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diff --git a/75421-h/75421-h.htm b/75421-h/75421-h.htm new file mode 100644 index 0000000..4456bfb --- /dev/null +++ b/75421-h/75421-h.htm @@ -0,0 +1,6276 @@ +<!DOCTYPE html> +<html lang="en"> +<head> + <meta charset="UTF-8"> + <title> + Shell Shock and Its Lessons | Project Gutenberg + </title> + <link rel="icon" href="images/cover.jpg" type="image/x-cover"> + <style> + +body { + margin-left: 10%; + margin-right: 10%; +} + + h1,h2,h3 { + text-align: center; /* all headings centered */ + clear: both; +} + +p { + margin-top: .51em; + text-align: justify; + margin-bottom: .49em; + text-indent: 1em; +} + +hr { + width: 33%; + margin-top: 2em; + margin-bottom: 2em; + margin-left: 33.5%; + margin-right: 33.5%; + clear: both; +} + +hr.chap {width: 65%; margin-left: 17.5%; margin-right: 17.5%;} + +div.chapter {page-break-before: always;} +h2.nobreak {page-break-before: avoid;} + +ul.index { list-style-type: none; } +li.ifrst { + margin-top: 1em; + text-indent: -2em; + padding-left: 1em; +} +li.indx { + margin-top: .5em; + text-indent: -2em; + padding-left: 1em; +} + +table { + margin-left: auto; + margin-right: auto; +} +table.autotable { border-collapse: collapse; } + +.tdl {text-align: left; line-height: 1.5em;} +.tdr {text-align: right;} +.tdc {text-align: center; line-height: 1em;} + +.pagenum { /* uncomment the next line for invisible page numbers */ + /* visibility: hidden; */ + position: absolute; + left: 92%; + font-size: small; + text-align: right; + font-style: normal; + font-weight: normal; + font-variant: normal; + text-indent: 0; + color: #A9A9A9; +} /* page numbers */ + +.blockquot { + margin-left: 5%; + margin-right: 10%; +} + +.center {text-align: center;} + +.right {text-align: right;} + +.smcap {font-variant: small-caps;} + +/* Images */ + +img { + max-width: 100%; + height: auto; +} + + +.figcenter { + margin: auto; + text-align: center; + page-break-inside: avoid; + max-width: 100%; +} + +/* Footnotes */ +.footnotes {border: 1px dashed;} + +.footnote {margin-left: 10%; margin-right: 10%; font-size: 0.9em;} + +.footnote .label {position: absolute; right: 84%; text-align: right;} + +.fnanchor { + vertical-align: super; + font-size: .8em; + text-decoration: + none; +} + + +.fs70 {font-size: 70%} +.fs80 {font-size: 80%} +.fs90 {font-size: 90%} +.fs120 {font-size: 120%} + +.no-indent {text-indent: 0em;} +.bold {font-weight: bold;} +.wsp {word-spacing: 0.3em;} + +p.drop-cap { + text-indent: 0em; +} +p.drop-cap:first-letter +{ + float: left; + margin: 0em 0.1em 0em 0em; + font-size: 250%; + line-height:0.85em; +} + +.upper-case +{ + text-transform: uppercase; +} + + </style> +</head> +<body> +<div style='text-align:center'>*** START OF THE PROJECT GUTENBERG EBOOK 75421 ***</div> + +<div class="figcenter" style="width: 85%"> +<img src="images/cover.jpg" alt="Cover"> +</div> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> +<p class="center no-indent fs120 wsp bold">SHELL SHOCK</p> +</div> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> +<p class="center no-indent fs90"> +Published by the University of Manchester at<br> +THE UNIVERSITY PRESS (<span class="smcap">H. M. McKechnie</span>, Secretary)<br> +12, Lime Grove, Oxford Road, Manchester.<br> +<br> +<span class="smcap">Longmans, Green & Co.</span><br> +London: 39, Paternoster Row<br> +New York: 443-449, Fourth Avenue and Thirtieth Street<br> +Chicago: Prairie Avenue and Twenty-fifth Street<br> +Bombay: Hornby Road<br> +Calcutta: 6, Old Court House Street<br> +Madras: 167, Mount Road<br> +</p> +</div> + +<hr class="chap x-ebookmaker-drop"> + + +<div class="chapter"> +<h1> +SHELL SHOCK<br> +AND ITS LESSONS</h1> +<br> +<p class="center no-indent wsp"><span class="fs70">BY</span><br> +G. ELLIOT SMITH, M.A., M.D., F.R.C.P., F.R.S.<br> +<span class="fs80"><em>Dean of the Faculty of Medicine and Professor of Anatomy</em></span><br> +<br> +<span class="fs70">AND</span><br> +T. H. PEAR, B.Sc.<br> +<span class="fs80"><em>Lecturer in Experimental Psychology</em></span></p> +<br> +<br> +<br> +<p class="center no-indent fs80 wsp">MANCHESTER<br> +AT THE UNIVERSITY PRESS<br> +<span class="smcap">12, Lime Grove, Oxford Road</span><br> +<br> +LONGMANS, GREEN & CO.