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Title: Shell shock and its lessons
Author: Grafton Elliot Smith
T. H. Pear
Release date: February 19, 2025 [eBook #75421]
Language: English
Original publication: Manchester & London: Manchester at the University Press & Longmans, Green, & Co, 1917
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SHELL SHOCK
Published by the University of Manchester at
THE UNIVERSITY PRESS (H. M. MCKECHNIE, Secretary)
12, Lime Grove, Oxford Road, Manchester.
LONGMANS, GREEN & CO.
London: 39, Paternoster Row
New York: 443-449, Fourth Avenue and Thirtieth Street
Chicago: Prairie Avenue and Twenty-fifth Street
Bombay: Hornby Road
Calcutta: 6, Old Court House Street
Madras: 167, Mount Road
SHELL SHOCK
AND ITS LESSONS
BY
G. ELLIOT SMITH, M.A., M.D., F.R.C.P., F.R.S.
_Dean of the Faculty of Medicine and Professor of Anatomy_
AND
T. H. PEAR, B.Sc.
_Lecturer in Experimental Psychology_
MANCHESTER
AT THE UNIVERSITY PRESS
12, LIME GROVE, OXFORD ROAD
LONGMANS, GREEN & CO.
LONDON, NEW YORK, BOMBAY, ETC.
1917
PUBLICATIONS OF THE UNIVERSITY OF MANCHESTER
No. CXI.
To
MAJOR R. G. ROWS, M.D., R.A.M.C.
Contents.
_Page_
PREFACE vii
INTRODUCTION ix
CHAPTER I.
THE NATURE OF SHELL-SHOCK 1
CHAPTER II.
TREATMENT 27
CHAPTER III.
PSYCHOLOGICAL ANALYSIS AND RE-EDUCATION 53
CHAPTER IV.
SOME GENERAL CONSIDERATIONS 77
CHAPTER V.
SOME LESSONS OF THE WAR 105
INDEX 133
Preface.
Our reasons for writing this book will be explained by the book itself.
We desire here gratefully to acknowledge the help of several friends
who have considerably facilitated our task. Our thanks are due to Major
R. G. ROWS, M.D., R.A.M.C., for his unfailing interest, encouragement
and help; to Captains W. H. R. RIVERS, M.D., F.R.C.P., F.R.S., and
J. W. ASTLEY COOPER of the R.A.M.C., and Mr. E. GLEAVES, M.Sc., for
their valuable suggestions and assistance in the preparation of the
manuscript; to Captain W. E. SAWERS SCOTT, M.D., R.A.M.C., Dr. ALBERT
HOPKINSON and Mr. W. PERCY STOCKS, F.R.C.S., of Manchester, for help
in other ways; and to our colleague, Professor H. BOMPAS SMITH, for
reading the proofs and helping us to eliminate some of the more glaring
literary defects. To the Editor of the _Lancet_ we are indebted for
permission to use part of an article written by one of us. The stream
of requests for fuller information and explanation that poured in upon
the author of that article made the writing of this book an unavoidable
duty.
G. E. S.
T. H. P.
THE MEDICAL SCHOOL,
THE UNIVERSITY,
MANCHESTER.
_20th April, 1917._
Introduction.
Some account of the reasons for the appearance of this book is due to
the reader. During the last year we have been asked repeatedly, both by
members of the medical profession and the lay public, to write a simple
non-technical exposition of the ascertained facts of that malady, or
complex of maladies, for which we have adopted the official designation
“shell-shock.” Until recently such an attempt would have been premature
and largely speculative. But it is now possible to collate the medical
reports, not only from our own army, but also from those of France and
Russia. Valuable and suggestive data have, furthermore, been obtained
from such of the German medical journals as have reached us. The facts
described in the various accounts which we have seen are in close
agreement. The conclusions in this book, therefore, are not based upon
our experience alone.
Our object in thus publishing a brief and simple description of these
facts is twofold: first, to make them available to those who have
neither the time nor the special knowledge necessary for consultation
of the medical journals; secondly, to call attention to the obvious
significance of these truths for the future welfare and happiness of
the nation.
It might seem that to publish a book on this subject at such a time is
merely to irritate existing wounds. The topic is painful; perhaps one
of the saddest of the many grievous aspects of the war. But a condition
exists at present which is immeasurably more painful—the exaggerated
and often unnecessary distress of mind in many of the sufferers and
their friends, which arises from the manner in which we, as a nation,
have been accustomed to regard even the mildest forms of mental
abnormality. Of all varieties of fear, the fear of the unknown is one
of the greatest. Not the least of the successful work performed in the
special hospitals during the war has been the dispelling of this fear
by helping the sufferer to understand his strange symptoms (many of
which are merely unusual for the patient himself) and, in the light of
this new self-knowledge, to win his own way back to health.
It is because we believe that a similar probing of the _public_
wound—the British attitude towards the treatment of mental
disorder—though painful, is justifiable and necessary, that we have
written the concluding chapters of this book. For it cannot be too
strongly urged that the shifting and unstable blend of apathy,
superstition, helpless ignorance and fear with which our own country
has too long regarded these problems is rapidly becoming our exclusive
distinction. It must be realised that America, France, Germany, and
Switzerland have long ago faced the problem in the only practical
way—the scientific one. And to the long list of sciences which we all
agree must be cultivated more assiduously after the war should be
added—but not at, or even near, the end—psychiatry, the science of the
treatment of mental disorders.
Not patriotic motives alone urge this reform, but common sense and
common morality. For shell-shock has brought us no new symptoms. Its
sole ground of difference from other disordered states of mind lies
in its unusually intense and wide-spreading causes. The problems of
shell-shock are the every-day problems of “nervous breakdown.” They
existed before the war, and they will not disappear miraculously with
the coming of peace. The war has forced upon this country a rational
and humane method of caring for and treating mental disorder among
its soldiers. Are these signs of progress merely temporary? Are such
successful measures to be limited to the duration of the war, and to
be restricted to the army? Germany has applied them for years to the
alleviation of suffering among her civilian population, with a success
which has made her famous—outside England. Can we be content to treat
our sufferers with less sympathy, insight and common-sense than Germany?
It is at this time, while our country is anxiously considering how best
to learn the lessons of the war, that we wish to call attention to one
of these lessons which is in danger of being overlooked.
CHAPTER I.
The Nature of Shell-Shock.
A French doctor has said, “Il n’y a pas de maladies; il n’y a que des
malades.”[1] Whatever may be the general validity of this statement,
it is undoubtedly true of the nerve-stricken soldier. Every case is
a case by itself, and as such it must be considered by anyone, be he
layman or doctor, who is interested in its nature and treatment. For
the troubles displayed in the many disorders classed under the official
title shell-shock are extraordinarily numerous and different, and their
removal necessitates a similarly varied repertoire of “opening moves”
on the part of the physician.
Although the term shell-shock has been applied to a group of
affections, many of which cannot strictly be designated as “shock,” and
into the causation of which the effect of the explosion of shells is
merely one of many exciting factors, this term has now come to possess
a more or less definite significance in official documents and in
current conversation. It is for this reason that we have chosen to use
it rather than the more satisfactory, but less widely employed term,
“War-Strain.” The reader will, therefore, understand that whenever
the term shell-shock appears in these pages, it is to be understood
as a popular but inadequate title for all those mental effects of
war experience which are sufficient to incapacitate a man from the
performance of his military duties. The term is vague; perhaps its
use implies too much; but this is not altogether a disadvantage, for
never in the history of mankind have the stresses and strains laid
upon body and mind been so great or so numerous as in the present war.
We may therefore expect to find many cases which present not a single
disease, not even a mixture, but a chemical compound of diseases, so
to speak. In civil life, we often meet with cases of nervous breakdown
uncomplicated by any gross physical injury. We are scarcely likely, for
example, to meet it complicated by gas poisoning and a bullet wound.
Yet such combinations as these—or worse—are to be met with in the
hospitals every day.
This is perhaps an opportune place to point out a significant popular
misunderstanding concerning the nature of such maladies as we shall
discuss in this chapter. A common way of describing the condition
of a man sent back with “shock” is to say that he has “lost his
reason” or “lost his senses.” As a rule, this is a singularly inapt
description of such a condition. Whatever may be the state of mind
of the patient immediately after the mine explosion, the burial in
the dug-out, the sight and sound of his lacerated comrades, or other
appalling experiences which finally incapacitate him for service in the
firing line, it is true to say that by the time of his arrival in a
hospital in England his reason and his senses are usually not lost but
functioning with painful efficiency.
His reason tells him quite correctly, and far too often for his
personal comfort, that had he not given, or failed to carry out, a
particular order, certain disastrous and memory-haunting results
might not have happened. It tells him, quite convincingly, that in
his present state he is not as other men are. Again, the patient
reasons, quite logically, but often from false premises, that since
he is showing certain symptoms which he has always been taught to
associate with “madmen,” he is mad too, or on the way to insanity. If
nobody is available to receive this man’s confidence, to knock away
the false foundations of his belief, to bring the whole structure
of his nightmare clattering about his ears, and finally, to help
him to rebuild for himself (not merely to re-construct for him) a
new and enlightened outlook on his future—in short, if he is left
alone, told to “cheer up” or unwisely isolated, it may be his reason,
rather than the lack of it, which will prove to be his enemy. And
nobody who has observed the hyperæsthesia to noises and light in the
nerve-hospital, nobody who has seen the effects upon the patients of
a coal dropping unexpectedly out of the fire, will have much respect
for the phrase, “lost his senses.” There exist, of course, cases of
functional blindness, deafness, cutaneous anæsthesia and the rest, but
the majority of the nerve patients show none of these disorders and
recovery from them is often rapid.
In a word, it is not in the intellectual but in the _emotional_ sphere
that we must look for terms to describe these conditions. These
disturbances are characterised by instability and exaggeration of
emotion rather than by ineffective or impaired reason.[2] And as we
shall see later, in the re-education of the patient, the physician is
compelled continually to take this fact into account.
As we have pointed out, every nerve-stricken soldier presents a case
by itself. Slavish adherence by the physician to one of the classical
names or labels used in diagnosis usually spells failure. The patient
must be approached _without prejudice_, and the doctor who wishes to
be of real help to him must make up his mind to examine and ponder
over the sufferer’s mental wounds with as much, nay, even more—care and
expenditure of time than would be given to physical injuries. A mere
cursory inspection in the course of the formal ward visit is a solemn
farce, if it pretends to be a serious attempt to cure the mentally
afflicted.
A man standing at “attention” by the side of his bed, surrounded by
his comrades and faced by the medical officer, the military sister,
and perhaps even by other members of the staff may volunteer the
information that he is sleeping badly. But this imposing procession
and cloud of witnesses is scarcely conducive to the production of any
further evidence as to the cause of his insomnia. For of those causes
even pre-war experience makes it possible to assert that their name
is legion, and their character often of an exceedingly intimate and
private nature.
The formal visiting of patients in the wards, while adequate for the
care of physical injuries (which can be subsequently attended to by
trained nurses and sisters) and necessary for administrative and
disciplinary purposes, is insufficient for “mental cases.” It is with
this fact in mind that the military authorities have instituted special
hospitals in which more detailed attention may be given to the latter
class of patients. In these institutions the soldier may have private
interviews with his medical officer, and the history of the trouble
can be unravelled in conversation. _It is only in this way that any
scientific insight into a case of mental disorder can be obtained._
A short time spent in such interviews, or even the perusal, by the
uninitiated, of the papers already published in the _Lancet_, _British
Medical Journal_, and elsewhere[3], will convince one of the immense
complexity of these unusual mental conditions, and moreover, of the
absolute necessity of obtaining and understanding the patient’s past
history, before and during the war. A dozen cases sent back from
the front as shell-shock may prove to possess not a single feature
in common—except the fact of the shell explosion. And this, as has
been pointed out, may be but the “last straw.”[4] The patient often
discloses in the first interview the fact that he was displaying all
his present symptoms _before_ the arrival of the particular shell which
laid him out.
It is now possible to attempt a brief sketch of the typical conditions
which give rise to some of the chief varieties of shell-shock.
Let us take a common case; that of the patient who is returned to
this country, figuring in the casualty lists under the terse and
businesslike military formula, “shock, shell.”
For various reasons, which the reader will easily supply, we choose to
present a composite picture of the history of such a soldier. Not all
the conditions described here need necessarily have operated in any
one case taken at random, but we shall err, if at all, on the side of
understatement. The correctness of the description may be checked by a
reference to the papers already mentioned.[5]
We must first try to conceive the experiences of the soldier before the
occurrence of the knock-out blow, so far as they bear on his present
condition. Let us suppose that his period of training has made him
physically and mentally fitter than he had ever been before, that no
military causes of anxiety or fear, such as the experience or the
anticipation of being torpedoed on the outward voyage, have operated
to any noteworthy extent in his case. He enters the trenches in
first-class condition. The duration of his stay there, provided he is
not wounded, or attacked by any bodily illness, will depend from that
time forward upon the nature, duration, intensity and frequency of the
emotion-exciting causes, and upon himself. By that all-inclusive word
“himself” we mean to signify chiefly his temperament, disposition and
character.[6]
It must be remembered that one of the greatest sources of breakdown
under such circumstances is intense and frequently repeated emotion.[7]
By this is meant not only experiences of fear or of sympathy with
suffering comrades, in short, those conditions the manifestations
of which might cause the man in the trenches to be spoken of as
“emotional,” but also other mental states associated with general
excitement, anxiety, remorse for major or minor errors, anger, elation,
depression and that complex but very real state, the fear of being
afraid. (The more definite terms of technical psychology are not used
here, as it is considered wiser to employ popular language.)
The soldier may be subjected to intense emotional stimuli of this kind
for days or weeks without relief. And whereas to the mental sufferer
in civil life sleep often is vouchsafed, “setting him on his feet”
to continue, more or less effectively, the struggle next day, to
the soldier sleep may be impossible, not necessarily because of his
excited mental state, but simply from the lack of opportunity or the
disturbances going on about him. In course of time this loss of sleep
from external causes may easily set up bodily and mental excitability,
which in its turn acts as a further cause of insomnia. The usual mental
conditions associated with loss of sleep then rapidly supervene:
pains and unpleasant organic sensations, hyperæsthesia, irritability,
emotional instability, inability to fix the attention successfully
upon important matters for any length of time, loss of the power of
inhibition and self-control.[8]
These symptoms, troublesome enough in civil life, become positively
dangerous to the man in the trenches, especially if he is in a position
of responsibility. In that case his standing as officer or N.C.O.
merely adds to his mental distress. Bodily hardship, such as exposure
to cold and wet, hunger, and the irritation from vermin, obviously
aggravates the disorders we have described.
We must not suppose, however, that the man who is experiencing some or
all of these mental and bodily conditions is at this period necessarily
displaying any obvious _outward_ signs of his trouble. There may be
no tremor, no twitchings, no loss of control of the facial or vocal
muscles which would indicate his state even to his neighbours. He may,
for a long time, “consume his own smoke.” And during this process he
may even appear to his comrades to be steadier and more contemptuous
of danger than before. Dr. Forsyth[9] has cited some dramatic
incidents, in which officers who imagined that their instinctive fear
was becoming apparent to the men under their command took unnecessary
risks in order to impress these men with the idea that they were not
afraid.
It must be understood that this suppression of the external
manifestations of an emotion such as fear is but a partial dominance
of the bodily concomitants of that emotion. The only changes which
can usually be controlled by the will are those of the voluntary or
skeletal muscular system, not those of the involuntary or visceral
mechanism. While no signs of fear can yet be detected in the face,
the body, limbs or voice, these disturbances of the respiratory,
circulatory, digestive and excretory systems may be present in a very
unpleasant degree, probably even intensified because the nervous energy
is denied other channels of outlet.[10]
The suppression of fear and other strong emotions is not demanded only
of men in the trenches. It is constantly expected in ordinary society.
But the experience of the war has brought two facts prominently before
us. First, before this epoch of trench warfare very few people have
been called upon to suppress fear continually for a very long period
of time. Secondly, men feel fear in different ways and in very various
degrees.
The first fact accounts for the collapse, under the long continued
strain of trench warfare, of men who have shown themselves repeatedly
to be brave and trustworthy. They may have felt intense emotions,
obviously not of fear alone, for a long time without displaying any
signs of them. But suppression of emotion is a very exhausting process.
As Bacon says, “We know diseases of stoppings and suffocations are the
most dangerous in the body; and it is not much otherwise in the mind.”
The second fact mentioned above is of great importance in the
consideration of our problem. There are undoubtedly men who seem to be
immune to fear of the dangers of warfare. But to them we can scarcely
apply the adjective “brave.” The brave man is one, who, feeling fear,
either overcomes it or refuses to allow its effects to prevent the
execution of his duty.
Other emotional states however, besides fear, arise and require
suppression. The tendency to feel sympathetic pain or distress at
harrowing sights and sounds, disgust or nausea at the happenings in
the trenches, the “jumpy” tension in face of unknown dangers such as
mines—all these, like fear, are or have been biologically useful under
natural conditions and, like it, are deeply and innately rooted in man.
But the unnatural conditions of modern warfare make it necessary that
they shall be held in check for extraordinarily long periods of time.
The impossibility of regarding modern methods of warfare in the same
light as natural and primitive means of fighting appears very clearly
when we consider the instinctive and emotional factors involved in the
two sets of circumstances. In natural fighting, face to face with his
antagonist, and armed only with his hands or with some primitive weapon
for close fighting, the uppermost instinct in a healthy man would
naturally be that of pugnacity, with its accompanying emotion of anger.
The effect of every blow would be visible, and the intense excitement
aroused in the relatively short contest would tend to obliterate the
action of other instincts such as that of flight, with its emotion of
fear. But in trench warfare the conditions are different. A man has
seldom a personal enemy whom he can see and upon whom he can observe
the effects of his attacks. His anger cannot be directed intensely
night and day against a trench full of unseen men in the same way
in which it can be provoked by an attack upon him by an individual.
And frequently the assaults made upon him nowadays are impersonal,
undiscriminating and unpredictable, as in the case of heavy shelling.
One natural way is forbidden him in which he might give vent to his
pent-up emotion, by rushing out and charging the enemy. He is thus
attacked from within and without. The noise of the bursting shells,
the premonitory sounds of approaching missiles during exciting periods
of waiting, and the sight of those injured in his vicinity whom he
cannot help, all assail him, while at the same time he may be fighting
desperately with himself. Finally, he may collapse when a shell bursts
near him, though he need not necessarily have been injured by actual
contact with particles of the bursting missile, earth thrown up by its
impact, or gases emanating from its explosion. He may or may not be
rendered unconscious at the time.[11] He is removed from the trenches
with loss of consciousness or in a dazed or delirious condition with
twitchings, tremblings or absence of muscular power.
Upon recovery of consciousness, which may take place after periods
varying between a few minutes and a few weeks, the immediate disorders
of sensation, emotion, intellect, and movement, are often very severe.
It may be presumed that at the beginning of the war they must have
appeared far more serious to most of the doctors who saw them in their
early stages than they would now. This speculation is suggested by the
evidence of the case-sheets sent with the men from France in the early
period of the campaign. Such diagnoses as “delusional insanity,” and
other similar terms taken from the current classifications of advanced
conditions of insanity, appear very frequently as descriptions of cases
which on arrival in England had almost entirely lost every sign of
mental unusualness. In fact, one of the most cheering aspects of work
amongst this type of case has been the rapidity with which men who have
presented quite alarming symptoms have subsequently recovered.
It may seem almost unnecessary to enumerate the bizarre phenomena which
constitute the immediate results of shell-shock, for our newspapers
have naturally seized upon such unusual details and have made the most
of their opportunities in this direction. But the reader will obtain a
clearer idea of the facts if they are catalogued once more.
The most obvious phenomena are undoubtedly the disturbances of
sensation and movement. A soldier may be struck blind, deaf or dumb
by a bursting shell: in rare cases he may exhibit all three disorders
simultaneously or even successively. It should be added that these
troubles often vanish after a short space of time, as suddenly and
dramatically as they appeared. Thus one of the blinded soldier
survivors of the _Hesperian_ recovered his sight on being thrown into
the water. Other blind patients have had their sight restored under
the action of hypnosis. Mutism is often conquered by the shock of a
violent emotion, produced accidentally or purposely. Examples of such
“shocking” events taken at random from our experience were the sight
of another patient slipping from the arms of an orderly, the “going
under” chloroform, the application of a faradic current to the neck,
the announcement at a “picture house” of Rumania’s entry into the war
(this cured two cases simultaneously), and the sight of the antics
of our most popular film comedian. The latter agency cured a case of
functional deaf-mutism, the patient’s first auditory sensations being
the sound of his own laugh.
The muscular system may be affected in an equally striking manner.
Contractures often occur in which a man’s fist may be immovably
clenched for months; or his back may be bent almost at right angles
to his lower limbs, there being in neither case any bodily change
discoverable by the neurologist which can account for such a condition.
These contractures, though curable, often prove very obstinate, and at
present their nature remains somewhat of a mystery. Other distressing
and long continued disturbances take the form of muscular twitchings
and tremors or loss of power in the limbs.
Not every nerve-case, however, presents such striking and objective
signs as those which we have just been describing. The _subjective_
disturbances, which are apt to go undiscovered in a cursory examination
of the patient, are frequently more serious than the objective,[12]
and are experienced by thousands of patients who to the mere casual
observer may present no more signs of abnormality than a slight tremor,
a stammer, or a depressed or excited expression. These afflictions:
loss of memory, insomnia, terrifying dreams, pains, emotional
instability, diminution of self-confidence and self-control, attacks
of unconsciousness or of changed consciousness sometimes accompanied
by convulsive movements resembling those characteristic of epileptic
fits, incapacity to understand any but the simplest matters, obsessive
thoughts, usually of the gloomiest and most painful kind, even in some
cases hallucinations and incipient delusions—make life for some of
their victims a veritable hell. Such patients may have recovered from
sensory or motor disturbances and yet may suffer from any or all of
these afflictions as a residuum from the original “shock-complex;” they
may suffer from them as a complication of the discomfort attending upon
a wound or an illness, or, on the other hand, they may have no overt
bodily disorder: their malady then being usually given the simple but
all-inclusive (and blessed) description “neurasthenia.”
Now the happiness and welfare of such men obviously is bound up to no
small extent with the character of the hospital or hospitals (for the
plural number is commonly to be used in writing the history of these
patients) to which they are sent. In the general military hospitals the
medical officers have neither the time nor, in many cases, the special
knowledge, necessary to deal with cases of this kind. Such patients
may recover of themselves without any treatment, but a large number
of them tend to get worse, and if they are left without attention
their symptoms are apt to become stereotyped into definite delusions
and hallucinations. Moreover, in a general ward such men may become
a constant source of disturbance and annoyance to other patients
and to the nurses. One of the symptoms of their illness is a morbid
irritability; they tend to become upset and to take offence at the
merest trifles[13]—and this leads to trouble with patients, nurses,
and the medical officers responsible for discipline. But if special
consideration is shown them by the nurses the other patients are apt to
misunderstand it and even to complain of favouritism. In other words,
when mixed with wound-cases in a general hospital, these nervous
patients are apt to be regarded as a nuisance—which is bad for them and
for the proper working of the hospital. Another consideration, too,
is that the subjection of such men to irksome regulations of military
discipline, and the usual penalties for infringing them, is often so
potent a factor in producing disturbances as to be quite fatal to any
hope of amelioration.
