Initial commitHEADmain

6 files changed, 11060 insertions, 0 deletions

diff --git a/.gitattributes b/.gitattributes
new file mode 100644
index 0000000..d7b82bc
--- /dev/null
+++ b/.gitattributes
@@ -0,0 +1,4 @@
+*.txt text eol=lf
+*.htm text eol=lf
+*.html text eol=lf
+*.md text eol=lf
diff --git a/75421-0.txt b/75421-0.txt
new file mode 100644
index 0000000..6eba648
--- /dev/null
+++ b/75421-0.txt
@@ -0,0 +1,4767 @@
+
+*** START OF THE PROJECT GUTENBERG EBOOK 75421 ***
+
+
+
+
+
+  Transcriber’s Note
+  Italic text displayed as: _italic_
+
+
+
+
+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
+
+
+
+
+*** END OF THE PROJECT GUTENBERG EBOOK 75421 ***
diff --git a/75421-h/75421-h.htm b/75421-h/75421-h.htm
new file mode 100644
index 0000000..4456bfb
--- /dev/null
+++ b/75421-h/75421-h.htm
@@ -0,0 +1,6276 @@
+<!DOCTYPE html>
+<html lang="en">
+<head>
+    <meta charset="UTF-8">
+    <title>
+      Shell Shock and Its Lessons | Project Gutenberg
+    </title>
+    <link rel="icon" href="images/cover.jpg" type="image/x-cover">
+    <style>
+
+body {
+    margin-left: 10%;
+    margin-right: 10%;
+}
+
+    h1,h2,h3 {
+    text-align: center; /* all headings centered */
+    clear: both;
+}
+
+p {
+    margin-top: .51em;
+    text-align: justify;
+    margin-bottom: .49em;
+    text-indent: 1em;
+}
+
+hr {
+    width: 33%;
+    margin-top: 2em;
+    margin-bottom: 2em;
+    margin-left: 33.5%;
+    margin-right: 33.5%;
+    clear: both;
+}
+
+hr.chap {width: 65%; margin-left: 17.5%; margin-right: 17.5%;}
+ 
+div.chapter {page-break-before: always;}
+h2.nobreak  {page-break-before: avoid;}
+
+ul.index { list-style-type: none; }
+li.ifrst {
+    margin-top: 1em;
+    text-indent: -2em;
+    padding-left: 1em;
+}
+li.indx  {
+    margin-top: .5em;
+    text-indent: -2em;
+    padding-left: 1em;
+}
+
+table {
+    margin-left: auto;
+    margin-right: auto;
+}
+table.autotable    { border-collapse: collapse; }
+
+.tdl      {text-align: left; line-height: 1.5em;}
+.tdr      {text-align: right;}
+.tdc      {text-align: center; line-height: 1em;}
+
+.pagenum { /* uncomment the next line for invisible page numbers */
+    /*  visibility: hidden;  */
+    position: absolute;
+    left: 92%;
+    font-size: small;
+    text-align: right;
+    font-style: normal;
+    font-weight: normal;
+    font-variant: normal;
+    text-indent: 0;
+    color: #A9A9A9;
+} /* page numbers */
+
+.blockquot {
+    margin-left: 5%;
+    margin-right: 10%;
+}
+
+.center   {text-align: center;}
+
+.right    {text-align: right;}
+
+.smcap    {font-variant: small-caps;}
+
+/* Images */
+
+img {
+    max-width: 100%;
+    height: auto;
+}
+
+
+.figcenter {
+    margin: auto;
+    text-align: center;
+    page-break-inside: avoid;
+    max-width: 100%;
+}
+
+/* Footnotes */
+.footnotes        {border: 1px dashed;}
+
+.footnote         {margin-left: 10%; margin-right: 10%; font-size: 0.9em;}
+
+.footnote .label  {position: absolute; right: 84%; text-align: right;}
+
+.fnanchor {
+    vertical-align: super;
+    font-size: .8em;
+    text-decoration:
+    none;
+}
+
+
+.fs70 {font-size: 70%}
+.fs80 {font-size: 80%}
+.fs90 {font-size: 90%}
+.fs120 {font-size: 120%}
+
+.no-indent {text-indent: 0em;}
+.bold {font-weight: bold;}
+.wsp {word-spacing: 0.3em;}
+
+p.drop-cap {
+  text-indent: 0em;
+}
+p.drop-cap:first-letter
+{
+  float: left;
+  margin: 0em 0.1em 0em 0em;
+  font-size: 250%;
+  line-height:0.85em;
+}
+
+.upper-case
+{
+  text-transform: uppercase;
+}
+
+    </style>
+</head>
+<body>
+<div style='text-align:center'>*** START OF THE PROJECT GUTENBERG EBOOK 75421 ***</div>
+
+<div class="figcenter" style="width: 85%">
+<img src="images/cover.jpg" alt="Cover">
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p class="center no-indent fs120 wsp bold">SHELL SHOCK</p>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p class="center no-indent fs90">
+Published by the University of Manchester at<br>
+THE UNIVERSITY PRESS (<span class="smcap">H. M. McKechnie</span>, Secretary)<br>
+12, Lime Grove, Oxford Road, Manchester.<br>
+<br>
+<span class="smcap">Longmans, Green &amp; Co.</span><br>
+London: 39, Paternoster Row<br>
+New York: 443-449, Fourth Avenue and Thirtieth Street<br>
+Chicago: Prairie Avenue and Twenty-fifth Street<br>
+Bombay: Hornby Road<br>
+Calcutta: 6, Old Court House Street<br>
+Madras: 167, Mount Road<br>
+</p>
+</div>
+
+<hr class="chap x-ebookmaker-drop">
+
+
+<div class="chapter">
+<h1>
+SHELL SHOCK<br>
+AND ITS LESSONS</h1>
+<br>
+<p class="center no-indent wsp"><span class="fs70">BY</span><br>
+G. ELLIOT SMITH, M.A., M.D., F.R.C.P., F.R.S.<br>
+<span class="fs80"><em>Dean of the Faculty of Medicine and Professor of Anatomy</em></span><br>
+<br>
+<span class="fs70">AND</span><br>
+T. H. PEAR, B.Sc.<br>
+<span class="fs80"><em>Lecturer in Experimental Psychology</em></span></p>
+<br>
+<br>
+<br>
+<p class="center no-indent fs80 wsp">MANCHESTER<br>
+AT THE UNIVERSITY PRESS<br>
+<span class="smcap">12, Lime Grove, Oxford Road</span><br>
+<br>
+LONGMANS, GREEN &amp; CO.<br>
+<span class="smcap">London, New York, Bombay, Etc.</span><br>
+<br>
+1917</p>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p class="center no-indent fs80 wsp">
+PUBLICATIONS OF THE UNIVERSITY OF MANCHESTER<br>
+<br>
+No. CXI.</p>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p class="center no-indent wsp">
+To<br>
+<span class="smcap">Major</span> R. G. ROWS, M.D., R.A.M.C.<br>
+</p>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_vi">[Pg vi]</span></p>
+
+<h2 class="nobreak" id="Contents">Contents.</h2>
+</div>
+
+
+<table class="autotable">
+<tr>
+<td class="tdl"></td>
+<td class="tdr"><em>Page</em></td>
+</tr>
+<tr>
+<td class="tdl"><span class="smcap">Preface</span></td>
+<td class="tdr"><a href="#Page_vii">vii</a></td>
+</tr>
+<tr>
+<td class="tdl"><span class="smcap">Introduction</span></td>
+<td class="tdr"><a href="#Page_ix">ix</a></td>
+</tr>
+<tr>
+<td class="tdc" colspan="2"><br>CHAPTER I.</td>
+</tr>
+<tr>
+<td class="tdl"><span class="smcap">The Nature of Shell-Shock</span></td>
+<td class="tdr"><a href="#Page_1">1</a></td>
+</tr>
+<tr>
+<td class="tdc" colspan="2"><br>CHAPTER II.</td>
+</tr>
+<tr>
+<td class="tdl"><span class="smcap">Treatment</span></td>
+<td class="tdr"><a href="#Page_27">27</a></td>
+</tr>
+<tr>
+<td class="tdc" colspan="2"><br>CHAPTER III.</td>
+</tr>
+<tr>
+<td class="tdl"><span class="smcap">Psychological Analysis and Re-Education</span></td>
+<td class="tdr"><a href="#Page_53">53</a></td>
+</tr>
+<tr>
+<td class="tdc" colspan="2"><br>CHAPTER IV.</td>
+</tr>
+<tr>
+<td class="tdl"><span class="smcap">Some General Considerations</span></td>
+<td class="tdr"><a href="#Page_77">77</a></td>
+</tr>
+<tr>
+<td class="tdc" colspan="2"><br>CHAPTER V.</td>
+</tr>
+<tr>
+<td class="tdl"><span class="smcap">Some Lessons of the War</span></td>
+<td class="tdr"><a href="#Page_105">105</a></td>
+</tr>
+<tr>
+<td class="tdl"><span class="smcap">Index</span></td>
+<td class="tdr"><a href="#Page_133">133</a></td>
+</tr>
+</table>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_vii">[Pg vii]</span></p>
+
+<h2 class="nobreak" id="Preface">Preface.</h2>
+</div>
+
+
+<p class="drop-cap"><span class="upper-case">Our</span> 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 <span class="smcap">R. G. Rows</span>,
+M.D., R.A.M.C., for his unfailing interest, encouragement and
+help; to Captains <span class="smcap">W. H. R. Rivers</span>, M.D., F.R.C.P., F.R.S.,
+and <span class="smcap">J. W. Astley Cooper</span> of the R.A.M.C., and Mr. <span class="smcap">E.
+Gleaves</span>, M.Sc., for their valuable suggestions and assistance
+in the preparation of the manuscript; to Captain <span class="smcap">W. E. Sawers
+Scott</span>, M.D., R.A.M.C., Dr. <span class="smcap">Albert Hopkinson</span> and Mr.