<br> +<span class="smcap">London, New York, Bombay, Etc.</span><br> +<br> +1917</p> +</div> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> +<p class="center no-indent fs80 wsp"> +PUBLICATIONS OF THE UNIVERSITY OF MANCHESTER<br> +<br> +No. CXI.</p> +</div> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> +<p class="center no-indent wsp"> +To<br> +<span class="smcap">Major</span> R. G. ROWS, M.D., R.A.M.C.<br> +</p> +</div> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> +<p><span class="pagenum" id="Page_vi">[Pg vi]</span></p> + +<h2 class="nobreak" id="Contents">Contents.</h2> +</div> + + +<table class="autotable"> +<tr> +<td class="tdl"></td> +<td class="tdr"><em>Page</em></td> +</tr> +<tr> +<td class="tdl"><span class="smcap">Preface</span></td> +<td class="tdr"><a href="#Page_vii">vii</a></td> +</tr> +<tr> +<td class="tdl"><span class="smcap">Introduction</span></td> +<td class="tdr"><a href="#Page_ix">ix</a></td> +</tr> +<tr> +<td class="tdc" colspan="2"><br>CHAPTER I.</td> +</tr> +<tr> +<td class="tdl"><span class="smcap">The Nature of Shell-Shock</span></td> +<td class="tdr"><a href="#Page_1">1</a></td> +</tr> +<tr> +<td class="tdc" colspan="2"><br>CHAPTER II.</td> +</tr> +<tr> +<td class="tdl"><span class="smcap">Treatment</span></td> +<td class="tdr"><a href="#Page_27">27</a></td> +</tr> +<tr> +<td class="tdc" colspan="2"><br>CHAPTER III.</td> +</tr> +<tr> +<td class="tdl"><span class="smcap">Psychological Analysis and Re-Education</span></td> +<td class="tdr"><a href="#Page_53">53</a></td> +</tr> +<tr> +<td class="tdc" colspan="2"><br>CHAPTER IV.</td> +</tr> +<tr> +<td class="tdl"><span class="smcap">Some General Considerations</span></td> +<td class="tdr"><a href="#Page_77">77</a></td> +</tr> +<tr> +<td class="tdc" colspan="2"><br>CHAPTER V.</td> +</tr> +<tr> +<td class="tdl"><span class="smcap">Some Lessons of the War</span></td> +<td class="tdr"><a href="#Page_105">105</a></td> +</tr> +<tr> +<td class="tdl"><span class="smcap">Index</span></td> +<td class="tdr"><a href="#Page_133">133</a></td> +</tr> +</table> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> +<p><span class="pagenum" id="Page_vii">[Pg vii]</span></p> + +<h2 class="nobreak" id="Preface">Preface.</h2> +</div> + + +<p class="drop-cap"><span class="upper-case">Our</span> reasons for writing this book will be explained by +the book itself. We desire here gratefully to acknowledge +the help of several friends who have considerably +facilitated our task. Our thanks are due to Major <span class="smcap">R. G. Rows</span>, +M.D., R.A.M.C., for his unfailing interest, encouragement and +help; to Captains <span class="smcap">W. H. R. Rivers</span>, M.D., F.R.C.P., F.R.S., +and <span class="smcap">J. W. Astley Cooper</span> of the R.A.M.C., and Mr. <span class="smcap">E. +Gleaves</span>, M.Sc., for their valuable suggestions and assistance +in the preparation of the manuscript; to Captain <span class="smcap">W. E. Sawers +Scott</span>, M.D., R.A.M.C., Dr. <span class="smcap">Albert Hopkinson</span> and Mr. +<span class="smcap">W. Percy Stocks</span>, F.R.C.S., of Manchester, for help in other +ways; and to our colleague, Professor <span class="smcap">H. Bompas Smith</span>, for +reading the proofs and helping us to eliminate some of the +more glaring literary defects. To the Editor of the <cite>Lancet</cite> we +are indebted for permission to use part of an article written by +one of us. The stream of requests for fuller information and +explanation that poured in upon the author of that article made +the writing of this book an unavoidable duty.</p> + +<p class="right"> +G. E. S.<br> +T. H. P.</p> +<p class="no-indent fs80"> +<span class="smcap">The Medical School,<br> +<span style="padding-left: 2em">The University,</span><br> +<span style="padding-left: 4em">Manchester.</span></span><br> +<br> +<em>20th April, 1917.</em><br> +</p> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> +<p><span class="pagenum" id="Page_ix">[Pg ix]</span></p> + +<h2 class="nobreak" id="Introduction">Introduction.