These considerations have led the military authorities to establish
special hospitals for nerve-cases.[14] In such institutions the
patients can be nursed and attended to by a staff which, being used to
the idiosyncrasies of such illnesses can make conditions more suitable
to them.
A man’s particular nervous malady is likely to be of common occurrence
in the nerve-hospital; it does not render him conspicuous, and
therefore an object of fussy solicitude, galling pity, or suspicious
contempt, as is too often the case in other institutions. If unwounded,
he need not suffer the taunt of “having nothing to show” as his reason
for staying in hospital. Further, while in the special hospital,
more importance is attached to some of the patient’s symptoms, less
disturbance is produced by others. The occurrence of a “fit” is
viewed by the rest of the men in this class of hospital in a truer
perspective, and the patient does not find himself a nine-days’
wonder, as he so easily may do in a small auxiliary hospital full of
straightforward wound cases.
Up to this point we have discussed the various troubles subsumed under
the term shell-shock in what may be termed its initial and middle
stages. In the middle stage, the patient having recovered from the
severe and acute symptoms constituting the former phase, is left with
a motley residuum of troubles, the chief of which we have enumerated
on pages 12, 13. In distinguishing between this middle stage and
that which follows it, we may perhaps ask the reader to assist us by
recalling the difference between a mechanical mixture and a chemical
compound. In the former the ingredients of the mixture remain unaltered
and unaffected by the proximity of other substances, as for example
when sugar is mixed with sand. In the compound, on the other hand,
chemical action and reaction occur between the components so that not
one of the substances is immediately recognisable in the complex, as
for example when carbon, hydrogen and oxygen combine to form alcohol,
which resembles none of them.
Now it would be distorting the facts of mind to suggest that while the
third stage of shell-shock is a compound (as it undoubtedly is) the
middle stage is a mixture. For the very essence of mind is its compound
nature. But what we wish to point out is that in this middle stage the
abnormalities have had very little time to react upon each other, with
the result that there is some resemblance to a state of mixture, the
phenomena existing temporarily side by side, so to speak. In this stage
a patient may be troubled simultaneously by several unusual mental
occurrences, such as terrifying dreams during very light sleep, loss
of memory for certain periods of his past, and inability to understand
or to carry out complex orders. For a short time in his “bowled-over”
state he may be worried by the separate attacks, of these various
troubles at different periods of the day and he may be too overwhelmed
to try to understand or to attempt to see relations between them. This
state of mind, in which the patient is still his “old self,” though
a somewhat overturned self, resembles the mechanical mixture in our
illustration. The reader may obtain some idea of this condition if he
recalls any one day in his own experience when “everything seemed to go
wrong”; when at one moment he was turning to face this difficulty, at
another, that, but still retained to a great extent his usual attitude
towards the world.
As has been pointed out, however, the state of “mechanical mixture” is
utterly alien to the normal mind, which tends rapidly to interpret, in
the light of its own experience, and to integrate as far as possible,
its events, however incongruous they may be. The mind cannot, for any
length of time, allow a new experience to remain strange or undigested.
It must gather in and assimilate that event to the systematised complex
which we call its own past experience. It follows that the ultimate
result upon any particular mind of a new experience, if it be of a
personally significant nature, will depend almost entirely upon the
past history of that mind.
Thus for example the question whether the patient can or cannot
satisfactorily stand up to his new troubles will be determined not only
by his disposition, temperament and character, but also by his previous
personal experience.
It is thus obvious to anyone who gives the matter any serious
consideration, that the manifestation of a severe psychical shock must
necessarily be determined in a large measure by the nature of the mind
upon which the injury falls. It would be idle to pretend therefore,
that, in diagnosis, the story of the patient’s past experience can be
left out of account, for the manifestation of the injury will obviously
depend largely upon the individual patient’s “mental make-up.”
Faced by the existence of a number of unusual mental phenomena the
patient will inevitably succeed in time in inventing for himself,
explanations of their co-existence. This “rationalisation,”[15] as it
is called, is a perfectly normal process which is constantly going on
in every individual, yet it plays a great part in complicating the
mental disorders of the middle stage, and thereby intensifying the
patient’s ultimate distress. For instance, he may not be more than
temporarily disturbed by the unusual experiences we have mentioned[16]
if they assail him separately. But, given time, he will soon begin
to connect their appearances, and will argue to himself that these
phenomena can have only one meaning: that he is mad or rapidly becoming
so. And in this completely erroneous procedure he will be aided and
abetted, not only by his own ignorance of the relation of mental
normality to abnormality, but also by the general tendency of the
uneducated to class everything unusual in the mental sphere as “mad.”
Once he is convinced that he is in this state he may easily lose all
hope of getting better, thereby increasing enormously the gravity
of his case. Completely illogical, but to him entirely satisfactory
explanations of his condition will then multiply.
As we have mentioned, this rationalisation is no unusual phenomenon
in ordinary life. It will be clear to anyone who gives the question
a moment’s thought that few of the non-scientific[17] beliefs held
by even a highly educated person have ever been logically reasoned
out from fundamental principles. In fact such principles frequently
cannot be reached, for the very good reason that they have never been
consciously conceived by the individual. One’s views on religion,
politics, or the relations and rights of the sexes may exhibit in their
outer casings a semblance of rational structure: their core, however,
is not reason but emotion. As James expresses it:—
“In its inner nature, belief or the sense of reality is a sort of
feeling more allied to the emotions than to anything else ... reality
means simply relation to our emotional and active life. This is the
only sense which the word ever has in the mouths of practical men....
Whenever an object so appeals to us that we turn to it, accept it,
fill our mind with it, or practically take account of it, so far it is
real for us and we believe it. Whenever, on the contrary, we ignore
it, fail to consider it or act upon it, despise it, reject it, forget
it, so far it is unreal for us and is disbelieved.... Whatever things
have intimate and continuous connection with my life are things whose
reality I cannot doubt.”[18]
Few people, however, realise this truth so clearly, or express it so
lucidly, as Professor James. Often we believe that we are logically
convinced when in reality we have been convinced first, and have
invented reasons for our conviction afterwards. But many of our beliefs
and attitudes have been implanted in us in childhood or early youth
by processes which could not by the wildest stretch of imagination be
called logical. And not the least important of those beliefs are those
held by the average Briton with regard to insanity.[19]
For the patient, then, his mental troubles, having intimate and
continuous connection with his life, become very real indeed. But the
longer he is left alone to “cheer up,” the longer he broods over his
troubles in isolation, the longer he is allowed to build theories
upon his inadequate and inaccurate data, the more intimately and
continuously connected with his life will the abnormalities become.
They may come to be so integrated with each other that his very
personality becomes tinged. Then he is no longer a normal person
battling with his separate enemies, but one who has made terms, and
those often disastrous ones, with his closely allied foes. An attempt
to cure him at this stage will then necessitate the analysis of a
highly complex compound, while in the early and middle stages merely
the attack upon separated elements is necessary.
We are concerned at present with the facts of shell-shock, but this
is perhaps a suitable place in which to deal with an opinion about
this set of phenomena, which is not uncommon, especially perhaps in
people above military age. That judgment, expressed sometimes bluntly,
but oftener in a more subtle fashion, is that shock or neurasthenia
are polite names for nothing else but “funk.” It is not easy to take
a dispassionate view of this question, but to persons holding this
opinion the following points are worthy of consideration.
First, the most severe and distressing symptoms occur to a surprising
extent in the case of those patients whose past history shows that,
far from possessing even the normal quota of timidity, they had been
noted for their “dare-devilry” and had been specially chosen as
despatch-riders, snipers and stretcher-bearers in the firing line.
Secondly, it is not uncommon for patients to ask to be sent back to
duty because they feel that they have been too long with nothing to
do, while it is quite obvious to the doctor that they are as yet unfit
to bear any great strain. Thirdly, the seasoned regular, officer or
N.C.O.,[20] as well as the young soldier of only a few months’ service
may display precisely the same symptoms as those we have described.
Such men have frequently been in the army for many years, and have
fought on previous occasions with great success. Their strength of
mind and body has been demonstrated over and over again, yet at last
they have broken down. And they manifest the greatest concern at their
unusual symptoms.
It will be readily granted, of course, that there exist among the nerve
patients returned from the front cases in which there is genuine fear
of the war, arising from memories of the experiences which they have
undergone. Even this state of mind, however, is usually expressed by
the patient in some such phrase as “I don’t want to go back, but I’ll
go quite willingly if I’m ordered to.” It should not be forgotten,
moreover, that not a small number of instances are known in which these
men prove to have made repeated attempts at enlistment after having
been rejected several times, or even discharged from the army, changing
their medical examiner until they have succeeded. One case, presenting
a great number of the symptoms of shell-shock in a very intense form,
including, beside the ordinary neurasthenic troubles, blindness,
deafness, and mutism at successive times, was that of a man who had
been discharged from the army as medically unfit and had re-enlisted.
Two cases may be quoted here in illustration of some of these
assertions:
The first is that of a non-commissioned officer who went through the
initial eleven months of the war in France and Flanders, was subjected
to every kind of strain, physical, mental and moral, which that
stricken field provided; and in addition was wounded twice, gassed
twice, and buried under a house, on all five occasions being treated
in the field ambulance and then returning to the trenches. After all
this experience he had not qualified for sick leave, but was granted
five days ordinary leave to return home, apparently in a good state of
health. After reaching England and while waiting for a train in the
railway station, he suddenly collapsed, became unconscious, and for
months afterwards was the subject of severe neurasthenia. Apparently at
the front the excitement, the sense of responsibility and especially
the example that he felt he should set his men, seem to have kept him
right. These stimuli removed, he broke down. The whole of his trouble
seemed to be due to the dread lest on his return to the front, the
added responsibilities which would fall upon his shoulders (because
most of his own officers had been killed and there would be new men
to replace them) might be too much for him. His intelligence seemed
(to himself) to have become numbed by his experiences, and he became
conscious of the unreliability of his memory and of his inability
to understand not only complex orders, but, as he put it, “even
the newspapers.” It was this that excited in him the dread lest he
should be incompetent to discharge adequately the duties which would
fall upon him. There was nothing of malingering or shirking in his
case. There was no fear of physical injuries or of returning to the
front; on the contrary, he was anxious to go back. His fear lest the
possibility of his failure would be bad for his platoon was wholly due
to that admirable sentiment of regimental loyalty, which comes out so
strikingly in the nervous troubles of the non-commissioned officer.
This class of case demands a great deal of patient and sympathetic
attention before the real cause of the trouble is elicited, and then
months of re-education may be required to build up anew the man’s
confidence in himself.
The second case is that of a soldier who had suffered from severe shock
symptoms and had recovered. In conversation with the medical officer
the soldier expressed his willingness, and even his desire, to return
to the front, in full knowledge of the fact that the officer’s report
in that sense would lead to his being sent back to fight. That night
the patient was awakened by a terrifying dream, the true significance
of which was certainly not adequately appreciated by him. Although
he dreamt that he was afraid to go back to the front, apparently he
did not realise that he was actually afraid—_i.e._, that the dream
had any meaning. On examination it proved to be a detailed forecast
of the imaginary incidents of his return to his regiment, and of his
attempt to commit suicide when ordered to go to France. Here was a
man who of his own initiative had asked his doctor to certify him as
ready to go back, yet in his sleep the train of thought, started by the
discussion of the possibility of his return, working subconsciously,
had stirred up images of what this implied, and reinstated emotions of
so terrifying a nature that in his dream he preferred suicide to facing
the ordeal again.
It may perhaps be allowable to quote in this connection the view of a
German neurologist, Prof. Gaupp, on the “shock-cases” which have been
sent back from the German front.[21] At the same time it is important
to remind our readers that Gaupp is writing of a conscript army,
the authorities in which are certainly not notorious for lenity to
the individual; further, that up to the time of writing the present
chapter, all the “shock” patients in Great Britain have been men who
voluntarily elected to serve their country, the majority of them
having enlisted in the earliest stages of the war.
In discussing cases where nervous trouble, uncontrollable in nature and
intensity, had led to the patients being kept in German hospitals for
months, it was sometimes found that the mental foundation which was a
causal factor of these troubles was a more or less conscious anxiety
concerning the possibility of a return to the front.
“There is no justification,” says Gaupp, “for calling every instance
of this a case of malingering or simulation. There are quite capable
men of irreproachable character whose nervous system is positively
unfitted for the hardships and horrors of war. They have enthusiasm
and the best of intentions but these cease to inspire them when the
horrors and terrors come. Their inner strength rapidly decreases,
and it only requires an acute storm to break upon the nervous system
(such as the explosion of a shell or the death of comrades) for their
self-control to vanish completely. Then automatically their condition
changes into what is popularly called ‘hysteria.’ The exhausted mind
then feels that it is no longer master of the situation, and therefore
‘takes refuge in disease.’ At first, as a rule, obvious signs of
terror and anxiety (trembling, twitching, etc.) manifest themselves;
if these are cured there still remain chronic symptoms of hypochondria
and despondency. Time, however, has its effect in many of these
cases.”[22]
If a patient comes into the hands of a physician before the processes
of rationalisation and systematisation have become established, the
medical officer should be able to meet his difficulties, and help him
correctly to interpret his unusual experiences by explaining to him
their origin and nature.
“The application of discreet sympathy and tact by a physician who
endeavours to discover something of the man’s past mental history may
be able to reassure a patient upon his particular trouble with the
happiest of results. To a man quite unacquainted with text-books or
speculation on psychology there can be no darker mystery than the
working of other people’s minds. To such a man the natural conclusion
is that his own mental processes are universal and normal. But if,
as a result of some nerve-shattering experience of warfare his mind
suddenly develops a trick which was quite unknown to him before,
though this development may be far from abnormal, to the troubled
patient it may seem to be an unquestionable symptom of madness.”[23]
Many of the cases in which a patient has merely needed reassuring
have been of this type. A short and very simple explanation of some
elementary facts of psychology is often sufficient to bring about an
immense change in the man’s condition, which has led to his curing
himself. And this is the ideal method of cure.
It may seem that an inordinate amount of space has been devoted to the
demonstration of a simple truth, that mental, like bodily disorder,
should be treated early, or complications may ensue. But there are
reasons for giving so much prominence to this aspect of the subject.
The chief is that in our own country, mental disorder is seldom treated
in its early stages. Nearly all our elaborate public machinery for
dealing with this distressing form of illness is devised, and in
practice is available, only for the advanced cases. This war has shown
clearly a truth which, of course, was already known before to many
doctors, but never adequately appreciated by the general public, that
a case of advanced mental disorder may pass not only through various
milder stages on its way, but that if intercepted at these earlier
stages, it may frequently be cured with ease.
Another point which should be emphasised is this: shell-shock involves
no _new_ symptoms or disorders. Every one was known beforehand in
civil life. If by any stretch of the imagination we could speak of a
specific variety of disease called shell-shock, it would be new only
in its unusually great number of ingredients. And the most gratifying
truth of all is that even this hydra-headed monster, if caught young,
can be destroyed.
From the fact that shell-shock includes no new disorders the important
inference may be drawn that the medical lessons taught by the war must
not be forgotten when peace comes. The civilian should be offered
the facilities for cure which have proved such a blessing to the
war-stricken soldier.
FOOTNOTES:
[1] There are no sicknesses, there are only sick people.
[2] This subject has been lucidly discussed by C. Burt, “Psychology and
the Emotions,” _School Hygiene_, May, 1916.
[3] Such as for instance, D. Forsyth, _Lancet_, Dec. 25th, 1915, p.
1399; C. S. Myers, _Lancet_, Mar. 18th, p. 608; R. G. Rows, _Brit. Med.
Jour._, Mar. 25th, 1916, p. 441; G. Elliot Smith, _Lancet_, April 15th
and 22nd, 1916; H. Wiltshire, _Lancet_, June 17th, 1916.
[4] Wiltshire, _op. cit._, p. 1210.
[5] On pp. 4, 5.
[6] The reader who is interested in these important distinctions should
consult McDougall, _Social Psychology_, London, 1915, p. 116.
[7] _Cf._ the statements of two experienced neurologists:—Déjerine and
Gauckler (written before the war), “Overwork and fatigue are no more a
cause of neurasthenia than they are of tuberculosis. Without emotion
there are no psychoneuroses.”
(_The Psychoneuroses and their Treatment by Psychotherapy_, Jelliffe’s
translation, 1913, p. 232.)
[8] An experimental investigation of the mental effects of loss
of sleep has been carried out by Miss May Smith of the Oxford
Psychological Laboratory. A short account of these experiments
and their results is given in “Some Experimental Investigations
of Fatigue,” by T. H. Pear, _Proceedings of London County Council
Conference of Teachers_, 1914.
[9] _Op. cit._, p. 1402.
[10] In his book, “Bodily Changes produced by Fear, Pain, Hunger and
Rage,” Professor Cannon has given a striking demonstration of the
importance of emotion in producing such bodily disturbances.
[11] Capt. Wiltshire, as a result of recent experience near the firing
line in France thinks that the men’s accounts of the duration of
unconsciousness are often exaggerated, owing to their faulty memory of
the time at which it occurred. He also says that in his opinion the
actual individual shell-shock which prostrates the man is but the final
precipitating cause. (_Op. cit._, p. 1207.)
[12] This fact is in danger of being overlooked by members of the
public whose knowledge of “shock” is obtained from the newspaper
reports.
[13] R. G. Rows, _op. cit._, p. 441.
[14] For particulars of these hospitals, see W. Aldren Turner’s
Report, _Lancet_, May 27th, 1916, p. 1073. The reports published in
the special war numbers of the _Revue Neurologique_ (and especially
Nos. 23, 24, November and December, 1915) bear ample testimony to the
magnificent work being done by the French in this direction. Not only
has special provision been made in each military district for dealing
with neurological and mental cases, but also admirable accounts of the
work are being published, and those responsible for the care of such
patients have been afforded many opportunities for discussing their
difficulties and learning from each other.
[15] Or “seeking conscious and rational grounds for actions”
(and beliefs) “whose motives are largely unconscious and perhaps
irrational.” (A description borrowed from Burt’s article, _q. v._)
[16] On pp. 12, 13.
[17] (and, obviously, the same may be said of not a few ‘scientific’
beliefs.)
[18] _Principles of Psychology_, II., 283-324.
[19] The opinions of Dr. Bedford Pierce upon this matter are highly
important. _British Medical Journal_, January 8th, 1916, p. 4.
[20] Our personal experience has been of privates and non-commissioned
officers only, but there is no _a priori_ reason for supposing that
these remarks do not apply to the commissioned ranks. It has been found
that in the French Army the cases of neurasthenia amongst officers have
been very numerous.
[21] “Hysterie und Kriegsdienst” (Hysteria and War Service), _Münchener
Medizinische Wochenschrift_, March 16th, 1915.
[22] The translation is very free, but it fairly represents the sense
of the German original.
[23] From a leading article on “War-Shock and its Treatment,” in the
_Manchester Guardian_.
CHAPTER II.
Treatment.
In discussing the question of treatment we do not propose to deal with
general therapeutic measures which every physician in charge of nervous
or mental patients is hardly likely to neglect.[24] The importance of a
generous and easily digested dietary is generally recognised: as also
is the need for quiet and congenial surroundings, and for shielding
patients from disturbances, such as noises and the sight of wounded,
which are likely to evoke painful emotions and vivid memories of their
experiences at the front. It is also obviously important that the
physician should deal promptly and discreetly with any bodily ailments
from which the patient is suffering, being careful neither to minimise
their gravity and so give him any reason for the grievance that he
is not receiving proper attention, nor by exaggerating them to add
this anxiety to his other troubles.[25] These are questions which may
confidently be left to the discretion of the physician in charge.
_Firmness and Sympathy._
But there are certain other therapeutic measures commonly recommended
in text-books for application in the cases of patients suffering from
neurasthenic and hysterical troubles, which cannot be thus summarily
dismissed. As many of these patients are irritable and childishly
peevish, it is necessary that they should be treated with sympathetic
firmness, tact and insight. But, unfortunately, the words “firmness”
and “sympathy” are interpreted in a great variety of ways. While it is
important, for purely therapeutic reasons, that discipline should be
maintained, and that when the physician has decided what he considers
the proper treatment for the patient this should be rigorously carried
out, it is manifestly disturbing and injurious in many cases for the
officer to insist upon all the exacting details of military rules and
regulations. For the mentally healthy soldier, obedience to stern and
even harshly rigid regulations is often vitally important; but an
attempt by a medical officer to treat a ward of neurasthenic patients
in this way usually has disastrous results.
Quite apart, however, from the military aspects of the case, the
physician, without really investigating the history of a patient,
may label his trouble “hysteria” and forthwith adopt a course of
“firmness.” He may assume the attitude of doubting the genuineness
of symptoms which are very real to the sufferer. Under the plea of
helping to cure the patient the officer may assure him that there is
nothing much the matter with him and that if he tries he will soon be
all right. Such advice may be justifiable if based on a real insight
into the state of the individual sufferer, but this knowledge can be
gained only by a patient investigation of the cause of his trouble.
If the advice is given without this insight, it is a mere shot in the
dark. The fact that the device succeeds in a certain number of cases
is no excuse for its general adoption. And when it “misfires” no one
realises the fact more quickly than the patient himself. He realises
that the officer does not appreciate his condition and his confidence
is thereby destroyed.
It is useful, too, to consider for a moment the nature of treatment by
“sympathy.” When we used the phrase “sympathetic firmness” we intended
to indicate the insistence upon a strict observance of such methods of
treatment as a real insight into the patient’s condition may suggest.
The word “sympathy” was used in its literal sense of “feeling with”
the sufferer. But there is no class of patients upon whom sympathy
of the injudicious kind is more prone to work serious harm than the
psychoneurotic. The knowledge of this fact is often the excuse for the
adoption of the opposite attitude and the prescription of “firmness”
which, as we have seen, may be equally unintelligent and injudicious.
But sympathy of the injudicious kind is not _real_ sympathy. For unless
the sympathiser has a true appreciation of the patient’s condition,
and can look at things from his point of view, he cannot really feel
_with_ the sufferer. The latter may arouse in the would-be sympathiser
tender emotions and sympathetic “pain,” but unless the sympathiser
have insight, the pain, to put it crudely, is not likely to be “in
the same place” as that of the patient. Such misplaced emotion and
false sympathy, whether on the part of the doctor, the nurse, or the
patient’s relations, may do much harm.
