diff options
Diffstat (limited to '75421-0.txt')
| -rw-r--r-- | 75421-0.txt | 4767 |
1 files changed, 4767 insertions, 0 deletions
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 *** |