</h2> +</div> + +<p class="drop-cap"><span class="upper-case">Some</span> account of the reasons for the appearance of +this book is due to the reader. During the last year +we have been asked repeatedly, both by members +of the medical profession and the lay public, to write a +simple non-technical exposition of the ascertained facts +of that malady, or complex of maladies, for which we +have adopted the official designation “shell-shock.” Until +recently such an attempt would have been premature and +largely speculative. But it is now possible to collate the +medical reports, not only from our own army, but also +from those of France and Russia. Valuable and suggestive +data have, furthermore, been obtained from such of +the German medical journals as have reached us. The +facts described in the various accounts which we have +seen are in close agreement. The conclusions in this +book, therefore, are not based upon our experience alone.</p> + +<p>Our object in thus publishing a brief and simple +description of these facts is twofold: first, to make them +available to those who have neither the time nor the +special knowledge necessary for consultation of the +medical journals; secondly, to call attention to the obvious +significance of these truths for the future welfare and +happiness of the nation.</p> + +<p>It might seem that to publish a book on this subject +at such a time is merely to irritate existing wounds. The +topic is painful; perhaps one of the saddest of the many +grievous aspects of the war. But a condition exists at<span class="pagenum" id="Page_x">[Pg x]</span> +present which is immeasurably more painful—the +exaggerated and often unnecessary distress of mind in +many of the sufferers and their friends, which arises from +the manner in which we, as a nation, have been +accustomed to regard even the mildest forms of mental +abnormality. Of all varieties of fear, the fear of the +unknown is one of the greatest. Not the least of the +successful work performed in the special hospitals during +the war has been the dispelling of this fear by helping +the sufferer to understand his strange symptoms (many +of which are merely unusual for the patient himself) and, +in the light of this new self-knowledge, to win his own +way back to health.</p> + +<p>It is because we believe that a similar probing of the +<em>public</em> wound—the British attitude towards the treatment +of mental disorder—though painful, is justifiable and +necessary, that we have written the concluding chapters +of this book. For it cannot be too strongly urged that +the shifting and unstable blend of apathy, superstition, +helpless ignorance and fear with which our own country +has too long regarded these problems is rapidly becoming +our exclusive distinction. It must be realised that America, +France, Germany, and Switzerland have long ago faced +the problem in the only practical way—the scientific +one. And to the long list of sciences which we all agree +must be cultivated more assiduously after the war should +be added—but not at, or even near, the end—psychiatry, +the science of the treatment of mental disorders.</p> + +<p>Not patriotic motives alone urge this reform, but +common sense and common morality. For shell-shock +has brought us no new symptoms. Its sole ground of +difference from other disordered states of mind lies in +its unusually intense and wide-spreading causes. The +problems of shell-shock are the every-day problems of +“nervous breakdown.” They existed before the war, +and they will not disappear miraculously with the coming<span class="pagenum" id="Page_xi">[Pg xi]</span> +of peace. The war has forced upon this country a +rational and humane method of caring for and treating +mental disorder among its soldiers. Are these signs of +progress merely temporary? Are such successful +measures to be limited to the duration of the war, and +to be restricted to the army? Germany has applied them +for years to the alleviation of suffering among her civilian +population, with a success which has made her famous—outside +England. Can we be content to treat our +sufferers with less sympathy, insight and common-sense +than Germany?