+<span class="smcap">W. Percy Stocks</span>, F.R.C.S., of Manchester, for help in other
+ways; and to our colleague, Professor <span class="smcap">H. Bompas Smith</span>, for
+reading the proofs and helping us to eliminate some of the
+more glaring literary defects. To the Editor of the <cite>Lancet</cite> 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.</p>
+
+<p class="right">
+G. E. S.<br>
+T. H. P.</p>
+<p class="no-indent fs80">
+<span class="smcap">The Medical School,<br>
+<span style="padding-left: 2em">The University,</span><br>
+<span style="padding-left: 4em">Manchester.</span></span><br>
+<br>
+<em>20th April, 1917.</em><br>
+</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_ix">[Pg ix]</span></p>
+
+<h2 class="nobreak" id="Introduction">Introduction.</h2>
+</div>
+
+<p class="drop-cap"><span class="upper-case">Some</span> 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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_x">[Pg x]</span>
+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.</p>
+
+<p>It is because we believe that a similar probing of the
+<em>public</em> 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.</p>
+
+<p>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<span class="pagenum" id="Page_xi">[Pg xi]</span>
+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?</p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_1">[Pg 1]</span></p>
+
+<h2 class="nobreak" id="CHAPTER_I">CHAPTER I.<br>
+<span class="fs120">The Nature of Shell-Shock.</span></h2>
+</div>
+
+<p class="drop-cap"><span class="upper-case">A French</span> doctor has said, “Il n’y a pas de
+maladies; il n’y a que des malades.”<a id="FNanchor_1" href="#Footnote_1" class="fnanchor">[1]</a> 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.</p>
+
+<p>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<span class="pagenum" id="Page_2">[Pg 2]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_3">[Pg 3]</span>
+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.</p>
+
+<p>In a word, it is not in the intellectual but in the
+<em>emotional</em> 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.<a id="FNanchor_2" href="#Footnote_2" class="fnanchor">[2]</a> And as we shall see
+later, in the re-education of the patient, the physician is
+compelled continually to take this fact into account.</p>
+
+<p>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 <em>without prejudice</em>, and the doctor who wishes
+to be of real help to him must make up his mind to<span class="pagenum" id="Page_4">[Pg 4]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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. <em>It is only in this way that any
+scientific insight into a case of mental disorder can
+be obtained.</em></p>
+
+<p>A short time spent in such interviews, or even the
+perusal, by the uninitiated, of the papers already published
+in the <cite>Lancet</cite>, <cite>British Medical Journal</cite>, and elsewhere<a id="FNanchor_3" href="#Footnote_3" class="fnanchor">[3]</a>,
+will convince one of the immense complexity of<span class="pagenum" id="Page_5">[Pg 5]</span>
+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.”<a id="FNanchor_4" href="#Footnote_4" class="fnanchor">[4]</a> The
+patient often discloses in the first interview the fact that
+he was displaying all his present symptoms <em>before</em> the
+arrival of the particular shell which laid him out.</p>
+
+<p>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.”</p>
+
+<p>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.<a id="FNanchor_5" href="#Footnote_5" class="fnanchor">[5]</a></p>
+
+<p>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<span class="pagenum" id="Page_6">[Pg 6]</span>
+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.<a id="FNanchor_6" href="#Footnote_6" class="fnanchor">[6]</a></p>
+
+<p>It must be remembered that one of the greatest sources
+of breakdown under such circumstances is intense and
+frequently repeated emotion.<a id="FNanchor_7" href="#Footnote_7" class="fnanchor">[7]</a> 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.)</p>
+
+<p>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<span class="pagenum" id="Page_7">[Pg 7]</span>
+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.<a id="FNanchor_8" href="#Footnote_8" class="fnanchor">[8]</a></p>
+
+<p>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.</p>
+
+<p>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
+<em>outward</em> 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<span class="pagenum" id="Page_8">[Pg 8]</span>
+of danger than before. Dr. Forsyth<a id="FNanchor_9" href="#Footnote_9" class="fnanchor">[9]</a> 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.</p>
+
+<p>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.<a id="FNanchor_10" href="#Footnote_10" class="fnanchor">[10]</a></p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_9">[Pg 9]</span>
+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.”</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_10">[Pg 10]</span>
+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.<a id="FNanchor_11" href="#Footnote_11" class="fnanchor">[11]</a> 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.</p>
+
+<p>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<span class="pagenum" id="Page_11">[Pg 11]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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 <em>Hesperian</em>
+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<span class="pagenum" id="Page_12">[Pg 12]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>Not every nerve-case, however, presents such striking
+and objective signs as those which we have just been
+describing. The <em>subjective</em> disturbances, which are apt
+to go undiscovered in a cursory examination of the
+patient, are frequently more serious than the objective,<a id="FNanchor_12" href="#Footnote_12" class="fnanchor">[12]</a>
+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<span class="pagenum" id="Page_13">[Pg 13]</span>
+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.”</p>
+
+<p>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<a id="FNanchor_13" href="#Footnote_13" class="fnanchor">[13]</a>—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<span class="pagenum" id="Page_14">[Pg 14]</span>
+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.</p>
+
+<p>These considerations have led the military authorities
+to establish special hospitals for nerve-cases.<a id="FNanchor_14" href="#Footnote_14" class="fnanchor">[14]</a> 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.</p>
+
+<p>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<span class="pagenum" id="Page_15">[Pg 15]</span>
+auxiliary hospital full of straightforward wound cases.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_16">[Pg 16]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.”</p>
+
+<p><span class="pagenum" id="Page_17">[Pg 17]</span></p>
+
+<p>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,”<a id="FNanchor_15" href="#Footnote_15" class="fnanchor">[15]</a> 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<a id="FNanchor_16" href="#Footnote_16" class="fnanchor">[16]</a> 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.</p>
+
+<p>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<a id="FNanchor_17" href="#Footnote_17" class="fnanchor">[17]</a> beliefs held by even a
+highly educated person have ever been logically reasoned
+out from fundamental principles. In fact such principles<span class="pagenum" id="Page_18">[Pg 18]</span>
+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:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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.”<a id="FNanchor_18" href="#Footnote_18" class="fnanchor">[18]</a></p>
+</div>
+
+<p>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.<a id="FNanchor_19" href="#Footnote_19" class="fnanchor">[19]</a></p>
+
+<p>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<span class="pagenum" id="Page_19">[Pg 19]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.,<a id="FNanchor_20" href="#Footnote_20" class="fnanchor">[20]</a><span class="pagenum" id="Page_20">[Pg 20]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>Two cases may be quoted here in illustration of some
+of these assertions:</p>
+
+<p>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<span class="pagenum" id="Page_21">[Pg 21]</span>
+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.</p>
+
+<p>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<span class="pagenum" id="Page_22">[Pg 22]</span>
+required to build up anew the man’s confidence in himself.</p>
+
+<p>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—<em>i.e.</em>, 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.</p>
+
+<p>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.<a id="FNanchor_21" href="#Footnote_21" class="fnanchor">[21]</a> 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<span class="pagenum" id="Page_23">[Pg 23]</span>
+them having enlisted in the earliest stages of the war.</p>
+
+<p>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.</p>
+
+<div class="blockquot fs90">
+
+<p>“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.”<a id="FNanchor_22" href="#Footnote_22" class="fnanchor">[22]</a></p>
+</div>
+
+<p>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.</p>
+
+<div class="blockquot fs90">
+
+<p>“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<span class="pagenum" id="Page_24">[Pg 24]</span>
+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.”<a id="FNanchor_23" href="#Footnote_23" class="fnanchor">[23]</a></p>
+</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Another point which should be emphasised is this:
+shell-shock involves no <em>new</em> symptoms or disorders.<span class="pagenum" id="Page_25">[Pg 25]</span>
+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.</p>
+
+<p>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.</p>
+<br>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote">
+
+<p><a id="Footnote_1" href="#FNanchor_1" class="label">[1]</a> There are no sicknesses, there are only sick people.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_2" href="#FNanchor_2" class="label">[2]</a> This subject has been lucidly discussed by C. Burt, “Psychology
+and the Emotions,” <cite>School Hygiene</cite>, May, 1916.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_3" href="#FNanchor_3" class="label">[3]</a> Such as for instance, D. Forsyth, <cite>Lancet</cite>, Dec. 25th, 1915,
+p. 1399; C. S. Myers, <cite>Lancet</cite>, Mar. 18th, p. 608; R. G. Rows,
+<cite>Brit. Med. Jour.</cite>, Mar. 25th, 1916, p. 441; G. Elliot Smith,
+<cite>Lancet</cite>, April 15th and 22nd, 1916; H. Wiltshire, <cite>Lancet</cite>, June
+17th, 1916.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_4" href="#FNanchor_4" class="label">[4]</a> Wiltshire, <em>op. cit.</em>, p. 1210.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_5" href="#FNanchor_5" class="label">[5]</a> On pp. 4, 5.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_6" href="#FNanchor_6" class="label">[6]</a> The reader who is interested in these important distinctions
+should consult McDougall, <cite>Social Psychology</cite>, London, 1915,
+p. 116.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_7" href="#FNanchor_7" class="label">[7]</a> <em>Cf.</em> 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.”</p>
+
+<p>(<cite>The Psychoneuroses and their Treatment by Psychotherapy</cite>,
+Jelliffe’s translation, 1913, p. 232.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_8" href="#FNanchor_8" class="label">[8]</a> 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, <cite>Proceedings of
+London County Council Conference of Teachers</cite>, 1914.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_9" href="#FNanchor_9" class="label">[9]</a> <em>Op. cit.</em>, p. 1402.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_10" href="#FNanchor_10" class="label">[10]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_11" href="#FNanchor_11" class="label">[11]</a> 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. (<em>Op.
