solution. The question of adequate treatment for these cases must obviously await that solution. At present it seems possible to accomplish something both by physiological and psychological methods of treatment, but until the various causal factors and their mode of action have been determined it is impossible to say which of these methods will ultimately prove to be the most effective. The great need here is for investigation and research. The problem must be attacked from every side, by the physiologist, the chemist, the anatomist and the psychologist, in the sure hope that their united labour will finally elucidate these causal factors, and indicate the ways in which they may be eradicated.

But there is one group in which it is becoming more and more certain that "mental" factors constitute the most important link in the chain of causation, and that is the group which we have called "nervous disorders." We have, indeed, reached the paradoxical conclusion that, while in many "mental" disorders mental factors play only a minor part amongst the causes which have produced them, in "nervous" disorders these mental factors are of fundamental significance. In this latter group the chain of causation will appear as in the diagram below:

The conviction that in the so-called nervous disorders the predominant part is played by mental causes has been steadily growing during the forty years which have elapsed since the work of Charcot, and has been very greatly strengthened by the experience given to us by the war. The war has brought into being a large number of cases of nervous disorder which have been grouped together under the misleading name of "shell shock." These cases are in every essential respect identical with the hysteria, neurasthenia, nervous breakdowns and so forth with which we have always been familiar, only differing from the latter in the colouring due to the particular circumstances of their origin. But the war has produced them in such numbers that in every country attention has been forced upon the problems of their causation and treatment, and the result of that attention has been a rapidly increasing consensus of opinion that the chief factors both in causation and treatment are of the mental order.

Now, if this is so, what are these mental causes that are responsible for the affections we are now considering? The popular idea is that they are worries, anxieties and emotional shocks, and this popular idea is true enough in the main, but it requires precision. The mind of the nervous patient differs in certain important respects from the mind of the healthy man, and we require to know exactly in what this difference consists.

Consider for a moment how we may conceive the ideal normal mind. It would constitute an harmonious whole, with all its constituent parts fitting perfectly one into the other, and all its forces pulling smoothly together, so as to issue in thought and conduct exactly adapted to the circumstances in which it lives. This, of course, corresponds to the biological conception of "adaptation to environment."

Every normal mind naturally falls short of this ideal, but the mind of the victim of nervous disorder falls very far short indeed. It is, in fact, in a condition which is the exact reverse of the ideal, because in it the harmony of the whole is destroyed, the constituent elements jangle and jar one against the other, and its forces, so far from pulling smoothly together, pull in opposite directions. This lack of internal harmony is expressed technically by the term "mental conflict." Because of the internal conflict the issue of a thought and conduct exactly adapted to the circumstances in which the mind lives is no longer possible. There is a failure of adaptation to the environment, because there is a failure of internal adaptation in the economy of the mind, and the mind has become a house divided against itself. This is the mental state which corresponds to the popular notion of worries, anxieties and so forth.

An example will help to make clear the nature of the condition just described, and we may select for this purpose a picture frequently to be seen in certain types of "shell shock." The soldier is tortured by memories of the terrifying events he has experienced, he cannot bear to think of these events, and he tries to avoid anything and everything which might recall them to him. Thus he will not read the newspapers, because the news they contain would inevitably rekindle the forbidden memories; if his comrades talk of the war he goes the other way, and he seeks constantly to occupy his mind with other things, so that there shall be no room in it for the spectres he dreads. Much of his activity is spent in the endeavour to push away the offending memories, to thrust them into the back of his mind, and to keep them off the stage of his thoughts. Now it is evident that these memories are constituents of his mind, that they jar and jangle with other constituents, that one force tends to drag them into the full light of consciousness while another seeks to thrust them into oblivion, and that here there is no harmony, but only a constant conflict.

We may, moreover, utilise this example to illustrate how the internal conflict generates some of the symptoms familiar in nervous disorder. When the patient goes to bed and composes himself for sleep, the stage of his consciousness is no longer crowded with thoughts of other things, the memories surge on to it, and he is once more filled with fears and apprehensions. Sleep becomes almost impossible, and there results the symptom of insomnia. Even if the patient should succeed in falling asleep, the memories, no longer controlled by the ban of waking consciousness, take undisputed possession of the stage, the patient dreams of trenches and battles, and wakes with all the horrors of nightmare. Moreover, in his waking state the constant conflict saps his available energy, so that he cannot concentrate his attention, nor carry out any sustained occupation, while the memories, ever present on the fringe of consciousness, engender in him a state of extreme "nervousness," so that he starts and trembles at the slightest sound.

From causes of this kind, acting no doubt upon a constitution favourable to their action, and complicated by the bodily effects to which these causes give rise, there result a large number of the symptoms of nervous disorder. The complications and repercussions produced by the bodily factors are unquestionably of importance, a fact which we have endeavoured to portray in the diagram given above, but the primary and essential causes would seem to be of the mental order described.