</p> + +<p>It is at this time, while our country is anxiously considering +how best to learn the lessons of the war, that +we wish to call attention to one of these lessons which is +in danger of being overlooked.</p> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> +<p><span class="pagenum" id="Page_1">[Pg 1]</span></p> + +<h2 class="nobreak" id="CHAPTER_I">CHAPTER I.<br> +<span class="fs120">The Nature of Shell-Shock.</span></h2> +</div> + +<p class="drop-cap"><span class="upper-case">A French</span> doctor has said, “Il n’y a pas de +maladies; il n’y a que des malades.”<a id="FNanchor_1" href="#Footnote_1" class="fnanchor">[1]</a> Whatever +may be the general validity of this statement, +it is undoubtedly true of the nerve-stricken soldier. Every +case is a case by itself, and as such it must be considered +by anyone, be he layman or doctor, who is +interested in its nature and treatment. For the troubles +displayed in the many disorders classed under the +official title shell-shock are extraordinarily numerous +and different, and their removal necessitates a similarly +varied repertoire of “opening moves” on the part of +the physician.</p> + +<p>Although the term shell-shock has been applied +to a group of affections, many of which cannot strictly +be designated as “shock,” and into the causation of +which the effect of the explosion of shells is merely one +of many exciting factors, this term has now come to +possess a more or less definite significance in official +documents and in current conversation. It is for this +reason that we have chosen to use it rather than the +more satisfactory, but less widely employed term, “War-Strain.” +The reader will, therefore, understand that +whenever the term shell-shock appears in these pages, +it is to be understood as a popular but inadequate title +for all those mental effects of war experience which are<span class="pagenum" id="Page_2">[Pg 2]</span> +sufficient to incapacitate a man from the performance +of his military duties. The term is vague; perhaps its +use implies too much; but this is not altogether a disadvantage, +for never in the history of mankind have the +stresses and strains laid upon body and mind been so +great or so numerous as in the present war. We may +therefore expect to find many cases which present not a +single disease, not even a mixture, but a chemical compound +of diseases, so to speak. In civil life, we often +meet with cases of nervous breakdown uncomplicated +by any gross physical injury. We are scarcely likely, +for example, to meet it complicated by gas poisoning and +a bullet wound. Yet such combinations as these—or +worse—are to be met with in the hospitals every day.</p> + +<p>This is perhaps an opportune place to point out a +significant popular misunderstanding concerning the +nature of such maladies as we shall discuss in this +chapter. A common way of describing the condition of +a man sent back with “shock” is to say that he has +“lost his reason” or “lost his senses.” As a rule, this +is a singularly inapt description of such a condition. +Whatever may be the state of mind of the patient immediately +after the mine explosion, the burial in the +dug-out, the sight and sound of his lacerated comrades, +or other appalling experiences which finally incapacitate +him for service in the firing line, it is true to say that +by the time of his arrival in a hospital in England his +reason and his senses are usually not lost but functioning +with painful efficiency.