+cit.</em>, p. 1207.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_12" href="#FNanchor_12" class="label">[12]</a> This fact is in danger of being overlooked by members of
+the public whose knowledge of “shock” is obtained from the
+newspaper reports.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_13" href="#FNanchor_13" class="label">[13]</a> R. G. Rows, <em>op. cit.</em>, p. 441.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_14" href="#FNanchor_14" class="label">[14]</a> For particulars of these hospitals, see W. Aldren Turner’s
+Report, <cite>Lancet</cite>, May 27th, 1916, p. 1073. The reports published
+in the special war numbers of the <cite>Revue Neurologique</cite> (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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_15" href="#FNanchor_15" class="label">[15]</a> 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, <em>q. v.</em>)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_16" href="#FNanchor_16" class="label">[16]</a> On pp. 12, 13.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_17" href="#FNanchor_17" class="label">[17]</a> (and, obviously, the same may be said of not a few ‘scientific’
+beliefs.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_18" href="#FNanchor_18" class="label">[18]</a> <cite>Principles of Psychology</cite>, II., 283-324.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_19" href="#FNanchor_19" class="label">[19]</a> The opinions of Dr. Bedford Pierce upon this matter are
+highly important. <cite>British Medical Journal</cite>, January 8th, 1916,
+p. 4.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_20" href="#FNanchor_20" class="label">[20]</a> Our personal experience has been of privates and non-commissioned
+officers only, but there is no <i lang="la" xml:lang="la">a priori</i> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_21" href="#FNanchor_21" class="label">[21]</a> “Hysterie und Kriegsdienst” (Hysteria and War Service),
+<em>Münchener Medizinische Wochenschrift</em>, March 16th, 1915.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_22" href="#FNanchor_22" class="label">[22]</a> The translation is very free, but it fairly represents the
+sense of the German original.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_23" href="#FNanchor_23" class="label">[23]</a> From a leading article on “War-Shock and its Treatment,”
+in the <cite>Manchester Guardian</cite>.</p>
+
+</div>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_27">[Pg 27]</span></p>
+
+<h2 class="nobreak" id="CHAPTER_II">CHAPTER II.<br>
+<span class="fs120">Treatment.</span></h2>
+</div>
+
+<p class="drop-cap"><span class="upper-case">In</span> 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.<a id="FNanchor_24" href="#Footnote_24" class="fnanchor">[24]</a> 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.<a id="FNanchor_25" href="#Footnote_25" class="fnanchor">[25]</a> These
+are questions which may confidently be left to the discretion
+of the physician in charge.</p>
+
+<p><span class="pagenum" id="Page_28">[Pg 28]</span></p>
+
+<p class="no-indent"><em>Firmness and Sympathy.</em></p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_29">[Pg 29]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>But sympathy of the injudicious kind is not <em>real</em>
+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 <em>with</em>
+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.</p>
+
+<p>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,<span class="pagenum" id="Page_30">[Pg 30]</span>
+to aggravate his troubles or even to discourage him from
+trying to recover.<a id="FNanchor_26" href="#Footnote_26" class="fnanchor">[26]</a> Perhaps it would be more accurate
+to say that such treatment gives him no inducement to
+get better.</p>
+
+<p>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
+“<em>detecting</em>,” instead of <em>diagnosing</em> hysteria.)</p>
+
+<p>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.<a id="FNanchor_27" href="#Footnote_27" class="fnanchor">[27]</a></p>
+
+<p>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.</p>
+
+<p>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.”</p>
+
+<p>We are not maintaining that such methods do not
+often meet with success in the case of many patients who<span class="pagenum" id="Page_31">[Pg 31]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_32">[Pg 32]</span>
+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.</p>
+<br>
+
+<p><em>Isolation.</em> 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.</p>
+
+<p>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<span class="pagenum" id="Page_33">[Pg 33]</span>
+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.<a id="FNanchor_28" href="#Footnote_28" class="fnanchor">[28]</a></p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_34">[Pg 34]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.<a id="FNanchor_29" href="#Footnote_29" class="fnanchor">[29]</a></p>
+
+<p>Déjerine and Gauckler<a id="FNanchor_30" href="#Footnote_30" class="fnanchor">[30]</a> 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,<span class="pagenum" id="Page_35">[Pg 35]</span>
+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, <em>i.e.</em>, 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.</p>
+
+<p>When Déjerine and Gauckler proceed to define the
+different degrees in which the method of isolation may be
+practised; <em>viz.</em>: (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.</p>
+
+<p>Even when writing of hysterical women these French
+physicians tell us that—</p>
+
+<div class="blockquot fs90">
+
+<p class="no-indent">“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<span class="pagenum" id="Page_36">[Pg 36]</span>
+which belongs to an isolation ward much more for
+humanitarian and social reasons than because absolute isolation
+seemed to be formally indicated.”<a id="FNanchor_31" href="#Footnote_31" class="fnanchor">[31]</a></p>
+</div>
+
+<p>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.</p>
+<br>
+
+<p><em>Suggestion and Hypnosis.</em> 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, <em>enlightened</em> stubbornness<span class="pagenum" id="Page_37">[Pg 37]</span>
+will be fatal to any further hope of influence on the part
+of that particular physician.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <cite>Lancet</cite>.<a id="FNanchor_32" href="#Footnote_32" class="fnanchor">[32]</a> When it is possible by
+such means to restore to the patient his lost memory or<span class="pagenum" id="Page_38">[Pg 38]</span>
+speech or banish his despondency it often proves that
+the only hindrance to the complete restoration of his
+normal personality has been removed.</p>
+
+<div class="blockquot fs90">
+
+<p>“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.</p>
+
+<p>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.”<a id="FNanchor_33" href="#Footnote_33" class="fnanchor">[33]</a></p>
+</div>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_39">[Pg 39]</span>
+for these cases, though undoubtedly it may be of great
+use as a part of such treatment.</p>
+
+<p>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.</p>
+
+<p>The following instance illustrates the use of hypnotic
+suggestion in the manner described above.</p>
+
+<p>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.</p>
+
+<p>Long continued treatment by persuasion failed to effect
+any improvement whatsoever. The medical officer in
+charge of the case therefore decided to try hypnotic<span class="pagenum" id="Page_40">[Pg 40]</span>
+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 <em>following his own effort</em>, 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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 <em>alone</em> 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<span class="pagenum" id="Page_41">[Pg 41]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_42">[Pg 42]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Both the danger and the possible usefulness of hypnotism<span class="pagenum" id="Page_43">[Pg 43]</span>
+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.</p>
+
+<p>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 <em>Derfflinger</em>, recorded by Blässig.<a id="FNanchor_34" href="#Footnote_34" class="fnanchor">[34]</a></p>
+
+<p><span class="pagenum" id="Page_44">[Pg 44]</span></p>
+
+<div class="blockquot fs90">
+
+<p>“A seaman from the <em>Derfflinger</em> 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.”</p>
+</div>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<div class="blockquot fs90">
+
+<p>“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 <em>persuasion</em>.’ “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<span class="pagenum" id="Page_45">[Pg 45]</span>
+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....”<a id="FNanchor_35" href="#Footnote_35" class="fnanchor">[35]</a></p>
+</div>
+
+<p>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:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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].</p>
+
+<p>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<span class="pagenum" id="Page_46">[Pg 46]</span>
+with the hand of the Samaritan. It is an art known only to
+sensitive and sympathetic souls.</p>
+
+<p>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 (<cite>Etude de la Nature</cite>, 1784).”</p>
+</div>
+
+<p>Déjerine and Gauckler add:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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.</p>
+
+<p>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.”<a id="FNanchor_36" href="#Footnote_36" class="fnanchor">[36]</a></p>
+</div>
+<br>
+
+<p><em>Rational Treatment.</em> So far in this chapter we have
+been discussing what may be described as general
+methods of treatment, which do not <em>necessarily</em> 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.</p>
+
+<p>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;<span class="pagenum" id="Page_47">[Pg 47]</span>
+but it is the primary object of this book to insist that
+<em>it is equally necessary to observe the same principle in
+the case of mental illness</em>.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_48">[Pg 48]</span>
+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.</p>
+
+<p>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 <em>individual and
+personal</em>. 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.</p>
+
+<p>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.</p>
+
+<p>Amongst those whom experience has convinced of the<span class="pagenum" id="Page_49">[Pg 49]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_50">[Pg 50]</span>
+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.</p>
+<br>
+
+<p class="no-indent"><em>The Therapeutic Value of Work.</em></p>
+
+<p>It should be unnecessary to emphasise the desirability
+of preventing the neurasthenic from dwelling upon his<span class="pagenum" id="Page_51">[Pg 51]</span>
+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<span class="pagenum" id="Page_52">[Pg 52]</span>
+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; <em>viz.</em>, 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.</p>
+
+<p>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.</p>
+<br>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote">
+
+<p><a id="Footnote_24" href="#FNanchor_24" class="label">[24]</a> Such, for example, as those set forth in the series of
+articles in Vol. VIII, of Sir Clifford Allbutt’s <cite>System of
+Medicine</cite>, 1899, pp. 88-233.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_25" href="#FNanchor_25" class="label">[25]</a> 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 <cite>System of Medicine</cite>, pp. 191-195.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_26" href="#FNanchor_26" class="label">[26]</a> Or in some mild cases, to encourage him to wish to
+remain an invalid under such pleasant conditions.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_27" href="#FNanchor_27" class="label">[27]</a> 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,” <cite>Lancet</cite>,
+Sept. 9th, 1916, p. 467.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_28" href="#FNanchor_28" class="label">[28]</a> This explanation of the reasons for the use of isolation is taken
+from Mohr’s article in Lewandowsky’s <cite>Handbuch der Neurologie</cite>.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_29" href="#FNanchor_29" class="label">[29]</a> As Sir Clifford Allbutt has pointed out (<em>op. cit.</em>, p. 158).</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_30" href="#FNanchor_30" class="label">[30]</a> <cite>The Psychoneuroses and their Treatment by Psychotherapy</cite>,
+translated from the French by Jelliffe, 2nd Edition,
+1913, p. 311.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_31" href="#FNanchor_31" class="label">[31]</a> <em>Op. cit.</em>, p. 315.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_32" href="#FNanchor_32" class="label">[32]</a> Feb. 13th, 1915 (p. 316); Jan. 8th, 1916 (p. 65); Mar.