In mild cases of mental trouble, however, where the patient still
retains a goodly portion of self-confidence and self-respect, this
“petting” variety of sympathy may sometimes be effective. Such a
patient may be cheered up by the presence of people sufficiently
interested in him to be sorry for his condition; and it may help him
to look on the brighter side of things and to forget his worries and
anxieties. But often it is apt, by suggestion, to aggravate his
troubles or even to discourage him from trying to recover.[26] Perhaps
it would be more accurate to say that such treatment gives him no
inducement to get better.
There are still not a few physicians who regard the group of functional
troubles commonly labelled “hysteria” as something closely akin to
malingering. If it would not be considered invidious we could quote
the opinions of well-known physicians published within the last five
years, suggesting that there is no real line of demarcation. (It is not
uncommon to meet the expression “_detecting_,” instead of _diagnosing_
hysteria.)
But even among those who regard these serious affections as something
more than mere simulation there is a tendency to look upon any form
of sympathy as a dangerous pandering to the patient’s lack of will
power.[27]
This attitude often finds expression in leaving the patient alone to
get better by his own efforts, or in suggesting to him that he is not
so ill as he thinks he is, and that all he needs is some work to occupy
his attention.
The attempt is often made to justify such methods by the plea that
it is “bad for the patient to talk to him of his worries.” But how
a physician is to rid a patient of the very root of all his trouble
without first discovering and then discussing it with him is not
apparent. Nor, again, is it any more rational merely to tell a man who
is weighed down with some very real anxiety to “cheer up,” or to “work
in the garden,” or “take a walking tour.”
We are not maintaining that such methods do not often meet with
success in the case of many patients who are only mildly affected and
earnestly want to get better. But experience shows that such advice is
often fraught with danger, and, in severe cases of mental affection
is worse than useless. The experience of those physicians who have
been treating such patients with sympathetic insight during the last
two years affords a striking condemnation of the theory that it is
generally “bad to talk to them of their worries.” It has repeatedly
happened that as soon as the patient was asked about his troubles he
made a full statement of all that was troubling him and was obviously
relieved to confess his worries to someone who took an intelligent
interest in his welfare.
In many cases the mere unburdening of this weight of anxiety and the
removal by the physician of quite trivial misunderstandings which were
the original causes of it, were sufficient to cheer up the patient and
to start him on the way to complete recovery. Yet many of these men had
been inmates of a series of hospitals in which no attempt had been made
to discover what was the real source of all the trouble. Thus to their
other worries and anxieties was added the real additional grievance
that they were being neglected and were of no account. In many cases
this constituted a serious aggravation of the patient’s mental
disturbance and encouraged him to believe that his state was already
beyond help.
Those physicians who look upon such milder psychoses as varieties of
simulation should be reminded that the methods we have just mentioned
are not often likely to be effective in cases of real malingering.
In discussing the therapeutic use of “firmness” we have not thought it
necessary to mention those applications of this method which at times
are practised by combatant officers at the front. The use of military
authority to suppress the minor manifestations of nervousness, or the
resort to such expedients as unexpectedly firing off a gun alongside
a man afflicted with functional deafness, are merely examples of the
application of “suggestion.” They are akin to the use of “firmness”
by the physician who has not investigated the cause of the patient’s
trouble. The results of such expedients are as erratic in the one case
as in the other. But there is no need for us to discuss this practice
further, except to add that the knowledge that such “treatment by
military authority” has been tried before, still further diminishes the
justification for resorting to such measures when the patient reaches
the home hospital.
_Isolation._ Many physicians regard isolation as an appropriate
method of treatment for soldiers suffering from shock, and they urge
in justification of such a procedure the success which often attends
its use in civil cases. We do not deny the utility of isolation for
suitable cases, and success has attended its use when the patient’s
condition obviously required it. But the circumstances which were
responsible for causing the mental disturbance in the soldier may be of
a totally different nature from those which have upset the civilian;
and therapeutic measures which may be appropriate in eliminating the
civilian’s sources of irritation might be wholly unsuitable, if not
positively harmful, in the case of soldiers.
It cannot be too strongly emphasised in connection with this subject
that most of the theory and practice of treating hysteria by isolation
has been developed in civil life, and in very many cases with reference
to well-to-do women living in the lap of luxury. When such persons
develop hysterical symptoms, some sources of irritation in the home
or the social environment are often responsible. By isolation the
patient is removed from the noxious influence of both domestic worries
and mistaken sympathy; his or her whims and fancies are compulsorily
subordinated by self-discipline and consideration for others. At
home it is impossible satisfactorily to enforce such measures and
the attempt to do so will almost inevitably fail, because sympathy,
curiosity and anxiety on the part of various relatives hinder the
attainment of these objects. By isolation the patient is removed from
these unfavourable psychical influences. Through the freedom from
such disturbing stimuli, the abnormally intense reaction of the mind
is reduced. And in many patients of this class the desire to be cured
or to be active, which is produced by the boredom of isolation, works
favourably.[28]
But in most soldiers the circumstances are altogether different. In
the first place, the patient secures the change of surroundings by his
removal from the trenches to the hospital. Isolation, therefore, can
hardly be justified on that score. At the same time, the removal to a
military hospital at any rate should obviate all danger of his being
pestered by foolish relatives and friends with their mistaken sympathy
or excessive attention. And as regards the importance of discipline
and routine, the soldier is in a position very different from that of
the wealthy society lady, for he has already been subjected to such
training.
In some instances, however, just as in the civil cases, the boredom of
isolation may produce the good effects noted above. But there is the
corresponding disadvantage that if you isolate a man and put a special
nurse to look after him it is impossible to convince him that his case
is not serious. It may, indeed, help him to persuade himself that he
is really going insane. As a matter of experience, it is found that
very many men cannot stand isolation for long; they feel that they
must break out, even if they realise that punishment is certain for
doing so. The conversation of patients who are undergoing treatment
by isolation is often perfectly frank about it. They tell the medical
officer they will break out at the first opportunity; that the few
hours of freedom would more than compensate for the punishment which
would come afterwards. Again, it must be apparent that, when the
trouble is due in any considerable measure to the re-awakening of
emotions linked up with some painful earlier experience, isolation
is not likely to be effective in many cases, and may be definitely
harmful. Neither should it be forgotten that such measures fail to
isolate the patient from his worst enemy, himself.
Even in those cases in which it is useful, isolation, if unduly
prolonged, may spoil its own good effects. It may so accustom the
patient to a solitary mode of existence that the presence of other
persons may make him irritable when at the end of his time of seclusion
he is compelled to associate with his fellows.
There is another fact which has to be taken into consideration—and
this applies especially in civil practice, where the patient or his
family have to pay for the treatment. We refer to the expensiveness
of treatment by isolation. Unless it can be shown that it is the
best or the only hopeful method to adopt, the physician must feel
some hesitancy in the majority of cases, in prescribing such costly
measures.[29]
Déjerine and Gauckler[30] have given an admirable account of the use
of isolation in the treatment of neurasthenia and hysteria. They are
careful to point out, however, that even in the case of civilian
patients, with whom of course their treatise is concerned, “isolation,
even accompanied by rest and overfeeding, is never enough.” It is
merely an adjunct, though, under certain circumstances, a necessary
one, of the treatment by persuasion. But “it would be irrational to
look upon the isolation of neuropaths as a therapeutic necessity from
which one might never depart. It only applies to particular cases.”
In proceeding to define the class of civilian patients for whom such
methods are appropriate they emphasise the value of isolation for
those whose troubles are due to, or aggravated by, “a bad family
environment.” In most cases the circumstances of the war-stricken
soldier do not come within the categories which they suggest as
justifying isolation. Moreover, most of the benefits which they
attribute to this therapeutic measure, _i.e._, removal from home
surroundings and from the particular worries and anxieties which have
caused the mischief, are attained (as we have already pointed out) when
the soldier is an inmate of a special—or, in fact, of any—hospital.
When Déjerine and Gauckler proceed to define the different degrees in
which the method of isolation may be practised; _viz._: (1) strict
isolation; (2) absolute isolation from one’s family circle and
environment, and (3) isolation from one’s family circle alone, or from
one’s usual environment alone—it becomes clear that the treatment of
every soldier who enters any hospital inevitably comes within the scope
of categories 2 and 3.
Even when writing of hysterical women these French physicians tell us
that—
“to show how slightly (their) experience has inclined (them) towards
any systematic treatment of the psychoneuroses by isolation,”
isolation has not seemed (to the doctors) to be necessary for “at
least a third of the neuropathic women who have been cared for at the
Salpêtrière. Again, it must be added that, of the patients admitted,
a certain number have been received at the hospital and naturally
submitted to the discipline which belongs to an isolation ward
much more for humanitarian and social reasons than because absolute
isolation seemed to be formally indicated.”[31]
From the completely different nature of the circumstances of the
nerve-stricken soldier and civilian respectively it is clear that
such total isolation can be considered necessary for soldiers only in
very few cases, even though the modified forms of isolation, to which
reference has been made, may be useful for most of such patients. The
important point that emerges from this discussion is the necessity
which is laid upon the physician of determining, in the case of each
individual patient, whether isolation of any kind is desirable, what
form it should take, and especially when it should be used, modified or
discontinued.
_Suggestion and Hypnosis._ We have already touched briefly on the
need for sympathetic firmness and for inspiring the patient with
confidence that he will recover. But such firmness can be useful only
when it is supported by respect for and confidence in the physician.
In most cases such respect can be gained only by acquiring a real
insight into the patient’s condition and by treating him tactfully and
reasonably. It is too often forgotten that the neurasthenic patient’s
continual and intense criticism of himself makes him especially quick
at intuitively becoming conscious of the physician’s failings. Under
such circumstances, if the doctor does not secure the patient’s respect
and convince him that he really understands his condition, the former’s
firmness and confident assurances will avail him nothing: he has
shown his hand; his failure will excite contempt; and the patient’s
intractable, _enlightened_ stubbornness will be fatal to any further
hope of influence on the part of that particular physician.
Ever since mankind first sought help from his fellows for his
afflictions of body or mind, confidence in the efficiency of the
adviser’s ability has been an essential factor in leech-craft. To be
able to convince a patient that he is going to recover and that medical
advice will help towards that end is certainly not the least of the
physician’s qualifications. But unless the assurances given him are
based upon real insight and understanding, the process of securing the
patient’s confidence is not very different from the charlatan’s blatant
boasting. In other words, it is analogous to the confidence trick.
The confidence which is inspired in the patient by his conviction of
the physician’s real understanding of his condition is an altogether
different matter. Such “suggestion” necessarily enters into all
successful treatment and this applies in a very special manner to the
cure of mental ailments.
But the question arises, is it useful or desirable to supplement these
measures of suggestion which are incidental to all human intercourse,
by more positive measures of induced “suggestion” or hypnotism? There
are wide discrepancies of opinion with regard to this matter. And, in
endeavouring to come to a conclusion concerning it, it is important
to eliminate as far as possible the emotional tone which the warm
discussion of this question has aroused in the past.
The positive usefulness of hypnosis in relieving many of the acute
symptoms in recent cases of shell-shock has been fully demonstrated by
the important series of articles by C. S. Myers, in the _Lancet_.[32]
When it is possible by such means to restore to the patient his lost
memory or speech or banish his despondency it often proves that the
only hindrance to the complete restoration of his normal personality
has been removed.
“It may be argued,” to quote Myers’s own account, “that mutism,
rhythmical spasms, anæsthesia, and similar purely functional
disturbances disappear after a time without specific treatment. But no
one who has witnessed the unfeigned delight with which these patients,
on waking from hypnosis, hail their recovery from such disorders can
have any hesitation as to the impetus thus given towards a final cure.
More especially is this the case in regard to the restoration of lost
memories. Enough has already been said here about the striking changes
in temperament, thought, and behaviour which follow on recovery from
the amnesia... The restoration to the normal self of the memories of
scenes at one time dominant, now inhibited, and later tending to find
occasional relief in abnormal states of consciousness or in disguised
modes of expression—such restoration of past emotional scenes
constitutes a first step towards obtaining that volitional control
over them which the individual must finally acquire if he is to be
healed.
Thus the minimal value that can be claimed for hypnosis in the
treatment of shock cases consists in the preparation and facilitation
of the path towards a complete recovery.”[33]
Even if we admit that other measures, such as the administration of
chloroform for the cure of hysterical mutism, may in some cases effect
similar improvements, this should not blind us to the incontrovertible
fact that hypnotism has been proved to be a valuable therapeutic agent
in the early stages of shell-shock.
As a cure for certain patients who have passed the acute stages of
shell-shock or other forms of war-strain, its use requires great
discrimination in the selection of suitable cases and extreme care in
its practice. It is very probable, too, that hypnotic suggestion by
itself should never be regarded as sufficient treatment for these
cases, though undoubtedly it may be of great use as a part of such
treatment.
A view endorsed by some well-known physicians is that all psychotherapy
should be addressed to the functions of consciousness, and that
hypnosis, which is addressed to the functions of automatism, is
therefore undesirable. As a general statement this is undoubtedly true
of a great number of cases, but there occur instances in which it seems
that this sensible rule may be wisely and judiciously broken. In some
cases hypnosis helps in more quickly breaking down resistances, which
occur in patients too beset by their own auto-suggestion and false
beliefs to be able easily to grasp the arguments and persuasions which
the physician may have spent days and weeks in vainly endeavouring
to get accepted. Thus assistance may be sought without in any way
interfering with subsequent treatment of the patient by psychological
analysis and re-education.
The following instance illustrates the use of hypnotic suggestion in
the manner described above.
The case was one of violent spasmodic tremor in the right arm of a
soldier. When in a state of convalescence from a wound and shell-shock
he suddenly encountered his company officer, to whom he was greatly
attached. This officer had lost his right arm since he was last seen
in France by the patient. The shock of suddenly meeting the officer
in this condition set up the man’s tremor. The case came under
psychotherapeutic treatment some weeks later, when the patient, who was
an extremely emotional individual, had lost all hope of recovery. Any
attempt at purposive movements of the right hand and arm threw all the
muscles of the right side of the body into a violent state of jerky
tremor.
Long continued treatment by persuasion failed to effect any improvement
whatsoever. The medical officer in charge of the case therefore decided
to try hypnotic suggestion. This was easily carried out; the hypnotic
state being moderately deep, though the patient was still in touch with
his environment. Hope, courage and assurance of recovery _following
his own effort_, together with determination to make every endeavour,
were suggested to him. The patient was assured at each sitting that
his nerves and muscles would every day respond more and more to his
efforts at self-control. After a very few short sittings the man’s
hopeless attitude became changed to one of hope, effort and attention
in the waking stage, and there was a slight but decided improvement
in his voluntary power. Hypnotic suggestion was then given up, and
the treatment was continued by means of encouragement, exercises and
explanation of his trouble, with the result that two months later he
was fit for discharge from the hospital.
It may reasonably be doubted whether methods of persuasion alone would
have cured this man. In any case, it is clear that it would have taken
a very long time. It is also probable that hypnotic suggestion alone,
if continued, would very quickly have removed the symptoms. It may
be doubted, however, whether it would have effected a permanent cure
in a person so open to auto-suggestion. It seems, therefore, that a
judicious combination of methods was advisable.
We are of the opinion that hypnotic treatment, when used with skill,
discretion, and discrimination, has its place in the treatment of
shell-shock and similar conditions, both in the acute and chronic
stages.
In the majority of cases of some considerable duration, however, and
in practically all those in which the trouble is due to some ante-war
worry or emotion, it may be regarded as provable that hypnosis _alone_
will be of relatively slight use and in many cases may be positively
harmful, for under such circumstances, even with the most favourable
conditions, it would result merely in the removal of symptoms; and the
removal of one may be followed by the appearance of another, which may
even be induced by the process of hypnosis. Moreover, in cases where
there is a tendency to the development of a double personality hypnosis
may have the effect of increasing the risk. Further, if the patient has
sufficient of his own will-power to enable the process of re-education
to be carried out, it is clearly undesirable, both on psychological and
ethical grounds, for the doctor to impress his influence from without.
In considering the possibility of the usefulness of hypnotic suggestion
it is important to bear in mind that various factors may come into play
in impressing an event upon the patient’s memory, or in determining
the effect of the shock from which he is suffering when he arrives
in hospital. In the first place there is the vividness or intensity
of the stimulus; in the second, the degree of recency; in the third,
the frequency of the stimulus; and in the fourth its relevancy. By
the latter is meant the extent to which a given event appeals to
the individual’s past experience, and becomes integrated into his
personality.
A patient who has recently received a severe shock, the effects of
which alone represent the real trouble, without the disturbance of
any antecedent experience, might quite well be relieved by hypnotic
suggestion from sleeplessness, pain, or amnesia; and in some cases
this removal of the acute symptoms which determine the persistence
of the shock effects may lead to complete recovery. A single and
sudden wholly irrelevant experience, such as the bursting of a shell,
which has no relationship whatever to the patient’s past experience,
and produces effects by its vividness and its recency, might quite
well be neutralised by another kind of wholly irrelevant intrusion,
such as hypnotic suggestion. This argument may perhaps be made more
intelligible by a homely analogy. A temperate man walking along the
street might be thrown temporarily into a condition of faintness or
collapse by seeing some ghastly accident, but by taking a “brandy and
soda,” which to such a man would be a wholly irrelevant experience,
the physiological expressions of his emotions might be controlled and
he might be able to proceed on his way, and to overcome completely
the effects of the transitory occurrence. But in the case of a man
who, for example, had been greatly worried by monetary troubles for
a number of years, the “brandy and soda” would not produce anything
more than a temporary alleviation of his troubles. The latter
illustration represents the chronic psychosis which, as Déjerine has
so admirably explained, is quite unsuitable for hypnotic treatment.
But the distinguished French neurologist’s statements do not seem to
apply to the former type of case, due to a vivid recent shock, in the
symptomatology of which troubles before the shock play no part. In
such cases the results of hypnotic suggestion are often brilliant, if
erratic, as is the “brandy and soda cure” for the man who is overcome
by a sudden terrible experience in the street.
There are, however, patients who have not sufficient will-power or
intelligence to be properly re-educated, to whom a certain amount of
suggestion may be of some use.
Those who have used hypnosis in civil practice are aware that in
certain individual cases of long-standing trouble, such, for example,
as chronic alcoholism, hypnotic treatment is of unquestionable value.
Among soldiers suffering from the long-standing effects of shell-shock,
hypnosis may be able in some cases to help in the restoration of health
with an effectiveness that no other method can rival.
Both the danger and the possible usefulness of hypnotism may be
illustrated by an actual case. It is that of a man all of whose
companions were destroyed by the bursting of a shell, and who suffered
for months afterwards from complete loss of memory. A medical man
hypnotised him, and perhaps with undue tactlessness, brought back
the memory of the critical incident at the front, stripped of all
the episodes which led up to or followed it. This excited in him
the most violent emotions, and he became sick with terror; for the
revived incident seemed perfectly real to him, or, as he described
it afterwards, “it jumped up against him,” and for weeks he was so
utterly terrified that he would not go near the doctor. Even though
he could not retain the memory of any other recent events the horror
of that experience seemed to have made him remember his dread of a
particular medical man. But by making use of the information gained
during that revival under hypnosis of an incident unknown to anyone
but the patient, which his amnesia up till then had kept sealed up, it
became possible for another medical officer to bridge the gap between
his memory of previous events and the experiences which the patient was
known to have had in the military hospitals.
In speaking of the results of hypnotic treatment as being brilliant
but erratic, it is important to remember that the same observations
apply to suggestion without hypnosis. For instance, the application of
electricity to the vocal cords in cases of hysterical aphonia affords
an admirable illustration of the treatment by suggestion, even if the
method savours of charlatanism. An excellent demonstration of the part
which psychical factors play in such cases is afforded by the story
of a sailor on the German battle-cruiser _Derfflinger_, recorded by
Blässig.[34]
“A seaman from the _Derfflinger_ was brought into a naval hospital
with loss of voice on Dec. 22nd, 1914, and could speak only in
a whisper. He said that he had always had good health, with the
exception that as a child he had diphtheria, but recovered without
tracheotomy or any complication. His voice had always been clear and
well under control. At the beginning of December he had a slight
cold, which he attributed to sentry duty on deck in very stormy and
wet weather. While in the ammunition chamber of the big guns he was
greatly upset during the firing and suddenly lost his voice. After
fourteen days he recovered his speech. On Feb. 12th, 1915, he returned
to hospital with complete loss of voice, immediately after the
naval engagement in the North Sea. On Feb. 15th he was treated with
electricity, directly applied to the vocal cords, and on March 20th he
was discharged with complete recovery of his speech. But on returning
to duty, as soon as he went on board his ship his voice was suddenly
lost for the third time, and he remained aphonic.”
This is clear evidence of the fact that his trauma was psychical. His
previous history perhaps contains the clue explaining why, in his case,
it was his voice which was affected. The application of the faradic
current was suggestion pure and simple.
In emphasising the limited usefulness and possible danger of suggestive
therapeutics in many cases that are not quite recent, we have not been
referring to that method of suggestion which is involved to a greater
or less degree in all successful treatment of disease—the process of
gaining the patient’s confidence and impressing him with the idea that
he is going to recover.
“The conversational attitude, the familiar manner of talking things
over, the heart-to-heart discussion, where the physician must
exert his good sense and feeling, and the patient be willing to be
confidential” is the method which Déjerine calls ‘psychotherapy
by _persuasion_.’ “It consists in explaining to the patient the
true reasons for his condition, and [for] the different functional
manifestations which he presents, and above all, in establishing
the patient’s confidence in himself and awakening the different
elements of his personality, so as to make them capable of becoming
the starting-point of the effort which will enable him to regain
his self-control. The exact comprehension of the phenomena which
he presents must be gained by the patient by means of his own
reasoning.... The part that the physician plays is simply to recall,
awaken, and direct....”[35]
No one who has not had the experience of guiding mental patients in the
way so lucidly expounded by the French physicians can form any adequate
conception of the remarkable efficacy of these common-sense methods
in restoring to those who are afflicted a normal attitude of mind. It
is certainly saving considerable numbers of soldiers from the fate of
insanity. These methods are not novel, even if the fuller comprehension
of their mode of operation is only dawning upon us now. This point has
been admirably expounded by Déjerine and Gauckler, from whose book we
must quote once more:—
“May we be permitted to quote a few lines in which Bernardin de St.
Pierre has defined, more exactly and better perhaps than we could do,
and with a sort of prescience of what is needed, the very rôle that we
would like to [see our physicians adopt towards their patients].
I wish that there might be formed in large cities an establishment,
somewhat resembling those which charitable physicians and wise jurists
have formed in Paris, to remedy the evils both of the body and of
one’s fortunes; I mean councils for consolation, where an unfortunate,
sure of his secret being kept and even of his incognito, might bring
up the subject of his troubles. We have, it is true, confessors and
preachers to whom the sublime function of offering consolation to the
unfortunate seems to be reserved. But the confessors are not always
at the disposition of their penitents. As for the preachers, their
sermons serve more as nourishment for souls than as a remedy, for
they do not preach against boredom, or unhappiness, or scruples, or
melancholy, or vexation, or ever so many other evils which affect the
soul. It is not easy to find in a timid and depressed personality the
exact point about which he is grieving, and to pour balm into his
wounds with the hand of the Samaritan. It is an art known only to
sensitive and sympathetic souls.