If this is so, treatment here must logically be treatment by psychological methods, and the goal which it must strive to achieve is evident. It must discover the jarring elements and warring forces, then proceed to rearrange them, and thus help the patient to recover the internal harmony he has lost. The advice so often given to these unfortunate people, "Pull yourself together," expresses literally and exactly what is required. It is, however, absolutely useless unless the patient knows what he has to pull together, and unless he is shown how to do it, and helped to do it. And these are just the points where all the practical difficulties are encountered.

To begin with, we have to find out what is wrong, and this is often by no means easy. It might be thought that, as the things that are wrong are in the patient's mind, the patient has only to be asked to describe them. But in these cases this is precisely what he cannot do; often he does not know the causes of his troubles, and even if he is aware of them he does not understand their real significance and relationship. There is a widespread belief that we are always fully acquainted with the workings of our own minds, and that we always know why we do and think things, but unfortunately the belief is for the most part an erroneous one. Often enough we do not know the causes of our thoughts and actions, and oftener still we ascribe them to causes which have actually played no part in their production. Thus the man who gives to a beggar because his neighbour is looking on may be fondly convinced that his action is dictated solely by the purest altruism. And if we all look through distorting glasses when we seek the causes of our own ideas and acts, these glasses are vastly more distorting and obscured in the case of the nervous patients with whom we are now dealing. Again, everything is not on the surface of the mind, and the phenomena on the surface may effectually conceal elements of a very different kind which are lurking underneath. Thus a sparkling wit may conceal a gnawing sorrow, and boisterous and aggressive conduct may be the cloak beneath which is an agonising shyness and diffidence. These buried elements often express themselves on the surface in astonishingly indirect ways, and here again the distorting processes are much more pronounced and intricate in the nervous patient than in the simple instances we have selected from everyday life. It is indeed to processes of this type that many of the protean symptoms of nervous disorder are due.

Hence it will be clear that, to discover what is wrong with the patient, technical psychological knowledge is necessary, a knowledge of the mechanisms of the mind, and of the ways in which its various elements may express themselves on its surface. We must be able to judge, from the surface picture, which is all that the patient can give, what causes are at work underneath, and how they have acted to produce the picture before us, just as the physician estimates, from the signs he can examine on the surface of the chest, what the condition of the lung is underneath. Moreover, when the first stage has been achieved, and the erring elements have been discovered, they have to be rearranged and fitted into place, and here again technical knowledge is required. Nevertheless, in spite of all these difficulties, much can be done, and there is every reason to hope that with the added knowledge that should result from organised investigation and research much more will be able to be done in the future.

What is meant by the process of rearranging and fitting into place may be illustrated with reference to the example of the "shell-shock" soldier described above. The patient must be made to understand what is going on in his mind, and to see how the civil war waged therein is sapping his energies and producing the symptoms from which he suffers so greatly. He must be taught that the memories he fears gain their injurious effects because they are dislocated and out of perspective, that they are constituents of his mind which he cannot abolish but only impotently struggle against, and that once they are properly fitted into the structure of the mind these effects will disappear. He must learn to regard the memories as part of the furniture of his mind, and as mere traces of events which are past. They must, in fact, be placed in their proper perspective, so that he will finally be able to contemplate them with equanimity. When this has been achieved the internal conflict will have disappeared, and with it the evil consequences which that conflict produces.

We may pause here for a moment and attempt to summarise the facts so far elicited. Throughout the history of medicine very different views have been held with regard to the causation and treatment of mental and nervous disorders. Some of these, "possession," for example, have only an historical interest, but in later years two schools of thought have arisen which still hold the field. One maintains that these disorders are the results of physiological processes occurring in the brain and other organs, and that all attempts at treatment should be directed solely to these processes. The other holds that the disorders are the result of disturbed mental processes, and that corresponding methods of treatment of a psychological order should be adopted. The view outlined in this lecture is that neither of these one-sided conceptions is wholly correct, and that the chain of causation includes in every case both physiological and psychological factors, but that these vary in relative importance very greatly in different types of disorder. In some the physiological factors are all predominant, and in such cases psychological methods of treatment are obviously unsuitable. In others mental factors are equally predominant, and in these cases the methods of treatment must logically be psychological in character. Owing to the growth of psychology in recent years, these methods are already attaining the exactness and systematisation demanded by science, and their employment in the cases due to the war has been eminently successful. In other types again we are as yet uncertain of the relative importance of physiological and mental factors in the chain of causation. Here the great need is for investigation and research, carried out along every promising line of approach, by the physiologist, the chemist, the anatomist and the psychologist. In the light of our present-day knowledge the only reasonable programme for dealing with mental and nervous disorders is to discover by systematic investigation all the causes at work, both physiological and psychological, to ascertain how they are combined and their relative importance, and to attack each and every one by all the means in our power, to act on the body with every weapon of physiology, and on the mind with every weapon of psychology.

We may now turn to the consideration of some facts which will serve to bring before us the magnitude of the question at issue, and finally we may ask what are the present facilities for dealing with it, and in what directions we may reasonably expect these facilities to be improved.