+18th, 1916 (p. 608); and Sept. 9th, 1916 (p. 461).</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_33" href="#FNanchor_33" class="label">[33]</a> <em>Op. cit.</em>, p. 69.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_34" href="#FNanchor_34" class="label">[34]</a> <cite>Münchener Medizinische Wochenschrift</cite>, June 15th, 1915,
+p. 335.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_35" href="#FNanchor_35" class="label">[35]</a> Déjerine and Gauckler, <em>op. cit.</em>, p. 283.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_36" href="#FNanchor_36" class="label">[36]</a> <em>Op. cit.</em>, pp. 302-3.</p>
+
+</div>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_53">[Pg 53]</span></p>
+<h2 class="nobreak" id="CHAPTER_III">CHAPTER III.<br>
+<span class="fs120">Psychological Analysis and<br>
+Re-education.</span></h2>
+</div>
+
+<p class="drop-cap"><span class="upper-case">The</span> 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<span class="pagenum" id="Page_54">[Pg 54]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_55">[Pg 55]</span></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_56">[Pg 56]</span></p>
+
+<p>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.</p>
+
+<p>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,<a id="FNanchor_37" href="#Footnote_37" class="fnanchor">[37]</a> 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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_57">[Pg 57]</span>
+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.<a id="FNanchor_38" href="#Footnote_38" class="fnanchor">[38]</a> 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 <em>chemical analysis</em> as well as to anatomical
+dissection.</p>
+
+<p>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,<a id="FNanchor_39" href="#Footnote_39" class="fnanchor">[39]</a> but in more advanced cases, or those
+of longer standing, real analysis is necessary in order
+to get at the unknown factors.</p>
+
+<p>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<span class="pagenum" id="Page_58">[Pg 58]</span>
+has called in the unconscious as a means of explanation,
+psychology becomes a mere “tumbling ground for
+whimsies.”</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.”<a id="FNanchor_40" href="#Footnote_40" class="fnanchor">[40]</a></p>
+
+<p><span class="pagenum" id="Page_59">[Pg 59]</span></p>
+
+<p>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<a id="FNanchor_41" href="#Footnote_41" class="fnanchor">[41]</a> and with the help of a
+second person skilful in such investigation.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_60">[Pg 60]</span>
+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?</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_61">[Pg 61]</span></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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,<a id="FNanchor_42" href="#Footnote_42" class="fnanchor">[42]</a> other methods of obtaining data are possible to<span class="pagenum" id="Page_62">[Pg 62]</span>
+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.</p>
+
+<p>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<span class="pagenum" id="Page_63">[Pg 63]</span>
+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.</p>
+
+<p>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.<a id="FNanchor_43" href="#Footnote_43" class="fnanchor">[43]</a> 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.</p>
+
+<p>Another objection, however, is frequently levelled<span class="pagenum" id="Page_64">[Pg 64]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_65">[Pg 65]</span>
+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.</p>
+
+<p>We may therefore dismiss the æsthetic objection as
+unworthy of the consideration either of a conscientious
+doctor, or of a reasonable patient.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_66">[Pg 66]</span>
+recognised that the convention exists, and like all social
+usages is extremely tenacious.</p>
+
+<p>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 <i lang="la" xml:lang="la">sine quâ non</i> 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.</p>
+
+<p>But not all visits to the doctor end so briefly or so
+easily as this. The patient’s trouble, on examination, may<span class="pagenum" id="Page_67">[Pg 67]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_68">[Pg 68]</span>
+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.<a id="FNanchor_44" href="#Footnote_44" class="fnanchor">[44]</a>
+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.</p>
+
+<p>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—<em>i.e.</em>,
+intimately interwoven into the tissues of the whole of his
+experience—is an assumption which has no foundation in
+fact.</p>
+
+<p>The point cannot be too much emphasised that many
+of these patients are quite sane, if conduct be regarded<span class="pagenum" id="Page_69">[Pg 69]</span>
+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.</p>
+
+<p>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 <i lang="fr" xml:lang="fr">reculer pour mieux sauter</i>. This
+procedure is often inevitable in the medical treatment of
+many disorders which have become complicated to any
+considerable extent.</p>
+
+<p>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<span class="pagenum" id="Page_70">[Pg 70]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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,<span class="pagenum" id="Page_71">[Pg 71]</span>
+they express valuable reminders that this delicate and
+powerful instrument, like all others with these attributes,
+must be used with care and discretion.</p>
+
+<p>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 <em>mental</em>. A neurosis may be regarded
+as the failure of an act of adaptation.<a id="FNanchor_45" href="#Footnote_45" class="fnanchor">[45]</a> 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.</p>
+
+<p>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<span class="pagenum" id="Page_72">[Pg 72]</span>
+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.</p>
+
+<p>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<a id="FNanchor_46" href="#Footnote_46" class="fnanchor">[46]</a> 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.</p>
+
+<p>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<span class="pagenum" id="Page_73">[Pg 73]</span>
+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.</p>
+
+<p>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<a id="FNanchor_47" href="#Footnote_47" class="fnanchor">[47]</a>,
+of Paris.</p>
+
+<p>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.</p>
+
+<p>It should be pointed out that much of the heated
+discussion which has raged around this word psychoanalysis<span class="pagenum" id="Page_74">[Pg 74]</span>
+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
+<em>method</em>; “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.”<a id="FNanchor_48" href="#Footnote_48" class="fnanchor">[48]</a></p>
+
+<p>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.</p>
+
+<p>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,<a id="FNanchor_49" href="#Footnote_49" class="fnanchor">[49]</a> and other mental phenomena, the doctor
+may use them freely without thereby subscribing to any
+one “doctrine of psychoanalysis.”</p>
+
+<p>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.</p>
+
+<p>When we come to consider the theoretical presuppositions
+which underlie the different methods of re-education<span class="pagenum" id="Page_75">[Pg 75]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+<br>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote">
+
+<p><a id="Footnote_37" href="#FNanchor_37" class="label">[37]</a> Such development involves a complicated set of processes
+the nature of which is by no means obvious to unaided
+common sense.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_38" href="#FNanchor_38" class="label">[38]</a> “... 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, <cite>The Psychology of Insanity</cite>, Cambridge, 1914, p. 32.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_39" href="#FNanchor_39" class="label">[39]</a> <em>Cf.</em> p. 15<em>f.</em></p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_40" href="#FNanchor_40" class="label">[40]</a> <em>Cf.</em> Hart, <em>op. cit.</em>, p. 66<em>f.</em></p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_41" href="#FNanchor_41" class="label">[41]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_42" href="#FNanchor_42" class="label">[42]</a> It should not be forgotten that when a patient in an early
+stage of mental disorder voluntarily seeks the doctor, his
+<em>active co-operation</em> 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. (<em>Cf.</em> K. Jasper’s
+<cite>Allgemeine Psychopathologie</cite>, Berlin, 1913, p. 317.) Such
+attitudes of the patient are obviously strengthened by our
+present custom of delaying the treatment of mental disorder.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_43" href="#FNanchor_43" class="label">[43]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_44" href="#FNanchor_44" class="label">[44]</a> p. 17<em>f.</em></p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_45" href="#FNanchor_45" class="label">[45]</a> Dr. C. G. Jung’s view, <cite>Analytic Psychology</cite>, p. 234.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_46" href="#FNanchor_46" class="label">[46]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_47" href="#FNanchor_47" class="label">[47]</a> CORRECTION.</p>
+
+<p>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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_48" href="#FNanchor_48" class="label">[48]</a> <em>Op. cit.</em>, p. 256<em>f.</em></p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_49" href="#FNanchor_49" class="label">[49]</a> <em>Cf.</em> Hart, <em>op. cit.</em>, p. 69<em>f.</em>, Jung, <em>op. cit.</em></p>
+
+</div>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_77">[Pg 77]</span></p>
+<h2 class="nobreak" id="CHAPTER_IV">CHAPTER IV.<br>
+<span class="fs120">Some General Considerations.</span></h2>
+</div>
+
+<p class="drop-cap"><span class="upper-case">It</span> is instructive to compare the public attitude towards
+insanity with that adopted in the case of another
+serious disease, tuberculosis.</p>
+
+<p>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<span class="pagenum" id="Page_78">[Pg 78]</span>
+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.</p>
+
+<p>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.”<a id="FNanchor_50" href="#Footnote_50" class="fnanchor">[50]</a>
+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.<a id="FNanchor_51" href="#Footnote_51" class="fnanchor">[51]</a> The attitude of the general public is<span class="pagenum" id="Page_79">[Pg 79]</span>
+not deliberately cruel, but it appears to be far more
+benevolent than it really is. The community treats the
+sufferer well, when, <em>but not before</em>, 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.