Oh! if only men who knew the science of grief could give unfortunate
people the benefit of their experience and sympathy, many miserable
souls would come to seek from them the consolation which they cannot
get from preachers or all the books of philosophy in the world. Often,
to comfort the troubles of men, all that is necessary is to find out
from what they are suffering (_Etude de la Nature_, 1784).”
Déjerine and Gauckler add:—
“One could not express any better, or any more directly, what we never
cease to maintain, however lacking in science it may seem at the
first—namely, the real therapeutic action of kindness.
Liberated morally, and having regained consciousness of self,
and freed in addition from his functional manifestations by the
appropriate processes ... the patient is cured. He is cured from
his actual attack. But his mental foundation, his psychological
constitution, still remains in the same condition which permitted
him under emotional influences to become a neurasthenic. The rôle of
the physician is, therefore, not ended. He must still build up his
patient’s life, still practise prophylaxis, and get the patient into a
condition where his character will be established.”[36]
_Rational Treatment._ So far in this chapter we have been discussing
what may be described as general methods of treatment, which do not
_necessarily_ involve any attempt to probe into distinctive individual
symptoms and to discover the real fundamental cause or causes of the
trouble. The measures so far considered are empirical rather than
rational. But they are the only methods of treatment discussed in most
of the text-books.
It is an axiom in medicine that correct diagnosis is the indispensable
preliminary to the rational and intelligent treatment of disease. This
fundamental principle is universally recognised in dealing with bodily
affections; but it is the primary object of this book to insist that
_it is equally necessary to observe the same principle in the case of
mental illness_.
It may seem ironical to stress this elementary consideration, but it
is notorious that accurate diagnosis is too often ignored in cases
of incipient mental disturbance. It is idle to pretend that such a
procedure is unnecessary, or to urge in extenuation of the failure to
search for causes that many patients recover under the influence of
nothing more than rest, quiet, and ample diet.
Many mild cases of illness, whether bodily or mental, may and do
recover even if undiagnosed or untreated. But on the other hand many
mild cases get worse; and it is the primary duty of the physician
correctly to diagnose the nature of the trouble and to give a
prognosis—to decide whether the illness is mild or severe. Some of the
most serious cases of incipient mental trouble are those of patients
who do not seem to be really ill, and are easily overlooked by a
visiting physician. They are quiet and inoffensive and display no
obvious signs of the insidious processes that are at work in them. But
all the time they may be, and often are, brooding over some grievance
or moral conflict, worrying about their feelings, misinterpreting them
and gradually systematising these misunderstandings until they become
set as definite delusions or hallucinations. If, acting on the belief
that it is bad to talk about a patient’s worries, the physician leaves
such a man alone, he is clearly neglecting his obvious duty. For the
whole trouble may be due to some trivial misunderstanding which he
could easily correct.
In the severer forms of mental disease, precise diagnosis is even more
intimately related to treatment than in the case of bodily illness.
For when a patient’s illness is recognised as some bodily affliction,
such as pneumonia or appendicitis, certain general lines of treatment
are laid down as soon as the appropriate label has been found for
the complaint, though, in the case of the latter illness, there is
added the further problem of whether or not surgical interference is
indicated.
In cases of mental disturbance, however, the general lines of treatment
cannot thus arbitrarily be determined merely by finding an appropriate
label. It is true that as in the treatment of bodily disease, certain
general principles must be observed, such as the provision of
abundant and suitable food, and the protection of the patient from
all disturbing influences. But the essence of the mentally afflicted
patient’s trouble is some particular form of anxiety or worry which
is _individual and personal_. The aim of the diagnosis, therefore,
should be not merely to determine the appropriate generic label for
the affliction, but rather to discover the particular circumstances
which have given rise to the present state. The special object of the
physician should be to remove or nullify the exciting cause of the
disturbance; and in order to do this it is essential that he should
discover the precise nature of the trouble. The diagnosis, therefore,
must be of a different nature from that demanded in case of physical
illness, where the condition may be adequately defined by some such
generic term as “lobar pneumonia” or “acute appendicitis,” and its
gravity estimated by the general condition and physique of the patient.
In the case of mental trouble, the physician has to make an individual
diagnosis, based not only upon an insight into the personality but also
into the particular anxieties of each patient.
But even when it is recognised that exact diagnosis of the particular
circumstances of each individual patient is essential, if the trouble
is to be treated rationally and with insight, there still remain many
difficult problems as to procedure.
Amongst those whom experience has convinced of the efficacy of
psychological treatment for this class of case, there are indications
of a divergence of opinion in the matter of procedure. Some believe
that it is sufficient if the medical man has discovered the real cause
of the trouble and explained it to the patient. Other workers look upon
a preliminary psychical examination merely as a means of diagnosis,
the unveiling of the hidden cause of the trouble; and consider that
the treatment should be the laborious and often lengthy process of
re-educating the patient, and so restoring to him the proper control of
himself. It is of the utmost importance to emphasise the undoubted fact
that those who maintain either of these views to the exclusion of the
other are committing a grievous and dangerous error, for there is no
sharp line of demarcation between the two procedures.
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.
[28] This explanation of the reasons for the use of isolation is taken
from Mohr’s article in Lewandowsky’s _Handbuch der Neurologie_.
[29] As Sir Clifford Allbutt has pointed out (_op. cit._, p. 158).
[30] _The Psychoneuroses and their Treatment by Psychotherapy_,
translated from the French by Jelliffe, 2nd Edition, 1913, p. 311.
[31] _Op. cit._, p. 315.
[32] Feb. 13th, 1915 (p. 316); Jan. 8th, 1916 (p. 65); Mar. 18th, 1916
(p. 608); and Sept. 9th, 1916 (p. 461).
[33] _Op. cit._, p. 69.
[34] _Münchener Medizinische Wochenschrift_, June 15th, 1915, p. 335.
[35] Déjerine and Gauckler, _op. cit._, p. 283.
[36] _Op. cit._, pp. 302-3.
CHAPTER III.
Psychological Analysis and Re-education.
The methods of treatment which have been described in the foregoing
pages: sympathy, firmness, isolation, suggestion in its various forms,
and hypnosis; while all useful in their proper place, often prove to be
of no avail in cases of psychoneurosis. Where the distressing symptoms
lie on the surface so that both they and their causes are easily
discoverable by the physician—if, indeed, they have not been known
from the beginning, to the patient himself—it is sometimes possible
to bring about a complete cure without any very penetrating analysis
by the doctor of the mental antecedents of the patient’s present
condition. Thus, for example, a courageous and keen soldier who,
suffering from loss of sleep and from the harassing experiences of the
battlefield, eventually breaks down, the precipitating cause perhaps
being shell-shock, may need little more to set him on his legs than the
comfort, assiduous attention, and pleasant distractions of a Red Cross
hospital. For the civilian whose chief trouble is the irritability
caused by a multiplicity of minor business worries, or family jars, a
few days of isolation, giving perhaps, among the other benefits which
we have mentioned, the opportunity to think things out, may have
excellent results. The beneficent action of hypnosis in removing the
acute disturbances caused by shell-shock has already been illustrated.
But a large number of cases fall into none of these categories.
Sympathy merely annoys them, isolation tortures them, for besides
letting them think—usually in a very unwise way—it helps to confirm
their impression that they are seriously ill, just because it involves
the treatment of them as special cases. Suggestive measures may be to
them like water on a duck’s back, and hypnosis may prove of no avail.
Firmness may have merely the effect of proving to the doctor that
there exist patients firmer than himself. But, fortunately, psychical
methods are not exhausted. There still remains at least one—that of
psychological analysis and re-education.
The employment of psychological analysis in medicine means the
resolution of the patient’s mental condition into its essential
elements, just as by chemical analysis it is possible to determine
that water, for example, is composed of certain definite proportions
of oxygen and hydrogen combined in a particular way. Re-education is
the helping of the patient, by means of the new knowledge gained by
analysis, to face life’s difficulties anew.
It is sometimes urged that if this be all that is meant by
psychological analysis, alienists have been doing this ever since
insanity was first treated, nay, further, doctors have been practising
it since the time of Hippocrates. It is pointed out that when a patient
is first interviewed by the physician, an inquiry is always made into
his mental state and behaviour, and into the presence of delusions and
hallucinations or other unusual mental phenomena. His relatives are
questioned concerning the relation of his recent behaviour to that
at the time when he was considered normal. Now the answer to this
assertion is that such an investigation is useful, indispensable in
fact, but it cannot be called psychological analysis.
The point may become clearer to the untechnical reader if he will
imagine for a moment that a carver, skilled in separating the legs and
wings from the body of a bird, should claim to be practising anatomy.
The anatomist would at once object that while such separation of
limbs from trunk is a small detail which sometimes forms part of the
anatomist’s task, it can scarcely be called more than a preliminary to
his study. For first of all, while to a carver a leg is an ultimate
unit, to the anatomist it is, for the naked eye, a collection of
bones, muscles, tendons, skin, nerves, veins, arteries, nails and the
rest, and, seen through the microscope, a tremendous organisation of
infinitely more complex structures. Furthermore, it might be pointed
out that merely to separate these more minute structures into their
constituent parts and to name them, by no means constitutes the whole
of the work of the intelligent anatomist. He wishes to study the
inter-relations of these parts, the way in which they work together for
the common good of the leg. And lastly, the leg must not be studied
only in separation from the trunk, for its functions are subordinate to
the requirements of the body as a whole.
So, in the same way, to record that a man is suffering from a delusion
of persecution or an unreasonable fear of open spaces is merely
to “carve up” the condition of his mind. First of all it must be
ascertained how far that delusion has interpenetrated with the rest of
his mental life; whether, for example, his false belief is restricted
to a specific kind of persecution from a particular person, or is a
general delusion that everybody and everything in the world is against
him. And again, if the delusion is strictly specific, it is important
to know whether it has been the cause of secondary false beliefs,
produced by rationalisation, to buttress the primary delusion against
the inevitable contradiction from facts which it would otherwise
suffer.
Further, the nature of the delusion must be analysed. Why is it of this
and not of that persecution? Why is this particular person feared or
hated? Is it a constant factor in the patient’s existence, or does it
break out at certain times? If so, the patient’s life at these critical
periods must be carefully examined. The doctor must discover where the
patient was at the time, what he was doing and thinking, who were his
companions, and so on.
Next comes the important inquiry into the history of the delusion. And
here, just as the anatomist is able nowadays to mobilise for service
all his knowledge of comparative anatomy and evolution, so if the
physician has really scientific knowledge, not only of the delusions
in other patients, but also of the development of ordinary beliefs in
sane people,[37] he will be immensely helped in his search, and may be
enabled thereby to make many short cuts to the essential facts. He will
endeavour to date the important stages of development of the delusion;
to find a time when, so far as the patient knows, his mind was free
from it.
Thus we may say that a psychological investigation of a case of mental
disorder dissects its normal as well as its abnormal phenomena into
their functional elements. Compared with the procedure which merely
records such gross units as delusions or hallucinations, it is as
anatomy to mere carving, however skilful the latter may be.
But the psychological investigation is not merely comparable to
anatomical dissection. We have also compared the mind to a chemical
compound, rather than a mechanical mixture. Especially is this true not
only of the normal but also of the abnormal mind, when the latter has
had time to settle down into its new position of relative equilibrium
and integration; when, for example, a delusion has become so fixed
that the patient’s life is entirely ordered in obedience to it, and
he has ceased to have any doubts as to its reality or to struggle
against its domination.[38] It is only when the warring elements in
the mind are relatively independent, and before they have succeeded in
“making terms” with each other, that the mind even remotely resembles a
mechanical mixture. It follows, therefore, that psychological analysis
of a case of mental disorder is usually comparable to _chemical
analysis_ as well as to anatomical dissection.
Now the most striking result of chemical analysis is to show that the
appearance and general properties of the elements composing a compound
are different from the appearance and properties of the compound
itself. This is exactly the case, too, with mental analysis. A mere
dissection of an abnormal condition is sometimes sufficient in the
milder cases to serve as the basis for curative measures,[39] but in
more advanced cases, or those of longer standing, real analysis is
necessary in order to get at the unknown factors.
It is just at this point that a number of investigators of mental
disorder decline to go any farther on the path of research. Up to this
stage, they say, one is relying upon ascertained facts, for one has
the warrant of the patient’s own memory for the data obtained. Further
analysis of a mental phenomenon must inevitably involve appeal to
unconscious factors. And, once one has called in the unconscious as a
means of explanation, psychology becomes a mere “tumbling ground for
whimsies.”
Probably there are few people to whom this statement does not appear
to express the universal verdict of common sense. That is precisely
what it does. But it should be unnecessary to point out that common
sense alone is not always the most reliable guide to the discovery of
fact. Unaided common sense not only informed men for centuries that
the sun moved round the earth, but told them so with such finality and
conviction that extraordinarily unpleasant consequences ensued for
those who did not believe in such an obvious fact. And the old belief,
wholly false as it is, has still to be unlearnt by every child.
In the same way, the ‘common sense’ point of view which we have
described is not flawless. It assumes that a patient is able not only
to surmount the great difficulties of translating his experiences
and beliefs precisely into words—a difficult task even for the
well-educated person—but also to account for and explain them
truthfully.
It may, however, be pointed out that, though this last-mentioned
misleading assumption is widespread, it is by no means so universal
or so tenacious in man as the “belief of his own senses” that the sun
goes round the earth. In fact, quite apart from the teachings of modern
psychology, we frequently find well-founded suspicions in the lay mind
that a man is not always competent to give the basis of and reasons for
his mental condition. This view is summed up in the famous advice to
the future judge, “Give your decision, it will probably be right. But
do not give your reasons, they will almost certainly be wrong.”[40]
What ordinary man, unversed in the subtleties of theology or
comparative religion, could give to an agnostic a satisfactory account
of the reason why—being let us say, a Christian, and a Protestant
Christian—he is a Primitive Methodist or an English Presbyterian? Let
us complicate the matter further by supposing that this sect to which
he now belongs is not that in which he was brought up by his family!
Many of the factors which have contributed to his present religious
beliefs may have been entirely forgotten now, recallable only with the
greatest difficulty[41] and with the help of a second person skilful in
such investigation.
We may take as a good example of the historical complexity of
significant attitudes and actions in life, the process of falling in
love—especially if it is not, or at least seems not to be, love at
first sight. It is generally admitted that, in the development of this
psychological phenomenon, onlookers see most of the game. In other
words, the actions of the two persons who are gradually becoming more
and more attracted to each other are partly determined by motives,
which, unknown to them, are patent to their observant relations and
friends.
Further examples may be given to illustrate this important and
oft-disputed point. Let us suppose that a musical critic, after
hearing a new symphony by an unconventional composer, immediately
writes a lengthy appreciation of the performance. It is clear that
nobody would expect him to be able to give, off-hand, an account of
his reasons for every sentence of the criticism. But it is obvious
that a single phrase in this account may be but the apex of a whole
pyramid of memories emanating from the critic’s technical training,
his attitude towards the new departure, experiences highly coloured
with emotion which a few notes of the music may have evoked, and his
mental condition at the time he heard the performance. Nobody denies
that these may have shaped or even determined his criticism. But who
believes either that they were all conscious at the time of writing
the article, or that he could resuscitate them without much time and
trouble and perhaps the help of a cross-examiner?
Again, there are occasions when society expects that a man shall be
unconscious of the reasons for some of his actions. He is expected, for
example, to behave politely, attentively and chivalrously to ladies,
not because at the moment of taking the outside of the pavement he
remembers why he does so, but simply because he has been brought up in
this way. And conversely, too conscious politeness in a man arouses in
others—and often rightly—the suspicion that it is a recent acquisition.
We see then that it is rare for a man to be able to give a true
account, even to himself, of the reasons underlying his important acts
and beliefs, when his mental condition is relatively calm and his
social relationships are normal. But when a case of mental disorder is
in question it becomes quite obvious that the patient is frequently
not in a position to give, either to himself or to another, anything
like a complete or true enumeration and description of the antecedent
experiences which have brought about his present condition.
It therefore becomes necessary to admit that unconscious factors of
great importance may play an influential part in the production of
mental disorder and that, therefore, some way must be found of tapping
these submerged streams.
The most direct way into the complexities of the unconscious mental
processes of a person is afforded by a study of his more “unusual”
actions and thoughts. For few persons are so completely adapted to
their environment or so perfectly balanced that moments never arise in
which their mental behaviour is not surprising, either to themselves
or to others. And even the Admirable Crichtons of our acquaintance are
not entirely immune from errant moments—at least in their sleep. The
dream, then, is the chief gate by which we can enter into the knowledge
of the unconscious. For in sleep, the relatively considerable control
which most of us in waking life possess over the coming and going
of mental events is almost if not entirely abrogated. Thoughts and
desires, which, if they attempted to dominate consciousness in waking
life, would be promptly suppressed, arise, develop and expand to an
astounding extent in the dream.
This statement, of course, is entirely independent of the implications
of any one “theory of dreams.” Its truth is evident to anyone who has
honestly recorded or considered his own dreams for even a short period.
Other unusual mental processes are manifested in such events as “slips
of the tongue,” “slips of the pen,” the mislaying of important objects,
the forgetting of significant facts, or conversely the inability to
get an apparently unimportant memory out of one’s mind. All these
phenomena, common enough in the normal individual, are usually more
frequent in the abnormal mind. Besides the patient’s voluntary account
of, and comments upon, these events,[42] other methods of obtaining
data are possible to the physician. He will note the matters about
which in conversation the patient is apt to become silent, embarrassed
or inexplicably irritated, to hesitate, to say he has forgotten, or
even to lie. All these sidelights upon the mental make-up are carefully
noted by the physician and the deductions from them compared, not only
with the patient’s accounts of himself on different days—narratives
which when put together may show important discrepancies and thin
places—but also with the information obtainable from his family. These
devices serve to bring to light in an extraordinary manner a whole
number of memories, many of them of immense significance for the
comprehension of the patient’s present mental state, which it would
be utterly impossible to discover in mere conversation or even by
cross-questioning.
It is sometimes felt that these methods which savour strongly of
catching the patient tripping, while they may unearth some interesting
details of his past life, do no more than exhibit under a strong
magnifying glass a few minute excrescences upon his otherwise fair
mental countenance. But it should be pointed out that nobody who has
ever honestly collected together and compared the memories which have
coalesced to compose a dozen of his dreams—especially if he has done
so with the help and under the cross-examination of a candid friend
who knows him well—will maintain that the material thus found is
unimportant. As Professor Freud says, “The dream never occupies itself
with trifles.” It is probably just because the thoughts and desires
underlying the dreams have been refused their normal outlet, that they
express themselves in such bizarre forms.
Moreover, the fact should not be overlooked that in other
sciences—including the most exact, the physical sciences—the most
profoundly important general conclusions are often arrived at by the
examination of unusual phenomena, of nature “caught tripping.” The
study of the thunderstorm was the foundation of our present knowledge
of that great force which is active not only in thunderstorms but
throughout all matter. Observation of the sporadic and relatively
unusual volcanic eruptions of the mind may prove to be an important
foundation of our future knowledge of general psychology. As in the
inorganic, so in the organic world, there is no sharp line dividing
normal from abnormal, and the unusual phenomenon is sometimes simpler
and more easily studied than the usual, as “Sherlock Holmes” was so
fond of demonstrating.[43] From a scientific standpoint, then, we
have every justification for pressing to the utmost our study of the
unusual mental phenomena exhibited by the patient, and for our belief
that their nature is not unimportant, but highly significant for
therapeutical purposes.
Another objection, however, is frequently levelled against such a
procedure, from quite a different direction, or rather from a number
of directions. This objection can be expressed simply in words, such
as “One ought not to probe so deeply into a patient’s innermost mental
life,” and is not to be met by a single argument. The reason is that it
is polyhedral in form, and that each of its faces or aspects must be
considered separately. For it should be obvious to everyone that such
an objection cannot be flippantly waved away.
The aspects of this question which seem to have more particularly
appealed to the critics of the method which we are describing, are at
least four in number, which we may describe as the æsthetic, social,
medical and moral.
The origin of the first, the æsthetic aspect, is easily seen. It is
quite clear that in the investigation of the inmost secrets of a
person’s life (and particularly of a life which has become so entangled
and complicated that the help of another is sought for its restoration
to ‘mental tidiness’) there must emerge frequently much that the
patient finds unpleasant to relate. When we remember that a neurosis
often (perhaps always) occurs as a result of the patient’s inability to
adjust his instinctive demands to the opportunities of his environment,
it becomes clear that in the investigation of his history discussion
is inevitable of mental events in which the fundamental instincts have
played a great part. Now, of those important instinctive impulses, it
is obvious that in a civilised community few are so often thwarted,
deliberately repressed, or otherwise obstructed as the powerful one
of sex. It therefore follows that in a large number of cases the
discussion of sexual matters becomes unavoidable. Some critics have
seized on this point as the weak spot against which to launch their
attacks, descanting upon the unpleasantness, even the nauseousness, of
such discussion. Not all of them, however, make it clear whether in
their opinion it is the patient or the doctor who should be shielded
from such unpleasant experiences. If the latter, the verdict of society
would probably be that the sooner a man requiring such protection was
excused not only from these uncongenial duties, but from all medical
obligations whatever, the better for the community. If the former, it
may be pointed out that every reasonable person will agree that the
man who does not tell the whole truth to his doctor or his lawyer is a
fool. Furthermore, even under present conditions, if it be considered
advisable in the interests of the patient’s bodily health, the doctor
does not hesitate to ask, and the patient to answer, questions about
the most intimate matters, some of them literally and not merely
metaphorically nauseous.
We may therefore dismiss the æsthetic objection as unworthy of the
consideration either of a conscientious doctor, or of a reasonable
patient.
We may turn now to what we have designated the social aspect of the
objection. It should need little explanation. There has arisen a
convention, subscribed to consciously or unconsciously by many, that
the doctor shall ask and the patient answer quite freely questions
relating to the patient’s bodily well-being, but that any unusual
mental occurrences must be considered the patient’s private affair into
which it is not the business of the doctor to pry.
It would be rash to deny that up to a certain point this convention
is susceptible of defence. But, carried too far, it is productive
of disastrous results. Moreover, it is impossible for a doctor to
treat many varieties even of physical disease without becoming to a
great extent the confidant not only of the patient but often of his
family. And there is no doubt that the present unwritten law that the
doctor should confine himself to the patient’s physical ills is often
judiciously disobeyed by very many successful practitioners. Yet it
must be recognised that the convention exists, and like all social
usages is extremely tenacious.