So far as actual insanity is concerned, statistics are available, though these do not by any means cover the whole field. On 1st January 1915 the number of patients actually certified as insane in England and Wales alone was 140,466, and this number does not include cases of mental deficiency, nor cases of insanity in those early stages when certification has not become imperative. The contemplation of these figures will alone suffice to bring home the vital importance of the problem to the health of the nation. With regard to nervous disorders statistics do not exist, but every doctor knows how considerable a proportion of his patients fall into this group, and it may at least be said that they are extremely prevalent, and that they constitute a problem the importance of which is as great as that of insanity, perhaps even greater.

Now what are the present facilities for dealing with mental and nervous disorder? For actual insanity there is a plentiful supply of asylums, which for comfort and care are among the best in the world. But these are only for fully developed cases, cases which have so far progressed that legal certification has become absolutely necessary. For the early cases, patients on the road to actual insanity, in those stages when treatment obviously has the best chance of success, there is almost nothing at all. Something can be done for the rich, but for the great bulk of the population nothing. The only course for them, a course which would be Gilbertian were it not so tragic, is to wait patiently until they are sufficiently bad for certification to be necessary. Then they will receive every care and attention. The words "almost nothing" were used above because here and there a few attempts have been made to provide what is required. Some of the general hospitals, for example, have out-patient departments to which these cases may be brought for advice. But, unfortunately, out-patient treatment is necessarily inadequate for patients of this type, and valuable though these departments unquestionably are, they do not afford any satisfactory solution of the problem.

With regard to nervous disorders, the neurasthenias, hysterias, and "nervous breakdowns," the facilities are somewhat greater, but they still fall very far short of reasonable adequacy. The general hospitals have out-patient departments for these cases, but few admit them to the wards, or possess wards in which the necessary treatment is obtainable. Special nerve hospitals are mainly concerned with organic diseases, and although a certain number of "functional nervous" patients are received into the wards, this number is very restricted. Moreover, these special hospitals are naturally few and far between. Here again treatment is available for those who can afford the consultant and the nursing home, but for the great bulk of the population little can be obtained.

The outlook for a certain class of these patients, however, has been radically altered by the experiences of the war. The cases of "shell shock," which are almost all typical examples of nervous disorder in the sense in which the word is employed in this lecture, have been very numerous, and it has been absolutely necessary to provide efficient treatment for them. Many special hospitals have, in fact, been established in which this treatment is obtainable. Moreover, the psychological methods of treatment whose suitability for these cases we have sought to demonstrate have been eminently successful, and have amply vindicated both their practicability and utility.

Lastly, in what directions may we reasonably expect the present facilities for treating mental and nervous disorders to be improved? In the first place, so far as actual insanity is concerned, it may be agreed that confirmed cases are already adequately provided for. But it is surely imperative that provision should be made for early cases, for patients in those incipient phases of mental disorder when treatment naturally promises the best results. There are difficulties in the way of this simple measure, difficulties of legal and other kinds, but there are none that are incapable of being surmounted. Institutions must be established in which such cases may be received, where efficient treatment is available, and where also will be found organised investigation and teaching. For there is no department of medicine where organised investigation is so urgently required. Isolated workers there have always been, and they have accomplished much, but their labours have been continually hampered by the lack of organised institutions, where physiologist, chemist and psychologist can attack the many problems that await solution, together and from every side.

In the case of nervous disorders a less revolutionary change is required, but there is much room for a great extension and reorganisation of the existing facilities. The accommodation for these patients should be increased, preferably in the shape of special departments of the general hospitals, where every available means of treatment should be capable of being employed, and especially those psychological methods whose success has been demonstrated in the war cases. For it must ever be remembered that these war cases are essentially the same as the nervous disorders, the neurasthenias, nervous breakdowns and so forth which were here before the war, and will still be here after the war. The number of these cases has always been very great, and it is a reasonable hope that the favourable results achieved with the war patients will lead to the establishment of similar methods of treatment for civilians, both men and women.

Here again treatment should be associated with organised investigation and with teaching. These three functions have their natural home in the universities and medical schools, and it is from them that we shall confidently expect the developments that are so urgently needed.

1. It is impossible in a lecture of this kind to consider the philosophical justification for postulating a chain of causes including both mental and physical factors, and how far the acceptance or rejection of "interactionism," "psycho-physical parallelism," or other theory is thereby involved. It may be said, however, that whether the pragmatic theory of science in general is sound or not, it is emphatically the one we are called upon to adopt in so far as we are practitioners of medicine. Our prime duty is to cure our patient, and we are entitled to conceive the chain of causes responsible for his symptoms in the way which will help us best to attack and remove them.
2. In this and in the succeeding diagrams an unnamed circle has been inserted in order to indicate that the chain of causes shown is not complete, and that additional factors of all sorts and kinds play a part in determining that end result which we call the "symptoms."