+<em>That is the British procedure to-day.</em></p>
+
+<p>Lest we should be accused of exaggeration, or worse,
+we will quote here from published articles and reports.</p>
+
+<p>Dr. Bedford Pierce says:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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.</p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_80">[Pg 80]</span></p>
+
+<p>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.” (<em>Op. cit.</em>, p. <a href="#Page_42">42</a>.)</p>
+</div>
+
+<p>In the words of the report of the Medico-Psychological
+Association:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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.</p>
+
+<p><em>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.</em>”<a id="FNanchor_52" href="#Footnote_52" class="fnanchor">[52]</a></p>
+</div>
+
+<p>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.</p>
+
+<p>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 <em>of his own free will</em>, often obtaining
+treatment in a relatively early stage of the disease.</p>
+
+<p>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<span class="pagenum" id="Page_81">[Pg 81]</span>
+which is extremely helpful and important in mild and
+uncomplicated cases of relatively recent occurrence, but
+of which, as we have seen,<a id="FNanchor_53" href="#Footnote_53" class="fnanchor">[53]</a> 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.</p>
+
+<p>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.<a id="FNanchor_54" href="#Footnote_54" class="fnanchor">[54]</a> 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<span class="pagenum" id="Page_82">[Pg 82]</span>
+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,<a id="FNanchor_55" href="#Footnote_55" class="fnanchor">[55]</a> we can only gladly
+recognise the efforts made by the asylums; we are,
+however, bound to ask: <em>What percentage of the
+inmates need ever have entered the asylum?</em> 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.</p>
+
+<div class="blockquot fs90">
+
+<p>“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 <em>48 per cent. of all patients escaped the usual
+lunacy procedure</em>.</p>
+
+<p><span class="pagenum" id="Page_83">[Pg 83]</span></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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, <em>op. cit.</em>,
+p. <a href="#Page_42">42</a>.)</p>
+</div>
+
+<p>In advocating the establishment of separate pavilions
+for nervous and mental disease in direct association with
+the general hospitals, Dr. Bedford Pierce says:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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.”</p>
+</div>
+
+<p><span class="pagenum" id="Page_84">[Pg 84]</span></p>
+
+<p>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.</p>
+
+<p>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,<span class="pagenum" id="Page_85">[Pg 85]</span>
+“Were you on the staff, then?” the visitor answered
+quite naturally, “Oh no, I was here as a patient.”</p>
+
+<p>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.”</p>
+
+<p>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.</p>
+
+<p>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<a id="FNanchor_56" href="#Footnote_56" class="fnanchor">[56]</a> 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<span class="pagenum" id="Page_86">[Pg 86]</span>
+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.</p>
+
+<p>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,
+<em>post-mortem</em>, 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:—</p>
+
+<div class="blockquot fs90">
+
+<p>“... 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.”<a id="FNanchor_57" href="#Footnote_57" class="fnanchor">[57]</a></p>
+</div>
+
+<p>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:<span class="pagenum" id="Page_87">[Pg 87]</span>
+hysteria, neurasthenia, psychasthenia and the
+rest, anatomical and physiological knowledge has not
+yet passed beyond the theoretical stage<a id="FNanchor_58" href="#Footnote_58" class="fnanchor">[58]</a>. 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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_88">[Pg 88]</span>
+be made “difficult” enough for him.<a id="FNanchor_59" href="#Footnote_59" class="fnanchor">[59]</a> 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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_89">[Pg 89]</span>
+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.”</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_90">[Pg 90]</span></p>
+
+<p>But when we come to ask <em>what</em> 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<a id="FNanchor_60" href="#Footnote_60" class="fnanchor">[60]</a>: 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.</p>
+
+<p>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<span class="pagenum" id="Page_91">[Pg 91]</span>
+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.<a id="FNanchor_61" href="#Footnote_61" class="fnanchor">[61]</a> 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.<a id="FNanchor_62" href="#Footnote_62" class="fnanchor">[62]</a></p>
+
+<p>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<span class="pagenum" id="Page_92">[Pg 92]</span>
+what shall we say of the unfortunate man whose caution
+has gone so far that he cannot cross <em>any</em> open space
+whatever, and is said to be suffering from agoraphobia?</p>
+
+<p>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.</p>
+
+<p>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 <em>Felis</em>. 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.</p>
+
+<p>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<span class="pagenum" id="Page_93">[Pg 93]</span>
+or agoraphobia?<a id="FNanchor_63" href="#Footnote_63" class="fnanchor">[63]</a> 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.</p>
+
+<p>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<span class="pagenum" id="Page_94">[Pg 94]</span>
+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<a id="FNanchor_64" href="#Footnote_64" class="fnanchor">[64]</a>—we represent the matter
+more truthfully.</p>
+
+<p>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<a id="FNanchor_65" href="#Footnote_65" class="fnanchor">[65]</a> 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 <em>are</em>
+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.<span class="pagenum" id="Page_95">[Pg 95]</span>
+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 <em>ought</em> to evoke?</p>
+
+<p>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!</p>
+
+<p>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:—</p>
+
+<div class="blockquot fs90">
+
+<p>“... 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....<span class="pagenum" id="Page_96">[Pg 96]</span>
+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.”<a id="FNanchor_66" href="#Footnote_66" class="fnanchor">[66]</a></p>
+</div>
+
+<p>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:—</p>
+
+<div class="blockquot fs90">
+
+<p>“The old definition of a neurosis as a nervous disease devoid
+of anatomical changes is inadequate. <em>Disease is inconceivable
+without some underlying physical basis.</em><a id="FNanchor_67" href="#Footnote_67" class="fnanchor">[67]</a> The lesion need not
+be visible microscopically: it may be molecular or bio-chemical.”<a id="FNanchor_68" href="#Footnote_68" class="fnanchor">[68]</a></p>
+</div>
+
+<p>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. <a href="#Page_91">91</a>, 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<span class="pagenum" id="Page_97">[Pg 97]</span>
+that wild animals, savages and children form the diseased
+class <i lang="fr" xml:lang="fr">par excellence</i>.</p>
+
+<p>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.<a id="FNanchor_69" href="#Footnote_69" class="fnanchor">[69]</a></p>
+
+<p>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<span class="pagenum" id="Page_98">[Pg 98]</span>
+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?</p>
+
+<p>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<span class="pagenum" id="Page_99">[Pg 99]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_100">[Pg 100]</span>
+hesitates to proceed further in the light of such knowledge.</p>
+
+<p>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.<a id="FNanchor_70" href="#Footnote_70" class="fnanchor">[70]</a> 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.</p>
+
+<p>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?</p>
+
+<p><span class="pagenum" id="Page_101">[Pg 101]</span></p>
+
+<p>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,<a id="FNanchor_71" href="#Footnote_71" class="fnanchor">[71]</a> “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<a id="FNanchor_72" href="#Footnote_72" class="fnanchor">[72]</a> 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,<a id="FNanchor_73" href="#Footnote_73" class="fnanchor">[73]</a> 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,”<span class="pagenum" id="Page_102">[Pg 102]</span>
+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 <em>why and how</em> he should not
+worry is what he wants to know.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_103">[Pg 103]</span>
+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.</p>
+
+<p>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 <em>Erewhon</em>.
+In <em>Erewhon</em>, 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,</p>
+
+<div class="blockquot fs90">
+
+<p class="no-indent">“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....”</p>
+</div>
+
+<p>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:—</p>
+
+<div class="blockquot fs90">
+
+<p>“I was struck with the delicacy with which he avoided even
+the remotest semblance of inquiry after the physical well-being<span class="pagenum" id="Page_104">[Pg 104]</span>
+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.”</p>
+</div>
+<br>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote">
+
+<p><a id="Footnote_50" href="#FNanchor_50" class="label">[50]</a> Hart, <em>op. cit.</em>, p. 7.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_51" href="#FNanchor_51" class="label">[51]</a> <em>Cf.</em> Dr. Bedford Pierce’s statement, (<em>op. cit.</em>, 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.”</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_52" href="#FNanchor_52" class="label">[52]</a> p. 5. The italics are ours.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_53" href="#FNanchor_53" class="label">[53]</a> pp. 77 and 78.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_54" href="#FNanchor_54" class="label">[54]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_55" href="#FNanchor_55" class="label">[55]</a> R. G. Rows, <cite>Journal of Mental Science</cite>, January, 1912.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_56" href="#FNanchor_56" class="label">[56]</a> pp. 77 and 78.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_57" href="#FNanchor_57" class="label">[57]</a> <cite>Analytic Psychology</cite>, London, 1916, p. 318.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_58" href="#FNanchor_58" class="label">[58]</a> “Everybody agrees,” say Déjerine and Gauckler (<em>op. cit.</em>, p.