The chief medical objection, which we shall now consider, is usually
expressed in some such form as the assertion that “it makes the
patient worse to talk about his worries” and that one should rather
“try to make him forget them.” Let us examine these statements, both
of which contain a certain amount of truth, but if applied without
qualification to serious cases of incipient mental disorder can by
their respective negative and positive tendencies do an incalculable
amount of harm. They are often the result of applying experience
acquired by the successful reassuring of a certain type of “malade
imaginaire,” to the consideration of far more complicated cases in
which such easy and straightforward treatment is impossible. A man,
let us say, visits a doctor and confesses to him his fear that he is
suffering from some organic disease. The physician after a careful
examination proves to the patient by objective means that there is
nothing the matter with him; the sufferer is reassured and returns to
his daily business and in due course forgets about this worry or ceases
to be troubled by the memory of it. Here the diagnosis, treatment,
and cure may be uncomplicated and “on the surface.” But even here it
should be emphasised that in one sense, far from “making the patient
worse” to talk about his trouble, the talking about it was the _sine
quâ non_ of cure; otherwise the doctor would never have known of the
fear. In another sense, however, talking about the trouble did make the
sufferer worse—but for a short time only, during a confession of his
apprehensions, or perhaps even for a few days, if more than one visit
to the consulting room were necessary before the doctor’s verdict could
be obtained.
But not all visits to the doctor end so briefly or so easily as this.
The patient’s trouble, on examination, may prove to be organic and
of long standing. Does the doctor consider then that it is his duty
to emulate the Christian Scientist or to “make the patient forget
it?” On the contrary, he does not flinch from the employment of the
most searching methods of investigation, lengthy and often painful
treatment, and, if it seems necessary in the patient’s interest, he
will carry out or arrange for operative interference which may be
difficult, expensive, by no means free from danger, and is quite likely
to “make the patient worse,” perhaps for a considerable time, before
its beneficial results appear.
It is therefore idle to argue that on the one hand psychological
methods of treating mental disorder are unnecessary because some
patients get better without their application; while, on the other,
they are dangerous because they may make a patient worse. The same
remarks could be applied to most of the successful operative methods of
present-day medicine. All of them are fraught with grave potentiality
for harm if applied by unskilled persons.
The degree to which the doctor is medically justified in probing the
patient’s intimacies is obviously dependent upon the individual case.
Not all patients require such drastic incisions; a fact which has been
clearly shown in the special military hospitals. An intelligent man
of strong will, whose social relations have hitherto been normal and
happy, might be temporarily “bowled over” by the emotional stress of
the campaign, but after a few inquiries into the causes of his mental
anguish and a few explanations, he is often set on his feet again.
We must not forget, however, the other side of the picture. There are
many patients, who, far from being made worse by the confidential
recital and discussion of their mental troubles to a suitable person,
experience great relief as a result of this unburdening. Men in the
military hospitals have expressed this over and over again, in such
phrases as, “I have been bursting to tell this to someone who would
understand,” or, “I have seen many doctors since I left the front,
but you are the first who has asked me anything about my mind.”
Frequently the troubles prove to be caused by their ignorance of the
great individual differences in minds, so that the appearance in them
of a new but by no means pathological mental phenomenon frightens them
unduly. We have already referred to cases of this kind in Chapter
I.[44] Another frequent cause of the most intense and continuous mental
anguish is the exaggerated self-reproach which the patients attach to
some real, but in the judgment of others, comparatively trivial defect
or delinquency in themselves. To borrow an expressive phrase, the
neurasthenic has “lost his table of values.” It is in such cases that
a talk with a tactful, sympathetic, broad-minded physician may produce
the happiest results.
To assume that one can make the patient forget such worries as these
without first discovering what they are, is obviously fatuity at its
grossest. Moreover, as we have seen, it is quite insufficient merely
to discover that the patient is “suffering from hallucinations” or
delusions and then to tell him to dismiss them from his mind. To
suppose that, without understanding the nature of and the specific
reasons for the development of a particular hallucination, one can
“make the patient forget” his interpretation of a real experience which
has appealed to him night and day for weeks, or banish a delusion which
is gradually becoming systematised and rationalised—_i.e._, intimately
interwoven into the tissues of the whole of his experience—is an
assumption which has no foundation in fact.
The point cannot be too much emphasised that many of these patients are
quite sane, if conduct be regarded as the criterion of sanity; but
they are growing afraid of the appearance of these abnormal phenomena,
and take them for signs of incipient—or, more usually perhaps, of
established—insanity. Hence follows the important corollary that while
treatment by isolation has obvious advantages in certain cases, in the
particular group of patients which we are now discussing it is often
dangerous, for the reasons already emphasised in the last chapter. The
presence of such mental phenomena is usually confided to the physician
only after great hesitation, and such worrying experiences are common
in cases of insomnia and other disorders, which, though troublesome,
do not appear to be grave. It is therefore possible that isolation may
have serious effects in many cases in which its net result seems merely
to be that the patient is no better.
It is granted then that in some instances (by no means all), the
patient may be temporarily pained by the dragging into daylight of the
causes of his worry, but it is usually a case of _reculer pour mieux
sauter_. This procedure is often inevitable in the medical treatment of
many disorders which have become complicated to any considerable extent.
We pass now to a difficult task; the consideration of the moral
objections to the procedure of psychological analysis. The difficulty
obviously lies in the circumstance that, while in the discussion of the
other objections one could continually point to facts upon which at
least, the great majority of civilised people are in cordial agreement,
such unanimity is not so complete upon moral questions. Some of the
varieties of the moral objection, however, are not based on such
disputable grounds. For example, there is the argument that it is bad
for the patient that he should have his inmost mental life dissected
and analysed in the thoroughgoing way which we have described, since
it is important for the preservation of his self-regard that, as far
as possible, he should consider himself “master of his soul.” With the
latter sentiment no reasonable person would quarrel. And where it is
possible (as it often is) for a slight mental tangle to be straightened
out without an extensive and lengthy inquisition, we hold that it is
urgent in the patient’s interest that his privacy shall be respected.
It should be pointed out, however, that since this procedure is equally
in the interests of the honest physician—for it will save him time and
trouble—it is likely to be adopted wherever possible. In the special
military hospitals, for instance, it was often found unnecessary, in
mild cases, to press the inquiry very far; the patient “learning his
lesson” successfully at an early stage of the proceedings.
But it obviously does not follow that the fact of a man having for very
sufficient reasons, admitted the physician into his confidence, must
necessarily bring as a consequence a diminution in his self-respect. On
the contrary, he often emerges from such an examination with increased
confidence and a better opinion of himself, especially if, as so
often happens, his self-reproaches have been unfounded. The civilised
world contains a relatively large proportion of people who habitually
confess their shortcomings to priests. One may recognise that the
confessional has its defects, but the assumption that to have recourse
to it inevitably promotes mental flabbiness is obviously unfounded.
The business man who, when faced with the necessity of successfully
meeting an entirely new situation, consults his legal adviser, is not
usually blamed for his lack of self-reliance. Conducting one’s own
legal transactions, like doctoring oneself, may appear (to the vulgar)
to show independence, but its results are not always happy.
It is therefore perfectly fair to claim that none of the arguments
against the use of psychological analysis have any very great
significance. In some cases, however, they express valuable reminders
that this delicate and powerful instrument, like all others with these
attributes, must be used with care and discretion.
We may now proceed to take stock of our present position and briefly
to summarise the contents of the foregoing remarks. Many cases of
“functional nervous disorder” or “neurosis” exhibit as their most
important characteristics symptoms, the underlying factors of which
are demonstrably _mental_. A neurosis may be regarded as the failure
of an act of adaptation.[45] The resultant mental disturbances do
not seriously affect the “reason” or the “intellect” as was formerly
supposed, but are in character predominantly instinctive and emotional.
The neurotic’s behaviour in the face of an insurmountable difficulty
presents a considerable resemblance to that of a child. The reasons why
this analogy is not always obvious (though often it is quite plain) is
that while in the child one can usually appreciate the cause of the
emotional disturbance and watch its progress, these possibilities are
often excluded in the case of the civilised neurotic adult. Both his
insurmountable difficulty and the historical circumstances which have
made it unconquerable may (they do not always) lie within his inmost
mental life. Further, the child’s difficulty usually is caused simply
by his inability to adjust himself to his environment; or perhaps more
often to adjust his environment to himself. The adult neurotic, on the
other hand, adds to these difficulties the further significant one of
a lack of inner harmony. There are warring elements inside as well as
outside him: he is trying to fight the enemy with an army which has
mutinied.
It follows then that any attempt to restore equilibrium between
himself and his social environment must be accompanied by a similar
endeavour to bring about his inner harmony. Therefore, in such cases,
a certain amount of psychological analysis is indispensable. Without
such investigation the application of physical or psychical methods of
treatment must inevitably be a shot in the dark.
The task of psychological analysis is rendered difficult by the fact
that not all the motives of the patient’s present beliefs, attitudes
and actions are conscious; the entry into consciousness of some of
the unacceptable motives and memories is obstructed by various mental
processes. When the action of these shielding mechanisms has been
subverted by various means the real significance and history of the
patient’s present mental condition becomes clear to him. In the light
of this new self-knowledge he begins to cure himself. In a few cases he
may require little or no subsequent assistance, but usually a process
of re-education[46] is necessary. He may still require to be helped
over some of the obstacles which he meets, and he may need more or
less frequent encouragement and advice to an extent determined by his
disposition, temperament, and character. By these means he is “freed
from himself,” liberated from the exaggerated emotional tone which has
become attached to so many of his memories, and so enabled to face life
anew with a harmonious and integrated mind.
The procedure which we have discussed is precisely that which the
sensible mother adopts towards a child who exhibits sudden and
unreasonable fear, anger, or any socially undesirable emotion. The same
method is adopted towards the man who, having muddled his financial
affairs, appeals for advice to an experienced and judicious business
friend. “Firmness”—of the unsympathetic and unintelligent order—may
occasionally produce good results in both these instances, but usually
it only makes matters worse. Paying for the commercial muddler a few
of his chief debts may remove his embarrassment for the time, but if
unaccompanied by an attempt to reform his business methods, the result
will usually be merely that such a treatment will enable him to incur
fresh liabilities. So it is when a symptom or set of symptoms in a
neurosis is unintelligently removed: new troubles frequently break out
in fresh places.
We believe that there exist and can exist no serious arguments against
the procedure of psychological analysis and re-education which we have
just described. But now we come to speak of a procedure introduced
during the last few years which has certainly not escaped criticism
both of the most flattering and the most hostile kind. This is the
method of “psychoanalysis” which we owe to Professor Sigmund Freud, of
Vienna, who developed it as an extension and elaboration of the pioneer
work of his former master, Professor Pierre Janet[47], of Paris.
Perhaps few terms in medicine have aroused so much misunderstanding,
so much criticism, well-informed and ill-informed—and so much enmity
as this word “psychoanalysis.” This latter fact alone, however, should
not prejudice the reader for or against it. He will probably remember
that it is the exception, rather than the rule, for an innovation to be
received without hostility, not only from the general public, but also
from experts who work in provinces bordering upon the field in which
the new method is introduced.
It should be pointed out that much of the heated discussion which has
raged around this word psychoanalysis is due to the fact that the
term has different meanings, as used, not only by its enemies, but by
its friends. Psychoanalysis, according to Dr. Jung, is a _method_;
“a method which makes possible the analytic reduction of the psychic
content to its simplest expression, and the discovery of the line of
least resistance in the development of a harmonious personality.”[48]
Psychoanalysis is therefore a method of psychological analysis. Why,
then, have we not used the term psychoanalysis in the earlier part of
the book? It was purely to avoid unnecessary and acrimonious discussion
on any particular doctrinal aspect of the question which this term may
be taken to imply.
It is clear to every thinking person that, in analysing a mental state
the physician should use every legitimate means at his disposal. If
these means include, as they do, the valuable assistance derived
from the study of the patient’s dreams, his “associations” whether
free or constrained,[49] and other mental phenomena, the doctor may
use them freely without thereby subscribing to any one “doctrine of
psychoanalysis.”
The term psychoanalysis has been widely applied, not only to the
diagnostic method, but also to the theories which underlie and
determine the subsequent process of re-education. This seems to be a
misuse of the useful word “analysis.” It may be objected that in all
scientific analysis there is some directive hypothesis to be confirmed
or disproved, and that in this sense all analysis is based on theory.
This is true, but it seems inadvisable to confuse the analytic process
with the theory which directs one form of it.
When we come to consider the theoretical presuppositions which underlie
the different methods of re-education adopted by various physicians,
it is not surprising, at this early stage of our knowledge, to discover
differences of opinion. The physician will find at every step that in
“tidying up” the disentangled functions of the patient’s mentality he
will need not one theory but many, for his problem is life itself.
All his own human sympathy, with its indispensable basis, a knowledge
of his own strength and weaknesses, all his learning in physical
science and psychology, all his knowledge of morality and religion
must be available for immediate and efficient use. In one interview
he may have to lay down the law for the benefit of some ignorant and
distressed patient who is desperately anxious to follow his advice
unquestioningly; in the next he may be at close grips with a mind more
flexible and independent than his own, knowing well that his every
little victory must be consolidated, and that every position won may
be subsequently counter-attacked by his patient. He must be ready to
suggest, discuss, persuade as the time and the conditions indicate.
While, therefore, the ultimate lines on which an ideal diagnostic
analysis and curative re-education will be possible are as yet
undefined, it would serve no good purpose in a book of this length to
raise discussion on the question of psychoanalysis. Its future will
be settled, not in the heated atmosphere of the debate, not in the
acrid polemics of the correspondence columns, but in the calm, careful
examination by the individual worker of his own actual findings and the
honest comparison of them with those of others.
FOOTNOTES:
[37] Such development involves a complicated set of processes the
nature of which is by no means obvious to unaided common sense.
[38] “... for example, a patient may maintain that he is the king, but
that an organised conspiracy exists to deprive him of his birthright.
In this way delusions are sometimes elaborated into an extraordinarily
complicated system and every fact of the patient’s experience is
distorted until it is capable of taking its place in the delusional
scheme.” Bernard Hart, _The Psychology of Insanity_, Cambridge, 1914,
p. 32.
[39] _Cf._ p. 15_f._
[40] _Cf._ Hart, _op. cit._, p. 66_f._
[41] The reader may pass an interesting time in trying to give himself
or others an historical account of the events in his life which
caused him to choose his present profession. He will probably find
that memories emerge of incidents and conversations which have been
forgotten for years. Yet he may find that they have influenced his
present life and his action at any moment of the present, to a very
great extent. Their present action clearly has been unconscious.
[42] It should not be forgotten that when a patient in an early
stage of mental disorder voluntarily seeks the doctor, his _active
co-operation_ in the task of tracing the causal factors of his trouble
is of the greatest value. This assistance cannot be relied upon after
the patient has been certified as insane and removed to an asylum, or
even after he has been taken to the doctor at the instance of others.
For obvious reasons he is then more likely to hide than to reveal his
eccentricities. The simulation of insanity is comparatively rare: it
is difficult and usually easily detected. It is dissimulation—the
concealment of symptoms of disease—which is the doctor’s greatest
enemy. The deluded man may hide his delusions because “everyone knows
that these beliefs are mad:” the melancholic may pretend for the time
to be cheerful in order that his liberty may not be interfered with.
(_Cf._ K. Jasper’s _Allgemeine Psychopathologie_, Berlin, 1913, p.
317.) Such attitudes of the patient are obviously strengthened by our
present custom of delaying the treatment of mental disorder.
[43] In his account of the wonderful exploits of “Sherlock Holmes,”
Sir Arthur Conan Doyle was merely applying, with inimitable skill and
literary resourcefulness, the methods of clinical diagnosis in medicine
to the detection of imaginary crimes. The unusual phenomenon in
medicine or in crime often affords the most obvious clue to the expert
who can appreciate its significance, whereas a simple dyspepsia or a
commonplace murder may present insoluble problems, because they reveal
no distinctive signs to guide the investigator.
[44] p. 17_f._
[45] Dr. C. G. Jung’s view, _Analytic Psychology_, p. 234.
[46] It is of importance to remember that successful re-education
utilises the emotional factors in the patient’s mental make-up, by
helping him to realise the value of the things which will make life
once more attractive and worth living. In this process the more the
physician knows of the patient’s social, moral or religious relations,
the earlier and more satisfactory will be his success.
[47] CORRECTION.
An unfortunate error in the second paragraph on page 73 escaped our
notice during the correction of proofs. Professor Pierre Janet was not
formerly the teacher of Professor Freud, but his fellow pupil when they
were studying under Charcot in Paris.
[48] _Op. cit._, p. 256_f._
[49] _Cf._ Hart, _op. cit._, p. 69_f._, Jung, _op. cit._
CHAPTER IV.
Some General Considerations.
It is instructive to compare the public attitude towards insanity with
that adopted in the case of another serious disease, tuberculosis.
There is nowadays a general conviction, not only amongst the medical
profession but also amongst a large proportion of the educated public,
that tuberculosis is a curable disease. It may exist in a mild and
incipient form in many persons regarded as healthy, and, if properly
treated in its early stages, with due regard not only to the actual
disease in the bodily organism, but also to the healthy environment of
the individual, it is almost certainly conquerable. Not many years ago,
however, this happy belief did not obtain. A person “in consumption,”
especially if “consumption was in the family,” was regarded as
being in a very serious and almost hopeless condition. The patient,
shielded from fresh air, inappropriately and insufficiently fed, often
succumbed, supplying one more example to support the unscientific
conception then prevalent of the inheritance of the disease. But such
conditions are passing away. In our medical schools and hospitals
special attention is paid to the diagnosis and treatment of early forms
of tuberculosis; the importance of preventive measures is emphasised;
the influence of the patient’s environment in favouring or combating
the disease is explained; and the future medical practitioner
is afforded frequent opportunities for personal investigation
of tubercular patients. The old ideas about the “inheritance of
consumption” are greatly modified. No longer is a patient’s disease
explained as “in the family” and left at that. Preventive measures,
early treatment, an attempt justly to appreciate the relative influence
of heredity and environment are the watchwords of the modern medical
attack upon tuberculosis.
If, however, we consider the attitude of the general public in this
country towards the malady of insanity we find a mixture of ignorant
superstition and exaggerated fear. From these there springs a tendency
to ignore the painful subject until a case occurring too near home
makes this ostrich-like policy untenable. The sufferer is removed to a
“lunatic” asylum, neither himself nor his relatives being spared the
gratuitous extra wrench to their feelings aroused by this name, which
has long struck terror into the uneducated mind. He is taken away by
the relieving officer of the district, often under the pretence of
being given “a few weeks in a convalescent home at the sea-side,” and
eventually finds himself under lock and key. Here, as is well known, he
is treated with great kindness. Neither public money nor the exertions
of the staff are stinted in the effort to render his lot as pleasant
as possible—“the asylum to-day has become a model of comfort and
orderliness.”[50] But the proportion of doctors to patients is on the
average, one to 400, and it is exceedingly difficult to ensure that
all patients, once inside the “lunatic” asylums, shall be regularly
visited by friends from the outside world.[51] The attitude of the
general public is not deliberately cruel, but it appears to be far
more benevolent than it really is. The community treats the sufferer
well, when, _but not before_, he has become a “lunatic.” It allows
his delusions to become fixed, his eccentricities and undesirable
acts to harden into habits, his moods of depression to permeate and
cement together the whole of his life—and then interns him and treats
him kindly for the rest of his life, but does not give him facilities
for gratuitous treatment while he is still sane. _That is the British
procedure to-day._
Lest we should be accused of exaggeration, or worse, we will quote here
from published articles and reports.
Dr. Bedford Pierce says:—
“Let me state in a few words the defects of our present system. At
present, broadly speaking, no person unable to pay its cost can
receive adequate treatment until he is certified as of unsound mind.
This practically means that no special treatment is possible until he
has utterly broken down, and is so seriously affected as to convince
a magistrate that he is decidedly insane. No general hospital will
receive such a patient; the public asylums are all closed to any
one who begs for protection or treatment, for county asylums cannot
receive voluntary boarders even when the cost of their maintenance is
forthcoming.
Consequently there is no alternative but to apply to the Poor Law
authorities, who, under certain circumstances, provide treatment for
a period of two weeks in the workhouse infirmary. The whole system
is radically wrong. When the wife of an artisan becomes depressed
after confinement, surely it is cruel in the extreme to make her a
pauper and send her to the workhouse infirmary, pending a decision
as to whether she is insane or no. It is obvious in such a case that
this course will not be adopted until the last possible moment, and
consequently much valuable time is lost.
Every practitioner will be able to call to mind patients travelling
steadily towards insanity in unfavourable surroundings. This question
is brought even more prominently before consulting physicians,
especially those interested in nervous and mental diseases.” (_Op.
cit._, p. 42.)
In the words of the report of the Medico-Psychological Association:—
“The present system, which compels all persons, except those able
to pay adequately for their maintenance, to apply to the Poor Law
authorities in order to secure treatment, is unsatisfactory and
unjust. In doubtful and undeveloped cases temporary care can be given
only in workhouses or Poor Law infirmaries, which, with very few
exceptions, lack proper facilities for treatment.
_A system which artificially creates paupers in order to obtain
medical treatment necessarily acts as a deterrent, so that too
frequently there is serious and even disastrous delay._”[52]
This is not exactly locking the stable door after the horse has
gone; it is double-locking him thoroughly, expensively and often
unnecessarily, in someone else’s stable.
Let us, for a moment, compare this state of affairs with that existing
in the case of tuberculosis. Nobody now believes that the scientific
way of treating this disease consists in waiting until the patient has
become a positive danger to others, and then locking him up. This point
needs no elaboration. But another fact in this connection should not be
forgotten. The tubercular patient usually seeks the doctor _of his own
free will_, often obtaining treatment in a relatively early stage of
the disease.
There are, however, many reasons that deter the mental sufferer from
seeking medical help. One of the strongest of these is the wish to cure
himself by his own unaided efforts. This is a laudable desire and one
which is extremely helpful and important in mild and uncomplicated
cases of relatively recent occurrence, but of which, as we have
seen,[53] the gratification is not always possible. Another factor
is the natural disposition which the patient shares with the rest
of conventional humanity, to conceal his worries, not only from his
friends, but perhaps above all from those of his own household. This
tendency to concealment, however, often only aggravates his mental
distress. Particularly is this the case in adolescents. As is well
known, a talk with a kindly, sympathetic and wise person, or even a
confession to such an adviser, frequently means the end of many painful
mental conflicts.
But in addition to these very natural reasons for deferring recourse to
medical help, there are in our own country special causes for delay.