</p> + +<p>His reason tells him quite correctly, and far too often +for his personal comfort, that had he not given, or +failed to carry out, a particular order, certain disastrous +and memory-haunting results might not have happened. +It tells him, quite convincingly, that in his present state +he is not as other men are. Again, the patient reasons, +quite logically, but often from false premises, that since<span class="pagenum" id="Page_3">[Pg 3]</span> +he is showing certain symptoms which he has always +been taught to associate with “madmen,” he is mad +too, or on the way to insanity. If nobody is available +to receive this man’s confidence, to knock away the false +foundations of his belief, to bring the whole structure +of his nightmare clattering about his ears, and finally, +to help him to rebuild for himself (not merely to re-construct +for him) a new and enlightened outlook on his +future—in short, if he is left alone, told to “cheer up” +or unwisely isolated, it may be his reason, rather than +the lack of it, which will prove to be his enemy. And +nobody who has observed the hyperæsthesia to noises +and light in the nerve-hospital, nobody who has seen +the effects upon the patients of a coal dropping unexpectedly +out of the fire, will have much respect for the +phrase, “lost his senses.” There exist, of course, cases +of functional blindness, deafness, cutaneous anæsthesia +and the rest, but the majority of the nerve patients show +none of these disorders and recovery from them is often +rapid.</p> + +<p>In a word, it is not in the intellectual but in the +<em>emotional</em> sphere that we must look for terms to describe +these conditions. These disturbances are characterised +by instability and exaggeration of emotion rather than +by ineffective or impaired reason.<a id="FNanchor_2" href="#Footnote_2" class="fnanchor">[2]</a> And as we shall see +later, in the re-education of the patient, the physician is +compelled continually to take this fact into account.</p> + +<p>As we have pointed out, every nerve-stricken soldier +presents a case by itself. Slavish adherence by the +physician to one of the classical names or labels used in +diagnosis usually spells failure. The patient must be +approached <em>without prejudice</em>, and the doctor who wishes +to be of real help to him must make up his mind to<span class="pagenum" id="Page_4">[Pg 4]</span> +examine and ponder over the sufferer’s mental wounds +with as much, nay, even more—care and expenditure of +time than would be given to physical injuries. A mere +cursory inspection in the course of the formal ward visit +is a solemn farce, if it pretends to be a serious attempt +to cure the mentally afflicted.</p> + +<p>A man standing at “attention” by the side of his bed, +surrounded by his comrades and faced by the medical +officer, the military sister, and perhaps even by other +members of the staff may volunteer the information that +he is sleeping badly. But this imposing procession and +cloud of witnesses is scarcely conducive to the production +of any further evidence as to the cause of his insomnia. +For of those causes even pre-war experience makes it +possible to assert that their name is legion, and their +character often of an exceedingly intimate and private +nature.</p> + +<p>The formal visiting of patients in the wards, while +adequate for the care of physical injuries (which can be +subsequently attended to by trained nurses and sisters) +and necessary for administrative and disciplinary purposes, +is insufficient for “mental cases.” It is with this fact in +mind that the military authorities have instituted special +hospitals in which more detailed attention may be given +to the latter class of patients. In these institutions the +soldier may have private interviews with his medical +officer, and the history of the trouble can be unravelled +in conversation. <em>It is only in this way that any +scientific insight into a case of mental disorder can +be obtained.</em></p> + +<p>A short time spent in such interviews, or even the +perusal, by the uninitiated, of the papers already published +in the <cite>Lancet</cite>, <cite>British Medical Journal</cite>, and elsewhere<a id="FNanchor_3" href="#Footnote_3" class="fnanchor">[3]</a>, +will convince one of the immense complexity of<span class="pagenum" id="Page_5">[Pg 5]</span> +these unusual mental conditions, and moreover, of the +absolute necessity of obtaining and understanding the +patient’s past history, before and during the war. A +dozen cases sent back from the front as shell-shock +may prove to possess not a single feature in common—except +the fact of the shell explosion. And this, as has +been pointed out, may be but the “last straw.”