+214<em>f</em>), “that neurasthenia is a neurosis, <em>i.e.</em>, 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_59" href="#FNanchor_59" class="label">[59]</a> <em>Cf.</em> pp. 19 <em>et seq.</em></p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_60" href="#FNanchor_60" class="label">[60]</a> <em>Cf.</em> Déjerine and Gauckler, <em>op. cit.</em>, p. 214<em>f.</em></p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_61" href="#FNanchor_61" class="label">[61]</a> As Professor Kraepelin says, “Nervenkranker sind Geisteskranker”
+(“Those ‘suffering from nerves’ are <em>sick in
+spirit</em>.”).</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_62" href="#FNanchor_62" class="label">[62]</a> The reader should consult Mr. W. McDougall’s excellent
+treatment of this subject in his <cite>Introduction to Social
+Psychology</cite>—especially pp. 45-89.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_63" href="#FNanchor_63" class="label">[63]</a> The remarks of Mr. George Bernard Shaw on Max Nordau’s
+“Degeneration” (<cite>The Sanity of Art</cite>, especially p. 88)
+might be consulted in this connection.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_64" href="#FNanchor_64" class="label">[64]</a> <em>Cf.</em> E. Régis, “Les Troubles Psychiques et Neuro-Psychiques
+de la Guerre,” <cite>Presse Médicale</cite>, 23, p. 177, May 27th,
+1915.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_65" href="#FNanchor_65" class="label">[65]</a> 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.”</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_66" href="#FNanchor_66" class="label">[66]</a> <cite>The Diagnosis of Nervous Diseases</cite>, 3rd Edition, London,
+1911, p. 355.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_67" href="#FNanchor_67" class="label">[67]</a> Italics ours.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_68" href="#FNanchor_68" class="label">[68]</a> p. 355.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_69" href="#FNanchor_69" class="label">[69]</a> 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 (<em>e.g.</em>, “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 <i lang="la" xml:lang="la">ex-officio</i> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_70" href="#FNanchor_70" class="label">[70]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_71" href="#FNanchor_71" class="label">[71]</a> “Tough-minded,” “matter-mongers,” modern writers have
+called this type, contrasting it with that of the “tender-minded,”
+“reason-mongers.”</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_72" href="#FNanchor_72" class="label">[72]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_73" href="#FNanchor_73" class="label">[73]</a> “... strong electric shocks, cold douches, and other decorous
+substitutes for a sound birching.” W. McDougall, <cite>Psychology</cite>,
+London, 1912.</p>
+
+</div>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_105">[Pg 105]</span></p>
+<h2 class="nobreak" id="CHAPTER_V">CHAPTER V.<br>
+<span class="fs120">Some Lessons of the War.</span></h2>
+</div>
+
+<p class="drop-cap"><span class="upper-case">Are</span> 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.</p>
+
+<p>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<span class="pagenum" id="Page_106">[Pg 106]</span>
+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.</p>
+
+<p>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 <cite>British Medical Journal</cite> 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.”<a id="FNanchor_74" href="#Footnote_74" class="fnanchor">[74]</a>
+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 <em>not</em> 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<a id="FNanchor_75" href="#Footnote_75" class="fnanchor">[75]</a>; but the incipient forms<span class="pagenum" id="Page_107">[Pg 107]</span>
+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. <a href="#Page_82">82</a> <em>et seq.</em>, 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.</p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_108">[Pg 108]</span></p>
+
+<p>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.<a id="FNanchor_76" href="#Footnote_76" class="fnanchor">[76]</a></p>
+
+<p>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.</p>
+
+<p>But if the lessons of the war are to be truly beneficial,
+much more extensive application must be made of these
+methods, <em>not only for our soldiers now, but also for
+our civilian population for all time</em>. 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<a id="FNanchor_77" href="#Footnote_77" class="fnanchor">[77]</a> “the subject (of mental disease) is left severely
+alone.”<a id="FNanchor_78" href="#Footnote_78" class="fnanchor">[78]</a> 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,<span class="pagenum" id="Page_109">[Pg 109]</span>
+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.’<a id="FNanchor_79" href="#Footnote_79" class="fnanchor">[79]</a></p>
+
+<div class="blockquot fs90">
+
+<p>In the <cite>Standard</cite> newspaper a few days ago, (<em>i.e.</em>, 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 <cite>Standard</cite> 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.’</p>
+</div>
+
+<p>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, <em>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</em>, 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<span class="pagenum" id="Page_110">[Pg 110]</span>
+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.”<a id="FNanchor_80" href="#Footnote_80" class="fnanchor">[80]</a></p>
+
+<p>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 <em>teaching the medical profession and
+the public</em> 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.”<a id="FNanchor_81" href="#Footnote_81" class="fnanchor">[81]</a></p>
+
+<p>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,<a id="FNanchor_82" href="#Footnote_82" class="fnanchor">[82]</a> it is impossible “to develop<span class="pagenum" id="Page_111">[Pg 111]</span>
+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.”</p>
+
+<p>This last consideration leads us to the examination of
+another potent factor in the present situation, <em>viz.</em>:—</p>
+
+<p><em>The Attitude of the Medical Profession.</em> 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.</p>
+
+<p>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 <em>personal investigation</em> 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 <em>advanced</em> cases of mental
+disease: “melancholia,” “mania,” “dementia,” etc.</p>
+
+<p><span class="pagenum" id="Page_112">[Pg 112]</span></p>
+
+<p>Lest we may be accused of wild statements, let us
+quote again from the Medico-Psychological Association’s
+report. (The italics are ours.):—</p>
+
+<div class="blockquot fs90">
+
+<p>“... 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 <em>has no
+opportunity of observing borderland or undeveloped cases</em>.”
+(p. <a href="#Page_6">6</a>.)</p>
+
+<p>“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; <em>to this we owe the lack of real equipment
+in those who enter the lunacy service</em>.” (p. <a href="#Page_21">21</a>.)</p>
+</div>
+
+<p>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<span class="pagenum" id="Page_113">[Pg 113]</span>
+upon the questions we are considering in this book that
+we will quote its most essential paragraph.</p>
+
+<div class="blockquot fs90">
+
+<p>“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 <em>saw</em> and
+<em>heard</em> but almost never <em>did</em>. 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.”<a id="FNanchor_83" href="#Footnote_83" class="fnanchor">[83]</a></p>
+</div>
+
+<p>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,<a id="FNanchor_84" href="#Footnote_84" class="fnanchor">[84]</a> is that of class-demonstration, but, as we have<span class="pagenum" id="Page_114">[Pg 114]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_115">[Pg 115]</span>
+which would be of the utmost value to them in dealing
+with <em>all</em> 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.</p>
+
+<p>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.</p>
+
+<div class="blockquot fs90">
+
+<p>“<em>The tendency of routine to kill enthusiasm and destroy
+medical interests.</em></p>
+
+<p>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<span class="pagenum" id="Page_116">[Pg 116]</span>
+the discharge of essential routine duties to the exclusion of
+careful clinical and scientific investigation.</p>
+
+<p>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.”<a id="FNanchor_85" href="#Footnote_85" class="fnanchor">[85]</a> (pp. <a href="#Page_8">8</a> and <a href="#Page_9">9</a>.)</p>
+</div>
+
+
+<p class="no-indent"><em>Methods of Making Appointments.</em></p>
+
+<div class="blockquot fs90">
+
+<p>“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. <a href="#Page_7">7</a>.)</p>
+</div>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_117">[Pg 117]</span>
+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.</p>
+
+<p>It must not, however, be inferred that the only reform
+needed is an increase and improvement of the <em>mental</em>
+treatment of mental disease. It is not merely the psychological
+side that is neglected. The most depressing
+aspect of the present state of affairs <em>is the comparative
+absence of all research</em>. 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, <em>et cetera</em>, how little we know
+of them! Are we to rest content in leaving this vast
+unknown land to be charted by other nations?</p>
+
+<p>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<span class="pagenum" id="Page_118">[Pg 118]</span>
+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.</p>
+
+<p>We shall again quote from the report of the Medico-Psychological
+Association in justification of our statement:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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. <a href="#Page_30">30</a>.)</p>
+</div>
+
+<p>If the reader will pause for a moment, and in imagination
+put himself in the position of a junior medical
+officer, “<em>placed in charge of chronic cases only</em>,” 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.</p>
+
+<p>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,<a id="FNanchor_86" href="#Footnote_86" class="fnanchor">[86]</a> morbid anatomy, and the<span class="pagenum" id="Page_119">[Pg 119]</span>
+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 <em>symptoms</em>
+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.</p>
+
+<p>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 <em>development</em> 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.</p>
+
+<p>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,<span class="pagenum" id="Page_120">[Pg 120]</span>
+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.</p>
+
+<p>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 <em>voluntarily</em> 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 <em>forbidden</em> 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?</p>
+