These are due to the prospects imagined by the sufferer to be awaiting
him if he discloses his trouble.[54] The treatment of incipient
mental disorder is often a long and complicated process for which
the average general practitioner has seldom either the time or the
special training. In very few hospitals in this country is out-patient
attendance for such maladies practicable. For the mental sufferer
whose means are not considerable, there exists nothing if the efforts
of the general practitioners fail, but trying to cure himself, or,
if he becomes worse, admission to an asylum. Unfortunately, however,
the average asylum, with its one doctor to 400 patients, does not and
can not meet his needs. The successful treatment of mental disease
usually requires individual care, often lasting over long periods. When
it is remembered that the asylums contain a considerable percentage
of patients whose bodily diseases, apart from their mental troubles,
require the doctor’s attention, and further, that by the time the
patient reaches the asylum, his disorder has usually passed through
its initial stages, it is easily seen that our asylum system in its
present state—to put it mildly—is far from conducive to recovery from
mental disease. Considering that, in spite of these drawbacks, 33 per
cent. of the patients are discharged,[55] we can only gladly recognise
the efforts made by the asylums; we are, however, bound to ask: _What
percentage of the inmates need ever have entered the asylum?_ It may
be objected that it is easy, but unfair, to ask such a question seeing
that no satisfactory answer can be given. To this objection there are
two replies: first that, judging from the present state of affairs,
this question cannot be publicly asked too often; secondly, that
materials for an answer are already forthcoming. It is conclusively
proved by the experience of other countries that a large proportion of
the patients might have been cured without being sent into an asylum.
Thus, for example, in Germany, in the province of Hesse, by reason
of suitable treatment during the early stages of mental illness the
authorities were able to postpone for ten years the erection of a new
asylum.
“The Psychopathic Hospital at Boston, Massachusetts, ... was built by
the State expressly to deal with recent acute cases. No fewer than
1,523 patients were received in its first year, and of these 590 were
received under a temporary care law, which provides for a week’s
detention only; large numbers were also received on a voluntary basis,
so that during the year _48 per cent. of all patients escaped the
usual lunacy procedure_.
On reading the reports of work done, one is struck with the enthusiasm
of the medical staff and the vast field of research undertaken.
During the two years eighteen medical men describe their work
covering almost every department of psychiatry: juvenile crime,
tests for feeble-mindedness, incidence of syphilis, alcoholism,
hydropathy in its influence on red blood cells, treatment of delirium,
prophylaxis, analysis of genetic factors, salvarsan treatment,
tests of cerebro-spinal fluid, and last, but not least, the value
of out-patients’ departments and after-care. There is a special
social service department for the purpose of following up cases in
their homes, and it was found that of every 100 admissions 20 needed
supervision on discharge, 24 needed advice, 3 required assistance in
arranging their discharge, and 10 showed a need for prophylactic work
in their families.
This bald statement of the activities of the Boston State Hospital
shows plainly what an important service it renders in providing
treatment apart from ordinary asylum associations. It shows how it
is possible at such a hospital to organise a medical service which
covers all departments of psychiatry; and further, that when the
mental symptoms clear up, a patient need not be thrown back into old
associations without help or supervision.
This hospital at Boston is but one of many that have been established
in the United States in recent years. Some of the others are due to
private munificence; in particular, reference may be made to the Henry
Phipps Psychiatric Clinic at Baltimore, the medical staff of which
consists of a director, assistant director, a resident physician, two
assistants, and five [resident medical officers]. In addition to these
are the heads of three research laboratories dealing (1) with clinical
pathology and bio-chemical investigation, (2) with neurological
research, and (3) with psychopathology.” (Bedford Pierce, _op. cit._,
p. 42.)
In advocating the establishment of separate pavilions for nervous and
mental disease in direct association with the general hospitals, Dr.
Bedford Pierce says:—
“At La Charité Hospital in Berlin, the visitor enters a small park,
and Dr. Ziehen’s clinic is but one of many detached buildings devoted
to special diseases. It is as easy and simple for the patient
suffering in mind to get advice there as for another with eye and lung
trouble.”
Let it be noted that none of these German patients, on returning to
their relatives and friends, suffer from the stigma of having been
to an asylum. In our country some of those same friends during the
patient’s absence would often have been engaged in “sympathetically”
spreading the news of the sufferer’s absence and his whereabouts
to everybody in the district. To a certain type of mind there is a
ghoulish fascination in gloating over the illnesses and afflictions
of neighbours. Even though people addicted to such habits may salve
their own consciences by exclaiming “poor fellow” at the end of their
narrative, the effect of their conduct is none the less brutal and
offensive. This is not the place for the discussion of so remarkable
and important a phenomenon of social psychology. Nevertheless it plays
a great part in the causation of the prevalent dread of treatment for
mental disorder.
For many reasons the psychiatric clinic is not regarded by the public
as a “lunatic” asylum. In the Giessen clinic in Germany, for instance,
both nervous and mental diseases are treated. The patient afflicted
with tremor or a paralysed finger visits this institution as well as
the sufferer whose troubles if neglected might develop into mental
disease. Difficult medico-legal cases resulting from such incidents as
those arising from the claims by workmen and others for compensation
after accident are sent to this clinic for observation and opinion.
“Rest-Cures” and similar treatment are also carried out there. The
official title of the institution, displayed at the entrance, is
“Clinic for Mental and Nervous Diseases.” The institution is therefore
regarded by most people in quite a different light from the asylum, and
it is not spoken of by the general public with bated breath. One of us,
while working in the laboratory of a German psychiatric clinic, was
introduced to a visitor who made some remark about “when I was here.”
To the question, “Were you on the staff, then?” the visitor answered
quite naturally, “Oh no, I was here as a patient.”
With this experience may be contrasted another incident, this time
from our own country. Delegates from a certain Board of Guardians paid
a visit to the county asylum to inspect the arrangements made for the
comfort of the inmates from their own district. In the next week’s
local newspaper a report of the visit appeared in the form of the
chief delegate’s speech at the subsequent board meeting. This report
consisted of “funny” stories of the eccentricities of the patients the
visitors had seen, and of the delusions from which some of the victims
were suffering, with sufficient detail to enable many of the relatives,
and possibly some of the friends, of these “lunatics” to identify the
afflicted ones. The newspaper account of this humorous effort was
punctuated at suitable intervals with “laughter.”
It is obviously not claimed that these two accounts are typical either
of Germany or of England. But what is claimed is that of these two
public attitudes the clinic system promotes the one, the “lunatic”
asylum the other.
Before leaving the comparison of insanity with tuberculosis we must
remind the reader of some other facts that are important in this
connection. We have seen[56] that the scientific study of tuberculosis
has materially modified the earlier views concerning its hereditary
transmission. It is now held that tuberculosis is not inherited as
such; but that a child of tuberculous parentage may begin life with
a subnormal power of resistance to the disease and perhaps greater
risk of exposure to infection. If later he develops the disease, it is
traceable directly to his environment. The corollary is that if his
environment be improved, and his body’s power of resistance increased
meanwhile by all the means in our power, he has a considerable chance
of living a life free from the disease. Thus the old pessimistic view
is replaced by a distinctly optimistic one.
In the mental disorders that are indubitably traceable to organic
disease of the central nervous system, heredity doubtless plays a great
role. But two points should be remembered in this connection. First,
among asylum patients the number of mental disorders which cannot,
_post-mortem_, be traced to organic causes is very great as compared
with those that can be so related. For example, of 1,325 patients
received at the Burgholzi Central Asylum and University Psychiatric
Clinic, Zürich, Dr. C. G. Jung states:—
“... in round figures a quarter of our insane patients show more or
less clearly extensive changes and destruction of the brain, while
three-fourths have a brain which seems to be generally unimpaired
or at most exhibits such changes as give no explanation of the
psychological disturbance.... We must take into account the fact that
those mental diseases which show the most marked disturbances of the
brain end in death; for this reason the chronic inmates of the asylum
form its real population, and among them are some 70 to 80 per cent.
of cases of dementia præcox, that is of patients in whom anatomical
changes are practically non-existent.”[57]
In a great number of mental disorders our present knowledge of
anatomy, physiology and pathology is of little help as a means of
throwing any light upon the patient’s condition. While in no way
attempting to belittle the magnificent work in these subjects during
the past century, it should be pointed out that its very success has
brought about, especially in this country, an unfortunate tendency
to regard these methods as the only ones suitable for attacking the
problems of insanity. But nothing is more certain than that in the
psychoneuroses: hysteria, neurasthenia, psychasthenia and the rest,
anatomical and physiological knowledge has not yet passed beyond
the theoretical stage[58]. But it is equally indisputable—and the
statistics of shell-shock cases have strengthened the evidence for
this assertion—that the psychological mode of attack, the treatment
of mental disorder by mental means, is now firmly established as a
practical method.
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.
We should remember also that many varieties of animals display the
kind of behaviour we have described, and regard as so unusual, if not
utterly eccentric, in our friends. Professor William James reminds us
of the chronic agoraphobia of our domestic cats; and the tamer of wild
animals has good reasons to respect the incessant touchiness of some
species of the genus _Felis_. Do we invoke theories of visceral ptosis,
intoxication and the rest to explain the behaviour of the average cat
or mule? Scarcely. We say that these animals are actuated by instinct.
Our arrogance makes it difficult for us to suppose that our suffering
human brothers are also acting instinctively. Yet this is undoubtedly
the case.
It has been said of the neurasthenic with aptness and truth that he
behaves like a child. But if a child, normal in its behaviour up to
a certain day, suddenly manifests fear of being left alone for a
moment in a room with closed doors, or in a street, do we rush for our
“Liddell and Scott” and forthwith proceed to babble of claustrophobia
or agoraphobia?[63] Do we follow this up by solemnly invoking
complicated physico-chemical theories concerning the state of his blood
or other bodily fluids? Finally, do we brand him as “insane” or at
least “neuropathic?” What we do in this case, if we have any sense, is
carefully to investigate the causes of the emotional outbreak. We try
sympathetically to understand and re-educate the child to meet such
situations without fear. In other words, we use a method precisely
similar to that which proves to be of such great use in treating the
psychoneuroses.
The analogy—if it be an analogy and not perhaps an identity—between
the two cases goes still farther. The child who manifests extreme fear
at “inadequate” causes, such as we have described, not infrequently
agonises his mother—perhaps soon after his outburst of fright—by an
exhibition of foolhardiness which, if we did not know of the previous
sign of weakness, would cause one to look upon him as fearless. In
short, the child’s fear is restricted to one or two special situations.
So it is with many neurasthenics. Some, for example, may be driven
through traffic in a fast motor car without experiencing the slightest
fear, though they cannot bring themselves to enter an ordinary slow
suburban train; others may surprise us not only by their exhibition
of anger at what we should consider an absurdly slight provocation,
but by their tolerance and self-control in other (to us) much more
annoying situations. Their exaggerated emotional reactions are excited
not by general but by specific stimuli; and a little tact, insight
and patience on the part of the physician often reveals in their
past experience, psychological factors which explain the tremendous
personal importance and overweighting of these stimuli. If for
neuropathic we write: “unduly hampered by instinct and emotion”—and
this is all we have the right to do[64]—we represent the matter more
truthfully.
Among the laity, before the war, the justification of an attitude of
inertia towards the treatment of mental disorder (more particularly
of the psychoneuroses) was often based upon two statements. The first
was that many of the phenomena reported were not real, but were the
imaginings of hysterical women. If to this it was objected that men
were not immune to hysteria[65] one was met by the retort: “But
they are ‘neuropaths.’” This war has, however, removed from honest
people’s minds the possibility of regarding these phenomena in such
a shamelessly unscientific light. In the military hospitals there
have been hundreds of patients suffering from psychoneuroses, who are
demonstrably neither women nor neuropaths, in any of the legitimate
senses of these terms. And many of these men have suffered intensely.
Their fears and other emotional troubles are such as they usually
conceal as long as possible, until further endurance is intolerable.
Their troubles are real enough to them. “But they are unreasonable,”
the healthy philistine may object. Some (by no means all) of the fears
_are_ unreasonable, if by that is meant that the actual danger (as
the healthy man estimates it) and the emotion which it evokes in the
patient are entirely disproportionate. But who among us has “sized
up” life’s dangers so accurately that he can say he knows the precise
degree of fear which each one _ought_ to evoke?
In some country places the inhabitants to-day are more afraid of the
presence in their houses of peacock’s feathers or of hawthorn blossom
than of scarlet fever. Their fears are unreasonable. But we do not call
these people neurasthenics. As a matter of fact, neurasthenia is one
of the last diseases likely to attack these rustics. If they vouchsafe
any reason for their fear, it is safe to assert that it will be a
rationalisation, for its real sources are hidden from them. And if we
really wish to discover the cause of their fear we turn for help to
the records of folk-lore and ethnology. In other words, we investigate
the history of the fear. This history may go back many centuries and
the process of recovering it from a series of clues will prove a task
of infinite fascination. Now the history of the neurasthenic’s fear is
likewise obtainable and much more easily, for it is of much more recent
date. Its discovery often means the freeing of a mind from torment,
the restoration of a useful member to society, and the enrichment of
the science whereby other similar liberations may become possible. But
how few investigators, as yet, have been attracted by this tremendous
unfilled field of knowledge!
However, our philistine, while agreeing to this, may, and often does,
change his ground. He may add: “When I said that the phenomena were not
real I had in mind rather the pains and the paralyses from which the
hysteric and neurasthenic suffer—or say they suffer.” To this we may
answer in the words of Dr. Purves Stewart:—
“... we must recognise that the neuroses are real diseases, as real
as small-pox or cancer. A sharp distinction must be drawn between a
hysterical or neurasthenic patient and a person who is deliberately
shamming or malingering.... The hysterical or neurasthenic patient
usually has no knowledge of the disease which he or she may
unconsciously simulate. The various paralyses and pains from which
hysterics and neurasthenics suffer are as real to the patient as if
they were due to gross organic disease.”[66]
There is a view which, while eminently useful and sensible in so far as
it concerns neurology alone, is apt, by virtue of these good qualities,
to retard the progress of psychical treatment of the neuroses. For it
tends to focus the attention of the medical world on their physical
basis alone. Such a view is expressed by Dr. Purves Stewart in the
manual from which we have just quoted. In his chapter on the neuroses
he says:—
“The old definition of a neurosis as a nervous disease devoid of
anatomical changes is inadequate. _Disease is inconceivable without
some underlying physical basis._[67] The lesion need not be visible
microscopically: it may be molecular or bio-chemical.”[68]
Now from the purely material standpoint such a statement is above
reproach. But some important reflections occur as one thinks over the
paragraph, and especially the statement: “Disease is inconceivable
without some underlying physical basis”—as applied for example,
to neurasthenia. What are the important signs of disease in the
neurasthenic, or what unusual phenomena are there which cause him to
seek the doctor? Chiefly, as we have seen on p. 91, the undue dominance
in his mental happenings of instinct and emotion. But we cannot say
that this by itself is a sign of disease. Otherwise we shall arrive at
the paradoxical conclusion that wild animals, savages and children
form the diseased class _par excellence_.
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.
We have noted two of the common obstacles which obstruct the path
of the physician anxious to treat mental disorder: his own lack of
training and, in not a few cases, his temperamental inclination to look
exclusively for visible and tangible material evidence of disease.
There is, moreover, at present another serious obstacle consisting in a
widespread social convention. This is the unwritten law which commands
a person to hide any troubles of a mental nature not only from his
friends, but even from his doctor, though he may speak of his physical
disabilities to everybody with unblushing frankness. Much could be
written on this subject, but the inconsistency of the current attitude
has been satirised with inimitable wit and humour by Samuel Butler.
His whimsical fancy has created a civilised country in which this
convention does not exist; in which, in fact, the opposite belief
obtains. In that land, while a man’s bodily ills are counted a
disgrace, and not to be mentioned, his mental troubles are regarded as
physical illness is with us. The name of that country is _Erewhon_.
In _Erewhon_, we are told, physical illness is not only considered
shameful but is punishable by imprisonment. Mental trouble, on the
other hand, even irritability or bad temper, is regarded as illness
requiring the attention of physicians, known as “straighteners.” And
the consequences of this are that a man will dissimulate the existence
of indigestion, giving out that he is being treated for dipsomania,
while in answer to questions about his general condition another will
quite freely and truthfully say that he is suffering from snappishness.
We in England, says the explorer,
“never shrink from telling a doctor what is the matter with us merely
through the fear that he will hurt us. We let him do his worst upon us
and stand it without a murmur, because we are not scouted for being
ill, and because we know that the doctor is doing his best to cure
us and that he can judge our case better than we can; but we should
conceal all illness if we were treated as the Erewhonians are when
they have anything the matter with them; we should do the same as with
moral and intellectual diseases—we should feign health with the most
consummate art till we were found out....”
This convention inevitably influences the “straightener’s” attitude
towards his patients, as we are told by the traveller in a description
of an interview between his host and an Erewhonian doctor:—
“I was struck with the delicacy with which he avoided even the
remotest semblance of inquiry after the physical well-being of his
patient, though there was a certain yellowness about my host’s eyes
which argued a bilious habit of body. To have taken notice of this
would have been a gross breach of professional etiquette. I was told,
however, that a straightener sometimes thinks it right to glance
at the possibility of some slight physical disorder if he finds it
important in order to assist him in his diagnosis; but the answers
which he gets are generally untrue or evasive, and he forms his own
conclusions upon the matter as well as he can. Sensible men have been
known to say that the straightener should in strict confidence be told
of every physical ailment that is likely to bear upon the case, but
people are naturally shy of doing this, for they do not like lowering
themselves in the opinion of the straightener, and his ignorance of
medical science is supreme. I heard of one lady, indeed, who had
the hardihood to confess that a furious outbreak of ill-humour and
extravagant fancies for which she was seeking advice was possibly
the result of indisposition. ‘You should resist that,’ said the
straightener, in a kind, yet grave voice, ‘we can do nothing for the
bodies of our patients; such matters are beyond our province, and I
desire that I may hear no further particulars.’ The lady burst into
tears and promised faithfully that she would never be unwell again.”
FOOTNOTES:
[50] Hart, _op. cit._, p. 7.
[51] _Cf._ Dr. Bedford Pierce’s statement, (_op. cit._, p. 43), “I have
met persons otherwise level-headed who cannot be persuaded to enter the
grounds of an asylum. Not infrequently all sorts of excuses are made
to escape the duty of visiting a relative who is under care, and so
real is the danger of neglect that the State has decreed that no order
for reception shall be granted without an undertaking that the patient
shall be visited at least every six months.”
[52] p. 5. The italics are ours.
[53] pp. 77 and 78.
[54] We have in mind throughout the discussion, not the richer members
of the community, for whom a relatively expensive holiday or period
spent in the nursing home is easily possible, but the great majority of
the public, to whom even the ordinary doctor’s bill may be a source of
financial embarrassment for months or years.
[55] R. G. Rows, _Journal of Mental Science_, January, 1912.
[56] pp. 77 and 78.
[57] _Analytic Psychology_, London, 1916, p. 318.
[58] “Everybody agrees,” say Déjerine and Gauckler (_op. cit._,
p. 214_f_), “that neurasthenia is a neurosis, _i.e._, a nervous
disease without any known lesions.... Neurasthenia is due wholly
to psychological factors which are essentially, if not exclusively
determined by emotion.” They then proceed to compare the
“materialistic” theories of neurasthenia, showing that they are all
still merely speculative.
[59] _Cf._ pp. 19 _et seq._
[60] _Cf._ Déjerine and Gauckler, _op. cit._, p. 214_f._
[61] As Professor Kraepelin says, “Nervenkranker sind Geisteskranker”
(“Those ‘suffering from nerves’ are _sick in spirit_.”).
[62] The reader should consult Mr. W. McDougall’s excellent treatment
of this subject in his _Introduction to Social Psychology_—especially
pp. 45-89.
[63] The remarks of Mr. George Bernard Shaw on Max Nordau’s
“Degeneration” (_The Sanity of Art_, especially p. 88) might be
consulted in this connection.
[64] _Cf._ E. Régis, “Les Troubles Psychiques et Neuro-Psychiques de la
Guerre,” _Presse Médicale_, 23, p. 177, May 27th, 1915.
[65] This term is derived from the Greek word for the womb. Hysteria
was once thought to be due to the wanderings of the uterus about the
body. The term well deserves its place beside that other ornament of
psychological medicine—the word “lunacy.”
[66] _The Diagnosis of Nervous Diseases_, 3rd Edition, London, 1911, p.
355.
[67] Italics ours.
[68] p. 355.
[69] This was seen repeatedly in the treatment of the relatively
uneducated soldiers who had become slightly neurasthenic as a result
of the war, especially of those whose life had been spent in open-air
manual work, or in the strict and healthy routine of the regular army.
They complained of emotional irritability, minor lapses of memory
such as the forgetting of relatively unimportant names or of errands,
disturbed sleep, soon “getting fed up” with their amusements (_e.g._,
“jig-saws,” or billiards for hours every day, month after month in
a converted schoolroom or outhouse!). Not only did these phenomena
disturb them, but in a great many cases they seemed to prove to these
unfortunate men that they were insane, or rapidly becoming so. They
would anxiously ask such questions as, “What is it that makes me so
irritable at a slight noise, or at being brushed against by another
patient? I used not to be like that.” Their conduct was also regarded
as unusual by their companions. Now would not the head of a business
firm, an over-worked medical man, a university professor or an army
officer in a position of responsibility, confidently expect to be
allowed _ex-officio_ a certain number of these eccentricities without
being called “diseased?” But let him drop the privileges and shelter of
his rank, live for a few weeks as a private in a barracks with a number
of high-spirited and thoroughly healthy soldiers and his behaviour
might certainly be considered by them to be queer, if nothing worse.
[70] Reform of this state of affairs is urgently needed. The matter is
of such fundamental and far-reaching importance that we have devoted
part of the next chapter to the further consideration of its bearings.
[71] “Tough-minded,” “matter-mongers,” modern writers have called this
type, contrasting it with that of the “tender-minded,” “reason-mongers.”
[72] Of a brilliant teacher of physiology, one who was himself
intensely interested in the sciences bordering on his own subject, it
was related that when, in lecturing upon the functions of the nervous
system in man, he approached difficult problems, he used to say, “But
that is a matter for the psychologist.” Whereupon the class heaved a
sigh of relief and prepared to take notes upon the next subject.
[73] “... strong electric shocks, cold douches, and other decorous
substitutes for a sound birching.” W. McDougall, _Psychology_, London,
1912.
CHAPTER V.
Some Lessons of the War.
Are we, as a nation, doing all that we should for the mentally
afflicted? This is the question—no less urgent and important now than
it was a century ago—to which we call the serious attention of the
reader.