+<p>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<span class="pagenum" id="Page_121">[Pg 121]</span>
+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.</p>
+
+<p>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 <em>early</em> and <em>incipient</em> 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.</p>
+
+<p>The chief functions of such a psychiatric clinic would
+be:—</p>
+
+<p>(1) Attendance on the mentally sick.</p>
+
+<p>(2) The provision of opportunities for personal intercourse
+between patients and the psychiatrists in training.</p>
+
+<p>(3) The theoretical and practical instruction of students.</p>
+
+<p>(4) Advising general practitioners and others who are
+faced with difficult problems arising in their daily work.</p>
+
+<p>(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.</p>
+
+<p>(6) The scientific investigation of the mental and bodily
+factors concerned in mental disease.</p>
+
+<p><span class="pagenum" id="Page_122">[Pg 122]</span></p>
+
+<p>(7) The furtherance of international exchange of
+scientific knowledge concerning mental disorder, by the
+welcome accorded to visitors from other countries.</p>
+
+<p>(8) The dissemination of medical views on certain
+important social questions and the correction of existing
+prejudices concerning insanity.</p>
+
+<p>(9) When necessary, the after-care of the discharged
+patient.</p>
+
+<p>We have already given some details of the activities of
+a few of the clinics abroad<a id="FNanchor_87" href="#Footnote_87" class="fnanchor">[87]</a> 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.</p>
+
+<p>We may quote from an article by Dr. R. G. Rows<a id="FNanchor_88" href="#Footnote_88" class="fnanchor">[88]</a>
+describing the psychiatric clinics at Munich and Giessen:</p>
+
+<div class="blockquot fs90">
+
+<p>“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.</p>
+
+<p>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<span class="pagenum" id="Page_123">[Pg 123]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>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<span class="pagenum" id="Page_124">[Pg 124]</span>
+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.</p>
+
+<p>Besides the patients admitted into the clinics for treatment,
+a large number obtain advice and help from the out-patients’
+department.”</p>
+</div>
+
+<p>It should be mentioned that in Germany there is a
+psychiatric clinic attached to every university.</p>
+
+<p>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.</p>
+
+<p>Of very special importance in the Munich clinic is the
+course for qualified medical men. In 1907 this was
+attended by <em>sixty men, of whom one third were
+foreigners</em>. 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.</p>
+
+<p>In the Munich clinic, again, we find well equipped
+rooms for clinical examination, for the deeper investigation
+of mental life by experimental psychology, for<span class="pagenum" id="Page_125">[Pg 125]</span>
+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.</p>
+
+<p>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.<a id="FNanchor_89" href="#Footnote_89" class="fnanchor">[89]</a> 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?”</p>
+
+<p>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<span class="pagenum" id="Page_126">[Pg 126]</span>
+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.</p>
+
+<p>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.</p>
+
+<p>Regarding the financial aspect of the question we may
+quote again from Dr. Rows’ article:—</p>
+
+<div class="blockquot fs90">
+
+<p>“... 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<span class="pagenum" id="Page_127">[Pg 127]</span>
+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.”</p>
+</div>
+
+<p>And</p>
+
+<div class="blockquot fs90">
+
+<p>“... 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,<span class="pagenum" id="Page_128">[Pg 128]</span>
+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.”</p>
+</div>
+<br>
+
+<p><em>Suggested Reforms.</em> 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.</p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_129">[Pg 129]</span></p>
+
+<p>No less important and urgent a reform than the foregoing,
+however, is another consideration—the <em>legal</em> aspect
+of the treatment of the mentally deranged.</p>
+
+<p>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
+<cite>British Medical Journal</cite> of January 8th, 1916.</p>
+
+<p>Again, Sir George Savage, writing in Allbutt’s <cite>System
+of Medicine</cite> (Vol. VIII, p. 429) states:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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.”</p>
+</div>
+
+<p>Dr. F. W. Mott writes:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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.”<a id="FNanchor_90" href="#Footnote_90" class="fnanchor">[90]</a></p>
+</div>
+
+<p>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<span class="pagenum" id="Page_130">[Pg 130]</span>
+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.”<a id="FNanchor_91" href="#Footnote_91" class="fnanchor">[91]</a></p>
+
+<p>The Medico-Psychological Association’s report says:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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. <a href="#Page_10">10</a>.)</p>
+</div>
+
+<p>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.</p>
+
+<p>In the <cite>Lancet</cite> of August 5th, 1916, Dr. L. A. Weatherley
+writes:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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 <em>recovery-rate of mental diseases
+is to-day no higher than it was in the ‘seventies’ of last
+century</em>. 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.”</p>
+</div>
+
+<p>“Marking time” since the seventies of the last century—how
+does this condition compare with that of most of<span class="pagenum" id="Page_131">[Pg 131]</span>
+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.</p>
+
+<p>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:—</p>
+
+<div class="blockquot fs90">
+
+<p>“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.”</p>
+
+<p>“... There ought to be a more numerous medical staff
+<em>and a permanent clinic</em> 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.”</p>
+</div>
+
+<p>The dust lies thick upon this volume, published a short
+time before the <em>Crimean</em>, not the present war. And<span class="pagenum" id="Page_132">[Pg 132]</span>
+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?</p>
+
+<p>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.</p>
+<br>
+
+<div class="footnotes"><h3>FOOTNOTES:</h3>
+
+<div class="footnote">
+
+<p><a id="Footnote_74" href="#FNanchor_74" class="label">[74]</a> p. 105.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_75" href="#FNanchor_75" class="label">[75]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_76" href="#FNanchor_76" class="label">[76]</a> <em>Cf.</em> W. Aldren Turner, <em>op. cit.</em></p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_77" href="#FNanchor_77" class="label">[77]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_78" href="#FNanchor_78" class="label">[78]</a> <cite>Appendix to Medico-Psychological Association Report</cite>,
+p. 18.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_79" href="#FNanchor_79" class="label">[79]</a> “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.” <em>Ibid.</em>, p. <a href="#Page_17">17</a>.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_80" href="#FNanchor_80" class="label">[80]</a> <em>Op. cit.</em>, p. 2.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_81" href="#FNanchor_81" class="label">[81]</a> <em>Op. cit.</em>, pp. 15-16.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_82" href="#FNanchor_82" class="label">[82]</a> <i lang="la" xml:lang="la">Vide infra.</i></p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_83" href="#FNanchor_83" class="label">[83]</a> p. 202.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_84" href="#FNanchor_84" class="label">[84]</a> “... at present we have few facilities for teaching the
+subject, and the subject is not taught.” (<cite>Medico-Psychological
+Association’s Report</cite>, p. 20.)</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_85" href="#FNanchor_85" class="label">[85]</a> Concerning this sentence the <cite>British Medical Journal</cite> 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.”</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_86" href="#FNanchor_86" class="label">[86]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_87" href="#FNanchor_87" class="label">[87]</a> pp. 82 <em>et seq.</em></p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_88" href="#FNanchor_88" class="label">[88]</a> “The Development of Psychiatric Science as a Branch of
+Public Health,” <cite>Journal of Mental Science</cite>, January, 1912.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_89" href="#FNanchor_89" class="label">[89]</a> 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.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_90" href="#FNanchor_90" class="label">[90]</a> <cite>Archives of Neurology</cite>, 1903, Vol. II, p. 1.</p>
+
+</div>
+
+<div class="footnote">
+
+<p><a id="Footnote_91" href="#FNanchor_91" class="label">[91]</a> <cite>Archives of Neurology</cite>, 1907, Vol. III, p. 28.</p>
+
+</div>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop">
+
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_133">[Pg 133]</span></p>
+<h2 class="nobreak" id="Index">Index.</h2>
+</div>
+
+
+<ul class="index">
+<li class="ifrst fs80"><span style="padding-left: 5em"> <em>Page</em></span></li>
+
+<li class="indx">Agoraphobia, <a href="#Page_92">92</a></li>
+
+<li class="indx">Alcohol and insanity, <a href="#Page_106">106</a></li>
+
+<li class="indx">Allbutt, Sir Clifford, <a href="#Page_27">27</a>, <a href="#Page_34">34</a></li>
+
+<li class="indx">Amendment of Lunacy Law, need for, <a href="#Page_130">130</a></li>
+
+<li class="indx">Appointments in asylums, <a href="#Page_116">116</a></li>
+
+<li class="indx">Asylums, lunatic, <a href="#Page_105">105</a> <em>et seq.</em></li>
+
+<li class="indx">Attitude of medical profession to psychology, <a href="#Page_102">102</a>, <a href="#Page_106">106</a>, <a href="#Page_111">111</a></li>
+
+<li class="indx">Attitude of public towards insanity, <a href="#Page_78">78</a></li>
+
+<li class="indx">Analysis, comparison of chemical and psychological, <a href="#Page_54">54</a></li>
+
+
+<li class="ifrst">Bacon, Francis, <a href="#Page_9">9</a></li>
+
+<li class="indx">Baltimore Psychiatric Clinic, <a href="#Page_110">110</a></li>
+
+<li class="indx">Bernardin de St. Pierre, <a href="#Page_45">45</a></li>
+
+<li class="indx">Blässig’s case of loss of speech, <a href="#Page_43">43</a></li>
+
+<li class="indx">Boston Psychopathic Hospital, <a href="#Page_82">82</a></li>
+
+<li class="indx">British attitude towards insanity, <a href="#Page_79">79</a>, <a href="#Page_120">120</a></li>
+
+<li class="indx">British medical training, <a href="#Page_114">114</a></li>
+
+<li class="indx"><em>British Medical Journal</em>, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_18">18</a>, <a href="#Page_106">106</a>, <a href="#Page_116">116</a>,
+    <a href="#Page_129">129</a></li>
+
+<li class="indx">Burt, C., <a href="#Page_3">3</a>, <a href="#Page_17">17</a></li>
+
+<li class="indx">Butler’s, Samuel, <em>Erewhon</em>, <a href="#Page_103">103</a></li>
+
+
+<li class="ifrst">Cannon on bodily effects of emotion, <a href="#Page_8">8</a></li>
+
+<li class="indx">Carnegie Foundation’s report, <a href="#Page_112">112</a></li>
+
+<li class="indx">La Charité Hospital, <a href="#Page_83">83</a></li>
+
+<li class="indx">Chloroform, use of in cases of loss of speech, <a href="#Page_12">12</a></li>
+
+<li class="indx">Clinics for treating mental disorders, <a href="#Page_84">84</a>, <a href="#Page_107">107</a>, <a href="#Page_121">121</a></li>
+
+<li class="indx">Clinics, cost of, <a href="#Page_125">125</a></li>
+
+<li class="indx">  ” functions of, <a href="#Page_83">83</a>, <a href="#Page_121">121</a></li>
+
+<li class="indx">  ” efficacy of, <a href="#Page_82">82-85</a>, <a href="#Page_123">123</a></li>
+
+<li class="indx">Common sense not infallible, <a href="#Page_58">58</a></li>
+
+<li class="indx">Conflict, mental and moral, <a href="#Page_98">98</a></li>
+
+
+<li class="ifrst">Déjerine and Gauckler, <a href="#Page_6">6</a>, <a href="#Page_34">34</a>, <a href="#Page_35">35</a>, <a href="#Page_42">42</a>, <a href="#Page_44">44</a>, <a href="#Page_45">45</a>,
+    <a href="#Page_46">46</a>, <a href="#Page_90">90</a>, <a href="#Page_120">120</a></li>
+
+<li class="indx">Defects of British methods, <a href="#Page_120">120</a></li>
+
+<li class="indx"><em>Derfflinger</em>, sailor from German battle-cruiser, <a href="#Page_43">43</a></li>
+
+<li class="indx">Diagnosis, importance of exact, <a href="#Page_47">47</a> <em>et seq.</em></li>
+
+<li class="indx">Dreams, <a href="#Page_22">22</a>, <a href="#Page_61">61-63</a></li>
+
+
+<li class="ifrst">Emotion of fear, <a href="#Page_92">92</a></li>
+
+<li class="indx">Emotions, <a href="#Page_3">3</a>, <a href="#Page_9">9</a></li>
+
+<li class="indx"><span class="pagenum" id="Page_134">[Pg 134]</span>Emotional factor as cause of mental disturbance, <a href="#Page_71">71</a></li>
+
+<li class="indx">Evils resulting from delay in treatment, <a href="#Page_81">81</a></li>
+
+
+<li class="ifrst">Fear, <a href="#Page_92">92</a>, <a href="#Page_95">95</a></li>
+
+<li class="indx">Financial aspect of reform, <a href="#Page_125">125</a> <em>et seq.</em></li>
+
+<li class="indx">Firmness, <a href="#Page_28">28</a>, <a href="#Page_31">31</a></li>
+
+<li class="indx">Flexner’s report on medical education, <a href="#Page_110">110-113</a></li>
+
+<li class="indx">Forgetfulness, <a href="#Page_49">49</a></li>
+
+<li class="indx">Forsyth, D., <a href="#Page_4">4</a>, <a href="#Page_8">8</a></li>
+
+<li class="indx">Freud, S., <a href="#Page_63">63</a>, <a href="#Page_73">73</a></li>
+
+
+<li class="ifrst">Gaupp on hysteria, <a href="#Page_22">22</a>, <a href="#Page_23">23</a></li>
+
+<li class="indx">German attitude towards mental disorder, <a href="#Page_84">84</a></li>
+
+<li class="indx">Giessen clinic, <a href="#Page_84">84</a>, <a href="#Page_122">122</a></li>
+
+
+<li class="ifrst">Hanwell asylum, <a href="#Page_131">131</a></li>
+
+<li class="indx">Hart, Bernard, <a href="#Page_57">57</a>, <a href="#Page_119">119</a></li>
+
+<li class="indx">Heredity, the influence of, <a href="#Page_78">78</a>, <a href="#Page_86">86</a>, <a href="#Page_88">88</a>, <a href="#Page_89">89</a></li>
+
+<li class="indx">Hesse, experience in, <a href="#Page_82">82</a></li>
+
+<li class="indx">Hypnotism, <a href="#Page_36">36</a> <em>et seq.</em></li>
+
+<li class="indx">  ” usefulness in recent cases, <a href="#Page_38">38</a></li>
+
+<li class="indx">Hypnotism, objections to use of, <a href="#Page_39">39-44</a></li>
+
+<li class="indx">Hysteria, <a href="#Page_22">22</a>, <a href="#Page_30">30</a>, <a href="#Page_94">94</a></li>
+
+
+<li class="ifrst">Instincts, <a href="#Page_3">3</a>, <a href="#Page_91">91</a></li>
+
+<li class="indx">International Congress of Medicine, <a href="#Page_110">110</a></li>
+
+<li class="indx">Isolation, treatment by, <a href="#Page_32">32</a> <em>et seq.</em></li>
+
+<li class="indx">Isolation, limits to usefulness of, <a href="#Page_34">34</a>, <a href="#Page_35">35</a></li>
+
+
+<li class="ifrst">Jung, C. G., <a href="#Page_71">71</a>, <a href="#Page_74">74</a>, <a href="#Page_86">86</a></li>
+
+
+<li class="ifrst">Kindness, therapeutic value of, <a href="#Page_45">45</a></li>
+
+<li class="indx">Kraepelin, E., <a href="#Page_91">91</a></li>
+
+
+<li class="ifrst"><em>Lancet</em>, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_14">14</a>, <a href="#Page_37">37</a>, <a href="#Page_130">130</a></li>
+
+<li class="indx">Law relating to Lunacy, need for amendment, <a href="#Page_130">130</a></li>
+
+<li class="indx">Loss of memory, <a href="#Page_43">43</a></li>
+
+<li class="indx">  ” sight, <a href="#Page_11">11</a></li>
+
+<li class="indx">  ” sleep, <a href="#Page_7">7</a></li>
+
+<li class="indx">  ” speech, <a href="#Page_11">11</a>, <a href="#Page_43">43</a></li>
+
+<li class="indx">Lunacy, need for amendment of law relating to, <a href="#Page_130">130</a></li>
+
+<li class="indx">Lunatic Asylums, <a href="#Page_78">78</a></li>
+
+
+<li class="ifrst">Maghull Military Hospitals, <a href="#Page_108">108</a></li>
+
+<li class="indx"><em>Manchester Guardian</em>, <a href="#Page_24">24</a></li>
+
+<li class="indx">Maudsley Clinic, <a href="#Page_125">125</a></li>
+
+<li class="indx">Medical education, inadequate teaching in psychology, <a href="#Page_100">100</a></li>
+
+<li class="indx">Medico Psychological Society’s report, <a href="#Page_80">80</a>, <a href="#Page_105">105</a>, <a href="#Page_108">108</a>, <a href="#Page_112">112</a>,
+    <a href="#Page_118">118</a></li>
+
+<li class="indx">Mott, F. W., on clinics, <a href="#Page_129">129</a></li>
+
+<li class="indx">Möhr, on theory of isolation, <a href="#Page_32">32</a></li>
+
+<li class="indx">Munich clinic, work of, <a href="#Page_122">122</a> <em>et seq.</em></li>
+
+<li class="indx">Myers, C. S., on hypnotism, <a href="#Page_5">5</a>, <a href="#Page_30">30</a>, <a href="#Page_37">37</a>, <a href="#Page_38">38</a></li>
+
+
+<li class="ifrst">Neurotic parents, influence of, <a href="#Page_89">89</a></li>
+
+
+<li class="ifrst">Pear, T. H., on effects of loss of sleep, <a href="#Page_7">7</a></li>
+
+<li class="indx">Persuasion, psychotherapy by, <a href="#Page_44">44</a></li>
+
+<li class="indx">Physical basis of disease, <a href="#Page_96">96</a>, <a href="#Page_99">99</a></li>
+
+<li class="indx"><span class="pagenum" id="Page_135">[Pg 135]</span>Pierce, Bedford, on need for reform, <a href="#Page_18">18</a>, <a href="#Page_79">79</a>, <a href="#Page_83">83</a>,
+    <a href="#Page_129">129</a></li>
+
+<li class="indx">Proportion of cases cured in asylums, <a href="#Page_82">82</a>, <a href="#Page_109">109</a></li>
+
+<li class="indx">Proportion of cases not needing asylum treatment, <a href="#Page_82">82</a></li>
+
+<li class="indx">Psychoanalysis, <a href="#Page_73">73-75</a></li>
+
+<li class="indx">Psychological analysis, <a href="#Page_53">53</a> <em>et seq.</em></li>
+
+
+<li class="ifrst">Rational treatment, <a href="#Page_46">46</a></li>
+
+<li class="indx">Re-education, <a href="#Page_53">53</a>, <a href="#Page_72">72</a></li>
+
+<li class="indx">Régis, on significance of word “neuropathic”, <a href="#Page_94">94</a></li>
+
+<li class="indx">Reform of methods for dealing with mental disturbance, <a href="#Page_128">128</a></li>
+
+<li class="indx">Research, the importance of, <a href="#Page_117">117</a></li>
+
+<li class="indx">Rows, R. G., <a href="#Page_82">82</a>, <a href="#Page_108">108</a>, <a href="#Page_122">122</a>, <a href="#Page_126">126</a></li>
+
+
+<li class="ifrst">Savage, Sir George, <a href="#Page_27">27</a>, <a href="#Page_129">129</a></li>
+
+<li class="indx">Shaw, G. Bernard, <a href="#Page_93">93</a></li>
+
+<li class="indx"><em>Sherlock Holmes</em>, <a href="#Page_63">63</a></li>
+
+<li class="indx">Smith, May, on effects of loss of sleep, <a href="#Page_7">7</a></li>
+
+<li class="indx">Sommer, R., <a href="#Page_109">109</a></li>
+
+<li class="indx">Stewart, Purves, <a href="#Page_95">95</a></li>
+
+<li class="indx">Subjective disturbances, <a href="#Page_12">12</a></li>
+
+<li class="indx">Suggestion, <a href="#Page_36">36</a></li>
+
+<li class="indx">Suppression of emotions, <a href="#Page_9">9</a></li>
+
+<li class="indx">Syphilis, <a href="#Page_106">106</a></li>
+
+<li class="indx">Sympathy, <a href="#Page_28">28</a>, <a href="#Page_29">29</a></li>
+
+<li class="indx">Stigma of insanity, <a href="#Page_84">84</a></li>
+
+
+<li class="ifrst">Text-books on psychological medicine, inadequacy of, <a href="#Page_118">118</a></li>
+
+<li class="indx">Treatment, <a href="#Page_27">27</a></li>
+
+<li class="indx">Tuberculosis, comparisons with, <a href="#Page_77">77</a>, <a href="#Page_85">85</a>, <a href="#Page_114">114</a></li>
+
+<li class="indx">Turner’s, W. Aldren, report, <a href="#Page_14">14</a>, <a href="#Page_108">108</a></li>
+
+
+<li class="ifrst">Unconscious factors, influence of, <a href="#Page_57">57</a> <em>et seq.</em></li>
+
+<li class="indx">Understaffing, medical, of asylums for the insane, <a href="#Page_81">81</a></li>
+
+
+<li class="ifrst">Weatherley, L. A., <a href="#Page_130">130</a></li>
+
+<li class="indx">Wiltshire, H., <a href="#Page_10">10</a></li>
+
+<li class="indx">Work, therapeutic value of, <a href="#Page_50">50</a></li>
+
+<li class="indx">Worry, relief of, <a href="#Page_67">67</a>, <a href="#Page_68">68</a></li>
+
+
+<li class="ifrst">Ziehen, T., <a href="#Page_83">83</a></li>
+
+<li class="indx">Zürich University Psychiatric Clinic, <a href="#Page_86">86</a></li>
+</ul>
+<br>
+<br>
+
+<div style='text-align:center'>*** END OF THE PROJECT GUTENBERG EBOOK 75421 ***</div>
+</body>
+</html>
+
diff --git a/75421-h/images/cover.jpg b/75421-h/images/cover.jpg
new file mode 100644
index 0000000..7c71beb
--- /dev/null
+++ b/75421-h/images/cover.jpg
diff --git a/LICENSE.txt b/LICENSE.txt
new file mode 100644
index 0000000..6312041
--- /dev/null
+++ b/LICENSE.txt
@@ -0,0 +1,11 @@
+This eBook, including all associated images, markup, improvements,
+metadata, and any other content or labor, has been confirmed to be
+in the PUBLIC DOMAIN IN THE UNITED STATES.
+
+Procedures for determining public domain status are described in
+the "Copyright How-To" at https://www.gutenberg.org.
+
+No investigation has been made concerning possible copyrights in
+jurisdictions other than the United States. Anyone seeking to utilize
+this eBook outside of the United States should confirm copyright
+status under the laws that apply to them.
diff --git a/README.md b/README.md
new file mode 100644
index 0000000..41cb6bc
--- /dev/null
+++ b/README.md
@@ -0,0 +1,2 @@
+Project Gutenberg (https://www.gutenberg.org) public repository for
+eBook #75421 (https://www.gutenberg.org/ebooks/75421)