It is no new discovery to recognise the immediate importance of its
proper consideration, of the honest facing of the present conditions,
and of the urgency for such reform as shall lead to an affirmative
answer to our question. Already it has been the subject of considerable
discussion in recent medical literature, and in the medical press
numerous efforts have been made to bring it to the attention of the
general public. In July, 1914, the Medico-Psychological Association
of Great Britain and Ireland, a body composed chiefly of the medical
officers of our asylums, issued the report of a special committee
which had been appointed, in November, 1911, to consider the “status
of Psychiatry as a profession in Great Britain and Ireland, and the
reforms necessary in the education and conditions of service of
assistant medical officers.” Unfortunately, within a few weeks of its
publication, the outbreak of war prevented that discussion of the
question which would otherwise assuredly have followed the publication
of so momentous a statement. For in the report stress was laid on the
“absence of proper provision for the early treatment of incipient
and undeveloped cases of mental disorder,” on the lack of adequate
“facilities for the study of psychiatry and for research” and upon
“the unsatisfactory position of assistant medical officers” in the
asylum service. Clearly the stressing of such points by a committee,
thoroughly competent to form a judgment in such matters, compels a
negative answer to our leading question. The report makes it perfectly
clear that this country has grievously lagged behind most of the
civilised nations in the treatment of mental disease.
Yet all attempts in the way of important and far-reaching reform have
been frustrated, at least during times of peace, by a strange state
of indifference and inertia and by lack of knowledge. Thus, even so
recently as January 15th, 1916, the _British Medical Journal_ was
responsible for the statement “The only hope that our present knowledge
of insanity permits us to entertain of appreciably diminishing the
number of ‘first attacks’ lies in diminishing habitual and long
enduring drunkenness and in diminishing the incidence of syphilis.”[74]
This statement would have been sufficiently amazing if it had been made
three years ago; but when the hospitals of Europe contain thousands of
“first attacks” of insanity, which are definitely _not_ due either to
alcohol or syphilis, the only conclusion to be drawn is that its author
must have been asleep since July, 1914, or have become so obsessed
by a fixed idea as to be unable to see the plain lessons of the war.
Syphilis, no doubt, is responsible for a considerable number of cases
of insanity, and drink perhaps for some more[75]; but the incipient
forms of mental disturbance which the anxieties and worries of warfare
are causing ought to impress even the least thoughtful members of the
community with the fact that similar causes are operative in peace
as well as in war, and are responsible for a very large proportion
of the cases of insanity. But—and this is still more important—it is
precisely these cases which can be cured if diagnosed in their early
stages, and treated properly. The chief hope of reducing the number
of patients in the asylums for the insane lies in the recognition of
this fact, and in acting on it by providing institutions where such
incipient cases of mental disturbance can be treated rationally, and
so saved from the fate of being sent into an asylum. We may refer the
reader to p. 82 _et seq._, on which was given a short account of the
success of these reforms. We reiterate some of the advantages of the
clinic system—treatment of the patient without the necessity of the
ordinary asylum associations and the consequent social stigma; and the
considerable reduction in the number of patients requiring internment
in asylums which has followed upon the establishment of the psychiatric
clinic.
In this country insuperable obstacles in the way of this urgent reform
have been raised by our distinctive national obstinacy, and our blind
devotion to such catch-phrases as “the liberty of the subject,”—even
when this involves the eventual incarceration of the patient whose
liberty to escape treatment and to become insane, is the issue
jealously defended. Now, however, the stress of war has compelled
us to see matters in another light. The present war, which has been
responsible for destroying so many illusions, has worked many wonders
in the domain of medicine.
The rational and humane treatment of early cases of mental disturbance
has now been inaugurated on precisely those lines which have been so
long urged, with such little success, by the more far-seeing members of
the medical profession.[76]
A good example of this reform is the splendid work now being
carried out, at the Maghull Military Hospitals, near Liverpool, for
officers and men, organised and superintended by Major R. G. Rows.
The institutions are specially devoted to the treatment of soldiers
suffering from “shock” and other psychoses. The success already
achieved there is sufficient evidence of the great value of these
special hospitals for the treatment of nervous and mental disorders in
their early stages.
But if the lessons of the war are to be truly beneficial, much more
extensive application must be made of these methods, _not only for our
soldiers now, but also for our civilian population for all time_. We
have before us the practical experience of those countries which have
undertaken this great experiment in preventive medicine, yet apart
from the encouraging results of its treatment practised in our special
military hospitals, its present position in this country is only too
accurately described in the report to which we have referred. With
few exceptions[77] “the subject (of mental disease) is left severely
alone.”[78] Our arm-chair writers direct their attention to safer
subjects, such as eugenics, for example, and here they can be happy in
feeling they are on secure ground, because they are aware that their
neighbour knows little more about it than they do. Or they inspire
reports, and I quote a sentence from a recent report as a contrast to
the encouraging sound of the word ‘recovering.’[79]
In the _Standard_ newspaper a few days ago, (_i.e._, in 1914) there
was a reference to a report issued by the London County Council in
which one paragraph began with the statement, ‘Once a lunatic, always
a lunatic.’ This is the message sent in this country to our sufferers,
a message as brutal as it is unjustifiable. Again, in the _Standard_
of February 11th in the year of grace 1913, there appeared the
statement that ‘the Camberwell Guardians have issued instructions that
the use of “anklets” on violent lunatics in their institutions is to
be discontinued.’
With reference to the dictum “Once a lunatic always a lunatic” we
should like to call attention to another statement in this report. “The
fact that, _even under the present conditions of delayed treatment,
about 33 per cent. of those admitted to the asylums of England and
Wales are discharged recovered_, demonstrates that the feelings of
helplessness and hopelessness, with which such illnesses are usually
regarded, are by no means justified. The evidence of many authorities
who have had practical experience of the value of treatment during
the incipient stages of the illness, shows conclusively that the
exercise of scientific care during the early phases of mental disorder
would save many from such a complete breakdown as would necessitate
certification and removal to an asylum. In all other branches of
medicine facilities for dealing with disease in its initial stages are
recognised as indispensable and therefore the Committee regard it as
essential that, in the large centres of population at any rate, means
should be provided to obviate the delay that now exists in providing
adequate treatment for mental disorders. It is, therefore, recommended
that psychiatric clinics should be established.”[80]
Again, at the International Congress of Medicine in London, in August,
1913, an important discussion of these problems was introduced by
an account of the Henry Phipps Psychiatric Clinic which has been
established in Baltimore for the treatment of mental disorders, and
for teaching and research in this subject. In the course of the
discussion special emphasis was laid upon “the necessity for _teaching
the medical profession and the public_ that many mental disorders are
absolutely recoverable, that good hospital and scientific treatment
save many, that the mere economy of our monster institutions represents
a sham economy paid for by the patients and their families, and that
psychiatry must extend beyond the asylums.”[81]
Emphasis was also laid upon the importance of making these hospitals,
for the care and cure of those suffering from mental illness, centres
for scientific education and research and for the development of
prophylactic measures. For, unless medical students are provided with
facilities for the study of these early cases the present deplorable
condition of affairs will be perpetuated. All honest medical work is
essentially research; for every individual patient presents problems
which need investigation; and facilities should be provided for making
such enquiries under the most favourable conditions. As Dr. Flexner has
well said,[82] it is impossible “to develop two types of physician,
one to find things out, the other to apply what has been ascertained.
For the same kind of intelligence, the same sorts of observation,
knowledge and reasoning power are needed for the application as for the
discovery of effective therapeutic procedure.”
This last consideration leads us to the examination of another potent
factor in the present situation, _viz._:—
_The Attitude of the Medical Profession._ When it is remembered that
mental factors play an important rôle in the causation and continuance
not only of obviously mental disorder but also of bodily troubles,
and that therefore successful diagnosis and treatment must inevitably
take these factors into account, it may seem remarkable that the
medical profession as a whole should take so little interest in, and
know so little of psychology. Even when the psychological aspect
of their problems becomes the outstanding element in diagnosis and
treatment, the vast majority of medical practitioners show little or no
inclination to satisfy their scientific curiosity and to endeavour to
understand the condition of their patients.
But this attitude becomes more comprehensible, and in a certain measure
more excusable, when we look into the courses of instruction provided
for students in our medical schools. What training in psychiatry—to say
nothing of psychology and psychopathology—have they received in the
schools? How many hours have been spent in lectures or demonstrations
upon mental diseases? And how has this modicum of time been spent? How
many hours are devoted to actual _personal investigation_ of patients
suffering from early mental disorder? All the instruction in such
matters that our students get at present in most of the medical schools
is given in a few hours during one term, when they visit an asylum
where demonstrations are given of _advanced_ cases of mental disease:
“melancholia,” “mania,” “dementia,” etc.
Lest we may be accused of wild statements, let us quote again from the
Medico-Psychological Association’s report. (The italics are ours.):—
“... the attention given to mental diseases before qualification
is much less than that given in many other countries. Owing to the
absence of clinics, the medical student _has no opportunity of
observing borderland or undeveloped cases_.” (p. 6.)
“To this absence of teaching facilities is due the lack of knowledge
of the general practitioner, who should be competent to recognise, and
possibly to deal with, some of the earliest symptoms; _to this we owe
the lack of real equipment in those who enter the lunacy service_.”
(p. 21.)
In this connection it is interesting to quote from a comparatively
recent report on medical education. Four years ago the Carnegie
Foundation for the Advancement of Teaching published a report on
“Medical Education in Europe.” This work was remarkable both for its
perspicacity and thoroughness and for the frankness and detachment with
which its author, Dr. Abraham Flexner, expressed the opinions he had
formed after a detailed study of the medical schools of this country
and on the Continent. This valuable and important document was barely
noticed by the medical press in this country. But this is not the place
for a discussion of the psychology of this conspiracy of silence. For
it certainly does not imply any reflection upon the impartiality or the
thoroughness of Dr. Flexner’s research; on the contrary, it is a silent
tribute to the seriousness of the exposure of the weaknesses of our
medical schools. But the report is also a most valuable appreciation of
the strength of our methods of medical education. It provides a minute
analysis and comparison of the methods of teaching clinical medicine
in Great Britain and on the Continent. The summary clearly defines the
distinctive merits of the British system, and has such an important
bearing upon the questions we are considering in this book that we
will quote its most essential paragraph.
“The limitations by which medical education in Great Britain is
hampered have now been candidly exposed. It is nevertheless true that
in respect to the student, nowhere else in the world are conditions
so favourable. In our discussion of Germany we pointed out that its
clinical instruction was overwhelmingly demonstrative; that the
student _saw_ and _heard_ but almost never _did_. Clinical education
in England has completely avoided this wasteful error. It is primarily
practical. It makes, indeed, the huge mistake of assuming that a more
scientific attitude towards the problems of disease is in some occult
way hostile to practicality; for it protests against the adoption of
modern methods of investigation, as though practical teaching would
be in some inexplicable fashion endangered thereby. However, that
may be, the English are indubitably correct in holding that sound
medical training requires free contact of the student with the actual
manifestations of disease. It is the merit of English and, as we shall
also perceive, of French medical education that the student learns
the principles of medicine concurrently with the upbuilding of a
veritable sense-experience in the wards, and that he acquires the art
of medicine by increasingly intimate and responsible participation in
the ministrations of physician and surgeon. The great contribution
of England and France to medical education is their unanswerable
demonstration of the entire feasibility of the method of instruction
which the end sought itself imposes.”[83]
We have quoted at length this vivid and accurate portrayal of the
distinctive feature of British methods of clinical instruction in order
to emphasise the fact that in the teaching of psychological medicine
the British utterly neglect this excellent method of instruction which
Dr. Flexner considered so admirable a feature of our medical schools.
The British method of teaching psychological medicine, so far as the
subject is taught at all,[84] is that of class-demonstration, but, as
we have seen, the avoidance of exclusive reliance upon this method is
the feature on which Dr. Flexner congratulates the British schools. On
the other hand, while the Germans are criticised for their adherence
to the class-demonstration, it should be remembered that, although
this source of weakness appears in their undergraduate classes, it
is they and not we who provide facilities, in their clinics, to the
post-graduate student for free contact with patients in incipient
stages of mental illness.
Therefore we have neglected to apply, in the case of mental diseases,
the very methods which in all other branches of medicine have been so
conspicuously successful as to be selected by an impartial critic as
the distinctive merit of British medical training.
We have indicated briefly the type of instruction in psychiatry
obtaining in our medical schools at present. Its educational value
is certainly very slight; and—what is worse—it serves to give the
future doctor a hopeless outlook on insanity. For the instruction of
students in the nature and treatment of tuberculosis we do not send
them to some sanatorium to gaze upon patients dying from the disease.
They personally examine patients in the early stages and learn to
recognise the subtler manifestations of the onset of the tubercular
attack, when there is some hope of giving useful advice and saving the
sufferer. Why cannot mental disease be dealt with in the same way? Why
cannot our students be afforded, in general hospitals, the opportunity
of personally examining patients in the incipient stages of mental
disturbance? They would then not only acquire a knowledge of the real
nature of insanity, but would also learn, in the school of experience,
the individual differences which are exhibited in the working of the
normal mind, a lesson which would be of the utmost value to them in
dealing with _all_ their patients, whether their ailments be bodily or
mental. But in addition such a training would impress on them, in a
way that nothing else could do, the vitally important fact that mental
disease is curable, and is not the hopeless trouble which is likely
to be suggested by the spectacle of a few asylum patients in advanced
stages of lunacy.
Even, however, if the asylums afforded better facilities for the
proper study of mental disease than unfortunately is the case in
most institutions in this country, they are usually not sufficiently
near the medical schools to permit the student properly to acquire
his knowledge, as he does of other diseases, by frequent and regular
attendance for a considerable period of time. Nor, as yet, have many
of the medical officers in our asylums sufficient up-to-date knowledge
of psychiatry to enable them usefully to co-operate with the medical
schools and the teaching staffs of the general hospitals in achieving
the desired aim. We know that there are some exceptions to this general
statement, and fortunately they are becoming more numerous. But viewing
the condition of affairs in the country as a whole, in respect of this
important matter, one can only accurately describe it as deplorable.
These are hard words, and we are well aware that their use may
expose us to the charge of superficial, uninformed and even spiteful
criticism. Let us, therefore, turn to the gratifyingly frank and honest
statements of the asylum workers themselves, embodied in the report
from which we have quoted.
“_The tendency of routine to kill enthusiasm and destroy medical
interests._
The promotion or advancement of a medical officer depends so little
upon his knowledge of psychiatry that he has no inducement for
that reason to devote himself to an earnest study of the subject.
His work is apt to begin and end with the discharge of essential
routine duties to the exclusion of careful clinical and scientific
investigation.
The work assigned to junior medical officers is, in the majority of
cases, monotonous, uninteresting and without adequate responsibility.
For those whose personal enthusiasm keeps alive in them the desire
to extend their knowledge, such opportunities as that of study-leave
are rarely afforded them. The existing system, therefore, leads to
the stunting of ambition and a gradual loss of interest in scientific
medicine. It tends, therefore, to produce a deteriorating effect upon
those who remain long in the service.”[85] (pp. 8 and 9.)
_Methods of Making Appointments._
“Appointments are made by lay committees, which, though they are
generally wishful to appoint the best candidate, are in most cases
without expert advice, and without adequate knowledge of the factors
involved. The results are, therefore, generally haphazard in
character, often dependent upon influence or personal consideration,
as they frequently bear out little relation to the actual claims and
qualifications of the candidate.” (p. 7.)
We submit then, that our expression of opinion is but a paraphrase of
the authorised report. The study of this publication as a whole will
only deepen this impression in the reader.
In the foregoing paragraphs we have pointed out the vital importance of
research in relation to mental disease. All properly conducted clinical
work is of the nature of original investigation; and in the examination
of patients suffering from mental disturbance this is particularly
the case. But a vast amount of research work must be carried out in
properly equipped hospitals and laboratories if we are to deal with the
problems of lunacy in the same efficient manner as we have learnt to
treat tuberculosis. In this connection it is important to emphasise the
lack of an adequate knowledge of normal psychology among many of the
medical officers and the absence of psycho-pathological research in so
many of our asylums.
It must not, however, be inferred that the only reform needed is an
increase and improvement of the _mental_ treatment of mental disease.
It is not merely the psychological side that is neglected. The most
depressing aspect of the present state of affairs _is the comparative
absence of all research_. Investigations into the material basis of
mental disease, while certainly more numerous than psychological
investigations, are at present few in number. Hosts of problems
concerned with the nervous system are awaiting investigation, and the
admirable results obtained by the small band of energetic workers in
our country serve to show how sadly our nation is neglecting its golden
opportunities for accomplishing much more in this respect. Important
problems in connection with the normal and morbid anatomy of the
nervous system, its pathology and its bio-chemistry, suggest themselves
to the worker at every step. The physiological and psychological
effects of different diets, of drugs like the hypnotics, _et cetera_,
how little we know of them! Are we to rest content in leaving this vast
unknown land to be charted by other nations?
Original research is thus urgently needed in all those departments
which should be included in asylum work. But it is also necessary for
the researches to be co-ordinated. Not a few individual doctors in
our asylums, usually members of the junior staffs, are endeavouring
to carry on original investigations; but in the majority of cases the
absence of any prospect of direct or indirect personal benefit from
this work damps their enthusiasm, if it does not make such work wholly
impossible. And, of course, without the willing co-operation of the
asylum authorities co-ordinated researches cannot be carried out.
We shall again quote from the report of the Medico-Psychological
Association in justification of our statement:—
“Research is largely dependent on individual enthusiasm, but can
certainly be stimulated and maintained by the co-operation of the
senior medical staff. There is reason to fear that such work is
undertaken in some quarters without any guidance or encouragement
from seniors, and laborious original investigations have received
little or no recognition from those in authority.... Although there
is no uniformity of practice, report is made that in many asylums
junior medical officers are placed in charge of chronic cases only,
and have no duties in reference to the treatment of newly-admitted
cases. This appears to be most undesirable. Junior medical officers,
in addition to their statutory routine duties, should be given the
opportunity of co-operation with their senior colleagues in clinical
work. Consultation between the various members of the medical staff in
doubtful and interesting cases is very desirable....” (p. 30.)
If the reader will pause for a moment, and in imagination put himself
in the position of a junior medical officer, “_placed in charge of
chronic cases only_,” he will not only come to understand the “stunting
of ambition and the gradual loss of interest in scientific medicine” of
which he has read, but may admire the self-restraint of a report which
can speak in temperate language of such a state of affairs.
Another difficulty that stands in the way of this urgently needed
reform in medical education is the inadequacy of the text-books
available for the student. In many of these text-books the introductory
chapters contain some, often irrelevant,[86] morbid anatomy, and the
remainder deals with “psychology.” The latter frequently consists
largely of anecdotes, often “funny” and sometimes more appropriate
to the “after-dinner” hour than the text-book, and enumerations of
the mental _symptoms_ of the cases. In practically every available
English text-book the latter are depicted only as they appear after
they have become fixed, habitual, hardened and rationalised. Such
“units” of terminology as “delusions,” or “delusions of persecution,”
“hallucinations,” etc., are freely used. In other departments of
clinical medicine the text-book writer does not describe a patient as
suffering from a cough, and leave it at that; yet the phrase “suffering
from delusions” is the veriest commonplace in the text-books. Yet
just as a cough may be due to tuberculosis of the lung, pharyngeal
irritation, hysteria, or a variety of utterly different causes, each
class of case requiring a different treatment, so the causes of
delusions are even more infinitely varied.
But the gravest defects of these text-books is that few of them make
any attempt whatever, except in the case of such forms of disease as
have an organic cause, to explain the _development_ of the trouble, the
precise nature of the primary cause or causes and the way in which the
disturbance of the patient’s personality has been gradually effected.
Unfortunately there are serious defects in many of the works upon
general psychology which render them almost useless to the student of
psychological medicine. This may explain, if it does not excuse, the
quaint selection of subjects, often wholly irrelevant or inappropriate,
which form the contents of the psychological section of many English
books on mental disorders. But this deficiency is not a sufficient
excuse for the neglect of the kind of instruction that is of vital
importance for the proper understanding of such disorders. When books
such as those written by McDougall, Stout, Hart, Shand, and Déjerine
and Gauckler, are available, it is possible to use the facts of normal
psychology as the natural, rational and necessary means of explaining
and interpreting departures from the normal state.
We may summarise here some of the chief defects of our national system
of treating mental disorder. First and foremost is the serious waste
of time which almost invariably occurs before the mental sufferer
comes under medical care. This is due to a variety of causes—all of
them preventable. The chief is that, lying in the path of patients who
would _voluntarily_ seek help, there is the insurmountable obstacle of
the asylum system and its restrictions. The men in the asylum service,
who have the opportunity of acquiring an intimate knowledge of mental
diseases, are _forbidden_ to carry that knowledge into the outside
world for the benefit of the mental sufferer. If a patient, suffering
from a mental disorder in its earliest and easily curable stage, should
voluntarily go to an asylum and ask for advice, all that can be done
for him is to suggest that he should consult a medical man outside, or
to recommend him to call and see the relieving officer. Now, unless
the patient has considerable means, it is practically certain that he
will be able to consult no medical man who is conversant with—much
less expert in—the treatment of early mental disorder. And, though
the relieving officer’s intentions may be of the best, it is just his
‘help’ and all that it means, that the unfortunate is so desperately
striving to avoid. In short, all that the officials under our present
system can say to such a man is, “Go away and get very much worse, and
then we shall be allowed to look after you!” Can stupidity go farther
than this?
Even, however, if the doctor were allowed to help such a person in the
asylum, this would be far from an ideal solution of the difficulty.
Entry into such an institution, even if voluntary, would entail the
serious social stigma which has been so often mentioned. Furthermore,
the asylum, with its associations and implications, particularly the
assumption of the irresponsibility of the patients interned in it,
would destroy one of the chief therapeutic agents in the treatment
of such cases. We mean the conviction of the patient that he is
still responsible for his actions, and that he is still able, under
direction, to cure himself.
The place to which such a patient should be able to go is obviously
one which is exempt from any stigma; one in which of his own free will
he may stay for a time under care, or if this be unnecessary, as is
very frequently the case, which he may visit at frequent intervals
for advice and treatment. It should be staffed by skilled specialists
who are familiar with the diagnosis and treatment of _early_ and
_incipient_ mental disorder, not only with that of advanced insanity.
For years such institutions have existed in other countries and form an
important part of their contribution towards the alleviation of human
suffering.
The chief functions of such a psychiatric clinic would be:—
(1) Attendance on the mentally sick.
(2) The provision of opportunities for personal intercourse between
patients and the psychiatrists in training.
(3) The theoretical and practical instruction of students.
(4) Advising general practitioners and others who are faced with
difficult problems arising in their daily work.
(5) To serve as a connecting link between investigation in the large
asylums and that in the anatomical, pathological, bacteriological,
bio-chemical, psychological and other laboratories of the universities.
(6) The scientific investigation of the mental and bodily factors
concerned in mental disease.
(7) The furtherance of international exchange of scientific knowledge
concerning mental disorder, by the welcome accorded to visitors from
other countries.
(8) The dissemination of medical views on certain important social
questions and the correction of existing prejudices concerning insanity.
(9) When necessary, the after-care of the discharged patient.
We have already given some details of the activities of a few of the
clinics abroad[87] and have pointed out their valuable function in
saving a high percentage of patients from the fate of an asylum, while
at the same time relieving the community of the serious expense of
keeping these patients for life as pauper lunatics.
We may quote from an article by Dr. R. G. Rows[88] describing the
psychiatric clinics at Munich and Giessen:
“They are carried on upon the lines of ‘freely come, freely go,’ as
far as is consistent with the safety of the patient and of the public.
In neither of these clinics is any legal document necessary for the
admission or discharge of patients. But where the character and
severity of the mental disturbance require the longer detention of the
patient in the clinic or in an asylum, such detention can be exercised
only under a legal procedure which carefully safeguards the rights of
the patients.
In this way it is possible to avoid the stigma which is attached to
certification and seclusion in an asylum. That this is appreciated
by the general public is demonstrated by the number of people who
make use of the opportunities offered them. To the clinic at Giessen,
with its seventy beds, between three and four hundred patients were
admitted in 1907. From the report of the clinic at Munich for the
years 1906-7 we learn that there were 1,600 admissions in 1905 (the
first complete year after it was opened), 1,832 admissions in 1906,
and 1,914 admissions in 1907. At the present time admissions go on
at the rate of ten or twelve per day. It should be mentioned that
at Munich the clinic is open night and day for the reception of
patients, so that they can be brought under the care of an expert at
the earliest possible moment, and the painful impressions produced
often by detention and restraint by unskilled persons and unsuitable
surroundings are reduced to a minimum. This immediate treatment at
the hands of men experienced in insanity is a matter of the greatest
importance, from the point of view of a favourable termination of many
of these cases.
Let us now consider the actual treatment of those admitted into these
institutions. What most strongly impressed us in these clinics was the
absence of noise and excitement amongst the patients; it was certainly
an ample demonstration of the value of the means of treatment adopted.
It is recognised in the first place that patients must not be crowded
together: none of the wards contain more than ten beds.... For the
patient who is too excited to be kept in bed or who disturbs the
others too much, experience has shown that prolonged warm baths
provide the best means of quieting him and bringing him into such a
condition as will allow of his being kept in the ward. The extent to
which the bath treatment is employed may be judged from the fact that
besides the baths used for ordinary purposes of cleanliness there
are in the clinic at Munich eighteen baths for prolonged treatment,
five movable baths, one electric, and one douche bath. The wet pack
is occasionally used. The baths are so arranged that the patient can
remain in the bath for days or weeks as the case demands, sleep there
and take his food there. The result of the treatment is that hypnotic
drugs and confinement to a single room have come to be regarded as
evils to be used only on rare occasions; in fact, the single rooms are
occupied by convalescent and quite quiet patients and not by recent
and acute cases.
Treatment on these lines will of course necessitate the employment
of a large medical and nursing staff. At Giessen, with 70 beds and
between three and four hundred admissions a year, there are five
medical officers including the director. At Munich, with one hundred
and twenty beds and three or four thousand admissions, there are
fifteen medical officers to carry on the work of examination and
supervision of the patients. The nursing staff must be provided in the
proportion of at least one to five. This is of course a high figure,
but there are two conditions to be remembered: first, the very large
number of admissions dealt with, and secondly, that these clinics are
established not for the housing of the insane, but for the care and
cure of those suffering from incipient mental disturbances—a most
important distinction, and one not yet fully appreciated in this
country.
Besides the patients admitted into the clinics for treatment, a large
number obtain advice and help from the out-patients’ department.”
It should be mentioned that in Germany there is a psychiatric clinic
attached to every university.
Among the most important functions of a clinic are instruction and
research. Each assistant in the Munich clinic carries on some chosen
line of study. In order that he may have better facilities for
becoming acquainted with the literature on the subject and finishing
his selected work, he is given, besides his annual month’s leave,
two months of each year for this purpose. Frequent evenings are set
apart for discussions of original work carried on in the clinic and
elsewhere. Besides this, numerous short courses in special subjects are
provided, so that it is possible to enter the clinic for instruction
in matters requiring a special knowledge of delicate technique and
diagnosis.
Of very special importance in the Munich clinic is the course for
qualified medical men. In 1907 this was attended by _sixty men, of
whom one third were foreigners_. What can we, in Great Britain, show
in comparison with this? Our physical, chemical, physiological, and
pathological laboratories attract distinguished foreigners from the
universities of other countries, though twenty would be a number on
which even our most celebrated laboratories would pride themselves. But
how many foreigners come to us to study insanity? Very few indeed, and
the reason is not far to seek.
In the Munich clinic, again, we find well equipped rooms for
clinical examination, for the deeper investigation of mental life
by experimental psychology, for the study of morbid anatomy and
pathology and for the finer examination of the blood and other fluids
of the body. Furthermore, these laboratories are not only spacious and
well-equipped, but are occupied by busy, keen and skilled workers.
Testimony to their activity is afforded in abundance by their frequent
publications.
We submit, then, that the clinic system is a decided advance in the
treatment of mental disorder which other countries have adopted while
for years we have stood by with folded hands.[89] From the humanitarian
and the scientific point of view there is everything to be said in
favour of the clinic. The practical Englishman will, however, ask “What
about the financial aspect? Are not these institutions, with their
heavy proportion of doctors and nurses to patients, prohibitively
expensive?”
The answer to this question is that certainly the clinic is relatively
more expensive than the asylum. But since the function of the clinic
is to save as many patients as possible from entering the asylum, it
is obvious that its expense must be judged from a special standpoint.
The maintenance of a repair shop is always comparatively costly,
whether the material to be mended be human or not. The cost per day
of repairing a motor car is usually distinctly higher than the daily
charge for garaging it in its broken-down state. Yet we gladly pay the
higher charge for the simple reasons that a motor car in its garage is
of no use to us, and that the daily charge for housing the car would
amount to a colossal figure if paid for many years. Cannot we apply the
same reasoning to the case of the mentally disordered human being?
This is to take the very lowest view of the value of the individual to
the community. Yet it would seem that the British public, so far, has
been impervious even to this financial consideration.
But, it may still be asked, cannot the doctors in the asylums carry
out the work suggested? The answer to this is, that apart from the
undesirability of allowing a patient suffering from a mild mental
disorder to be associated with an institution housing the definitely
insane, it is a physical impossibility for the asylum doctors to do
this work so long as the present proportion of doctors to patients
remains unchanged. How many members of the British public realise the
fact that it is quite usual for an asylum doctor to be in charge of
at least 400 patients, and that this number sometimes rises to 600?
When it is remembered that insane patients are even more prone than
the average person to suffer from physical ailments, and that their
mental disorders are infinitely complicated by the delay incurred
before they come under medical care, it becomes clear that the doctor
who would succeed in treating such patients individually would require
titanic energy and the addition of at least twenty-four more hours to
each of his working days. We cannot therefore compare the staff of a
clinic with that of a British asylum, for the staff of the latter is
lamentably and obviously too small.
Regarding the financial aspect of the question we may quote again from
Dr. Rows’ article:—
“... we shall no doubt be met with the objection that the provision
of such institutions will involve the expenditure of such an immense
sum of money. I believe we spend in Great Britain about £3,000,000
a year on those suffering from various forms of mental affliction.
That, certainly, is an immense sum to spend while getting so little in
return. A large proportion of this money is spent in housing, feeding,
clothing, and taking care of the 97,000 inmates of the county and
borough asylums of England and Wales. We learn from the commissioners’
report, published in 1910, that 20,000 patients were admitted into
these asylums during the previous year, and of these, over 30 per
cent. were discharged after a longer or shorter detention. Now it may
safely be said that very few of these 20,000 fresh admissions did
obtain, or could have obtained, any advice for their mental illness
at the hands of anyone who had had experience of mental disorders,
before they reached the stage when certification and seclusion in an
asylum became necessary. When we visited Giessen we were informed by
Professor Sommer that in the province of Hesse, by reason of suitable
treatment during the early stages of mental illness they had been
enabled to postpone for some years the erection of a new asylum in
the province. Is it not therefore fair to assume that, if facilities
were provided whereby expert advice and treatment in a well-organised
psychiatric clinic could be obtained by those threatened with a mental
breakdown, we should save enough of the £3,000,000 to justify the
expenditure involved in the establishment of such clinics? Further
benefits would be derived from them in that we should be able to avoid
the breaking-up of the home, which now, in so many instances, follows
the removal of the bread-winner of the family to an asylum and his
long detention there.”
And
“... it may be suggested that we should attempt to demonstrate the
possibility of saving money in order to carry the public with us in
the matter. I do not think that is necessary. The value of treatment
of the early stages of mental disorder cannot be expressed in pounds,
shillings and pence. Moreover, I submit that our duty as medical
men is to guarantee the satisfactory treatment of the patient, and
we have no right to allow our action to be dominated by monetary
considerations. I feel sure that the more this question is placed
before the public in an intelligent manner, the more we insist upon
the necessity for early treatment and for scientific knowledge as
a basis of any treatment, the less will the public grumble about
expense. We have ourselves to thank if the public refers so constantly
to money matters. Do we ever encourage the public to regard the
question from any other point of view? Do we point out that insanity
is a product of civilisation? Do we encourage people to regard
insanity as an illness for which something can be done and which
should be treated with intelligent and humane consideration? Do we
not rather say with the public, “Lock him up, put him where he can
neither harm himself nor his neighbour?” Do we not talk of sterilising
the unfortunate sufferers and preventing marriage and procreation
before we have made an honest effort to investigate what insanity
really is, what is the mechanism of its production, and how we can
teach those so afflicted to help themselves? How then can we expect
the public to do anything but grumble at the expense? The public
has not objected to spend money in other branches of medicine when
the necessity has been demonstrated, and there is no reason, if the
members of the lunacy service in this country will develop confidence
in themselves, why they should not be able to instil confidence into
those outside the profession.”
_Suggested Reforms._ After the depressing picture of the present state
of affairs in this country it will be asked, “What should be done to
remedy it?” The answer to this question is clear and definite.
For the relief of the mentally afflicted amongst us, and especially
for the prevention of insanity, it is our bounden duty as a nation
to take measures such as most civilised countries have adopted some
time ago. For this purpose it is necessary that there should be
hospitals to which patients in the early stages of mental disturbance
can go, without any legal formalities, and receive proper treatment
from physicians competent to diagnose their troubles and to give them
appropriate advice. It is important that such special hospitals should
be attached to general hospitals, so that sensitive patients may not
be deterred from resorting to them by the fear of the stigma which in
this country, unfortunately, is so inseparably linked with the idea of
a “lunatic asylum.” It is also important that such institutions should
be affiliated to medical schools, not merely to ensure the adequate
education of the coming generations of medical practitioners, but
also to afford the staffs of such hospitals the proper opportunities
for carrying on the work of investigation which is essential for the
success of the scheme we have sketched out.
No less important and urgent a reform than the foregoing, however,
is another consideration—the _legal_ aspect of the treatment of the
mentally deranged.
The glaring defects of the present system have been well and briefly
pointed out by Dr. Bedford Pierce in his article from which we have
quoted, published in the _British Medical Journal_ of January 8th, 1916.
Again, Sir George Savage, writing in Allbutt’s _System of Medicine_
(Vol. VIII, p. 429) states:—
“The lunacy legislation of this country, despite the Acts of 1890 and
1891, remains in an unsettled state; and the care and treatment of the
insane are burdened with vexations and unnecessary restrictions. Not
only are the steps required for the placing of a person of unsound
mind under legal care complicated and clumsy, but they result in many
cases in a delay of that early treatment which is so important in
cases of mental disease.”
Dr. F. W. Mott writes:—
“There is yet one point which it is desirable to mention, as the
result of both hospital and asylum experience, and that is the
necessity of some earnest attempt being made to establish a means
of intercepting, for hospital treatment, such cases of incipient
and acute insanity as are not yet certifiable. It is probable that
many would not come into the asylums, and a certain number of cases
thus come under observation willingly, and in time to retard the
progress of the disease. Practitioners could send doubtful cases for
observation and treatment to such hospitals, where, moreover, the
opportunity would be afforded of improving their own knowledge as to
the early signs of insanity.”[90]
He urges the desirability of the establishment of special wards in
connection with general hospitals, pointing out that a mental case
coming from such a ward would not thereby be stigmatised as insane. He
quotes from ‘an American writer on psychiatry’:—“Fortunate would be
the community in which there was a fully equipped and well-organised
psychiatrical clinic under the control of a university and dedicated
to the solution of such problems. The mere existence of such an
institution would indicate that people were as much interested in
endeavouring to increase the public sanity as they are in the results
of exploration in the uttermost parts of the earth, or in the discovery
of a new star.”[91]
The Medico-Psychological Association’s report says:—
“The lunacy law does not permit of the establishment of clinics on
the lines which have been recommended, nor does it provide for the
admission of uncertified cases to the public asylums. This, for the
present at any rate, renders nugatory the suggested schemes for
affording treatment for incipient and non-confirmed cases of mental
disorder, and with that, to a large extent, fail the opportunities for
study on which stress has been laid for adding to the knowledge and
increasing the efficiency of asylum medical officers.” (p. 10.)
Such weighty opinions as these serve to emphasise a further factor in
the urgently needed reform—the necessity for a thorough overhauling of
the law of lunacy, so that, while guarding the liberty of the subject,
every obstacle should be removed that obstructs patients threatened
with the dire calamity of insanity from securing preventive treatment
at the earliest possible moment.
In the _Lancet_ of August 5th, 1916, Dr. L. A. Weatherley writes:—
“The great fact that must be continually brought forward in all these
discussions is that, according to the reports of the Commissioners
in Lunacy, the _recovery-rate of mental diseases is to-day no higher
than it was in the ‘seventies’ of last century_. The ever-increasing
difficulty in getting mental cases with small means quickly under
skilled care must, I feel sure, account to a great extent for this
lamentable fact.”
“Marking time” since the seventies of the last century—how does this
condition compare with that of most of the other branches of medical
science? Heart disease, diphtheria, tuberculosis, tetanus, sepsis of
all kinds, all these troubles and many others have shown unmistakable
signs of yielding to the incessant and many-sided assaults of medical
research. And, of insanity, all we have to report in this country is
“little or no progress for fifty years.” Verily we have buried our
talent deep in the ground.
Finally, we may quote from an article the opening sentences of which
might have been written yesterday, yet it was published in 1849! It
was the fourth report of the visiting committee of Hanwell Asylum. The
committee say:—
“In the constitution of the Hanwell Asylum we are also struck by the
paucity of the medical officers attached to it. There appear in round
numbers to be about 500 patients on the male and 500 on the female
side, yet there is only one resident medical officer attached to each
department, and one visiting physician for the whole establishment.
The inefficiency of so small a medical staff is obvious. If we
look across the Channel we find in Paris that the Salpêtrière,
with its thousand patients, has four times the number of visiting
physicians and ten times the number of resident medical officers. The
disproportion between the sane and the insane is here so great that it
is impossible under such a system to bring any moral influence to bear
upon the afflicted multitude.”
“... There ought to be a more numerous medical staff _and a
permanent clinic_ attached to such an institution.... The County
Asylum of Hanwell, supported largely as it is by county rates and
parish assessments, is as much a hospital as St. George’s or St.
Bartholomew’s, and ought to have a medical staff as numerous and
efficient as those of any other metropolitan hospitals. While charity
might thus be administered upon the highest principles of Christian
benevolence, something ought to be done to advance our knowledge of
science and thereby enable us to relieve the afflictions of suffering
humanity.”
The dust lies thick upon this volume, published a short time before the
_Crimean_, not the present war. And to-day, like this early Victorian
committee, we still ask for clinics, we still ask for scientific work
to be carried out by a more numerous and better equipped staff, we
still look across the Channel with admiration—in short, approving the
better, we follow the worse. We have dawdled away half-a-century and
more in comparative idleness. Now the war has taught us our lesson. Are
we to forget it again?
Excuses for inertia, brought forward before August, 1914, can be
accepted no longer. The thousands of cases of shell-shock which have
been seen in our hospitals since that time have proved, beyond any
possibility of doubt, that the early treatment of mental disorder is
successful from the humanitarian, medical and financial standpoints.
It is for us, not for our children, to act in the light of this great
lesson.
FOOTNOTES:
[74] p. 105.
[75] It should not be forgotten, however, that resort is often made to
alcohol as an easy means of drowning the worry of an incessant mental
conflict. In other words, it is clear that in treating alcoholism,
as in treating insanity, we are not absolved from the plain duty of
seeking its mental cause or causes. “Drink” then, in many cases,
appears rather as a secondary complication than as a primary factor.
[76] _Cf._ W. Aldren Turner, _op. cit._
[77] One of the most gratifying of these is the generous gift of
a clinic to London by Dr. Henry Maudsley. Up to the present this
institution has been rendering valuable service to the country as part
of the 4th London General Military Hospital.
[78] _Appendix to Medico-Psychological Association Report_, p. 18.
[79] “One thing which impressed ... [us] ... when going through ...
the Giessen clinic with Professor Sommer, was the frequency with which
we heard him utter the word ‘recovering’ as we passed the patients.”
_Ibid._, p. 17.
[80] _Op. cit._, p. 2.
[81] _Op. cit._, pp. 15-16.
[82] _Vide infra._
[83] p. 202.
[84] “... at present we have few facilities for teaching the subject,
and the subject is not taught.” (_Medico-Psychological Association’s
Report_, p. 20.)
[85] Concerning this sentence the _British Medical Journal_ wrote, on
Nov. 29th, 1914, “A more severe indictment of the existing system than
is contained in this report it would be difficult to frame.... We can
add nothing to this strongly worded condemnation except an expression
of agreement with the opinion that the statement of the facts submitted
demands the earnest attention of public authorities and all interested
in the welfare of the insane.”
[86] Irrelevant because such books give an account of the morbid
anatomy of the nervous system only as it presents itself after disease
of very long duration.
[87] pp. 82 _et seq._
[88] “The Development of Psychiatric Science as a Branch of Public
Health,” _Journal of Mental Science_, January, 1912.
[89] The gratifying establishment of the Maudsley clinic and the
provision of facilities for out-patient treatment at a few hospitals
in England and Scotland are signs that matters are at last improving.
But we are sure that the physicians in charge of such out-patient
departments would be the first to admit their inadequacy and to urge
the desirability of the psychiatrical clinic of the kind described in
this book.
[90] _Archives of Neurology_, 1903, Vol. II, p. 1.
[91] _Archives of Neurology_, 1907, Vol. III, p. 28.
Index.
_Page_
Agoraphobia, 92
Alcohol and insanity, 106
Allbutt, Sir Clifford, 27, 34
Amendment of Lunacy Law, need for, 130
Appointments in asylums, 116
Asylums, lunatic, 105 _et seq._
Attitude of medical profession to psychology, 102, 106, 111
Attitude of public towards insanity, 78
Analysis, comparison of chemical and psychological, 54
Bacon, Francis, 9
Baltimore Psychiatric Clinic, 110
Bernardin de St. Pierre, 45
Blässig’s case of loss of speech, 43
Boston Psychopathic Hospital, 82
British attitude towards insanity, 79, 120
British medical training, 114
_British Medical Journal_, 4, 5, 18, 106, 116, 129
Burt, C., 3, 17
Butler’s, Samuel, _Erewhon_, 103
Cannon on bodily effects of emotion, 8
Carnegie Foundation’s report, 112
La Charité Hospital, 83
Chloroform, use of in cases of loss of speech, 12
Clinics for treating mental disorders, 84, 107, 121
Clinics, cost of, 125
” functions of, 83, 121
” efficacy of, 82-85, 123
Common sense not infallible, 58
Conflict, mental and moral, 98
Déjerine and Gauckler, 6, 34, 35, 42, 44, 45, 46, 90, 120
Defects of British methods, 120
_Derfflinger_, sailor from German battle-cruiser, 43
Diagnosis, importance of exact, 47 _et seq._
Dreams, 22, 61-63
Emotion of fear, 92
Emotions, 3, 9
Emotional factor as cause of mental disturbance, 71
Evils resulting from delay in treatment, 81
Fear, 92, 95
Financial aspect of reform, 125 _et seq._
Firmness, 28, 31
Flexner’s report on medical education, 110-113
Forgetfulness, 49
Forsyth, D., 4, 8
Freud, S., 63, 73
Gaupp on hysteria, 22, 23
German attitude towards mental disorder, 84
Giessen clinic, 84, 122
Hanwell asylum, 131
Hart, Bernard, 57, 119
Heredity, the influence of, 78, 86, 88, 89
Hesse, experience in, 82
Hypnotism, 36 _et seq._
” usefulness in recent cases, 38
Hypnotism, objections to use of, 39-44
Hysteria, 22, 30, 94
Instincts, 3, 91
International Congress of Medicine, 110
Isolation, treatment by, 32 _et seq._
Isolation, limits to usefulness of, 34, 35
Jung, C. G., 71, 74, 86
Kindness, therapeutic value of, 45
Kraepelin, E., 91
_Lancet_, 4, 5, 14, 37, 130
Law relating to Lunacy, need for amendment, 130
Loss of memory, 43
” sight, 11
” sleep, 7
” speech, 11, 43
Lunacy, need for amendment of law relating to, 130
Lunatic Asylums, 78
Maghull Military Hospitals, 108
_Manchester Guardian_, 24
Maudsley Clinic, 125
Medical education, inadequate teaching in psychology, 100
Medico Psychological Society’s report, 80, 105, 108, 112, 118
Mott, F. W., on clinics, 129
Möhr, on theory of isolation, 32
Munich clinic, work of, 122 _et seq._
Myers, C. S., on hypnotism, 5, 30, 37, 38
Neurotic parents, influence of, 89
Pear, T. H., on effects of loss of sleep, 7
Persuasion, psychotherapy by, 44
Physical basis of disease, 96, 99
Pierce, Bedford, on need for reform, 18, 79, 83, 129
Proportion of cases cured in asylums, 82, 109
Proportion of cases not needing asylum treatment, 82
Psychoanalysis, 73-75
Psychological analysis, 53 _et seq._
Rational treatment, 46
Re-education, 53, 72
Régis, on significance of word “neuropathic”, 94
Reform of methods for dealing with mental disturbance, 128
Research, the importance of, 117
Rows, R. G., 82, 108, 122, 126
Savage, Sir George, 27, 129
Shaw, G. Bernard, 93
_Sherlock Holmes_, 63
Smith, May, on effects of loss of sleep, 7
Sommer, R., 109
Stewart, Purves, 95
Subjective disturbances, 12
Suggestion, 36
Suppression of emotions, 9
Syphilis, 106
Sympathy, 28, 29
Stigma of insanity, 84
Text-books on psychological medicine, inadequacy of, 118
Treatment, 27
Tuberculosis, comparisons with, 77, 85, 114
Turner’s, W. Aldren, report, 14, 108
Unconscious factors, influence of, 57 _et seq._
Understaffing, medical, of asylums for the insane, 81
Weatherley, L. A., 130
Wiltshire, H., 10
Work, therapeutic value of, 50
Worry, relief of, 67, 68
Ziehen, T., 83
Zürich University Psychiatric Clinic, 86
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