<a id="FNanchor_4" href="#Footnote_4" class="fnanchor">[4]</a> The +patient often discloses in the first interview the fact that +he was displaying all his present symptoms <em>before</em> the +arrival of the particular shell which laid him out.</p> + +<p>It is now possible to attempt a brief sketch of the +typical conditions which give rise to some of the chief +varieties of shell-shock. Let us take a common case; +that of the patient who is returned to this country, +figuring in the casualty lists under the terse and businesslike +military formula, “shock, shell.”</p> + +<p>For various reasons, which the reader will easily +supply, we choose to present a composite picture of the +history of such a soldier. Not all the conditions +described here need necessarily have operated in any one +case taken at random, but we shall err, if at all, on the +side of understatement. The correctness of the description +may be checked by a reference to the papers already +mentioned.<a id="FNanchor_5" href="#Footnote_5" class="fnanchor">[5]</a></p> + +<p>We must first try to conceive the experiences of the +soldier before the occurrence of the knock-out blow, so +far as they bear on his present condition. Let us suppose +that his period of training has made him physically and +mentally fitter than he had ever been before, that no<span class="pagenum" id="Page_6">[Pg 6]</span> +military causes of anxiety or fear, such as the experience +or the anticipation of being torpedoed on the outward +voyage, have operated to any noteworthy extent in his +case. He enters the trenches in first-class condition. +The duration of his stay there, provided he is not +wounded, or attacked by any bodily illness, will depend +from that time forward upon the nature, duration, intensity +and frequency of the emotion-exciting causes, and +upon himself. By that all-inclusive word “himself” we +mean to signify chiefly his temperament, disposition and +character.<a id="FNanchor_6" href="#Footnote_6" class="fnanchor">[6]</a></p> + +<p>It must be remembered that one of the greatest sources +of breakdown under such circumstances is intense and +frequently repeated emotion.<a id="FNanchor_7" href="#Footnote_7" class="fnanchor">[7]</a> By this is meant not only +experiences of fear or of sympathy with suffering +comrades, in short, those conditions the manifestations +of which might cause the man in the trenches to be +spoken of as “emotional,” but also other mental states +associated with general excitement, anxiety, remorse for +major or minor errors, anger, elation, depression and +that complex but very real state, the fear of being afraid. +(The more definite terms of technical psychology are not +used here, as it is considered wiser to employ popular +language.)</p> + +<p>The soldier may be subjected to intense emotional +stimuli of this kind for days or weeks without relief. And +whereas to the mental sufferer in civil life sleep often is<span class="pagenum" id="Page_7">[Pg 7]</span> +vouchsafed, “setting him on his feet” to continue, more +or less effectively, the struggle next day, to the soldier +sleep may be impossible, not necessarily because of his +excited mental state, but simply from the lack of opportunity +or the disturbances going on about him. In course +of time this loss of sleep from external causes may easily +set up bodily and mental excitability, which in its turn +acts as a further cause of insomnia. The usual mental +conditions associated with loss of sleep then rapidly +supervene: pains and unpleasant organic sensations, +hyperæsthesia, irritability, emotional instability, inability +to fix the attention successfully upon important matters +for any length of time, loss of the power of inhibition and +self-control.<a id="FNanchor_8" href="#Footnote_8" class="fnanchor">[8]</a></p> + +<p>These symptoms, troublesome enough in civil life, +become positively dangerous to the man in the trenches, +especially if he is in a position of responsibility. In that +case his standing as officer or N.C.O. merely adds to +his mental distress. Bodily hardship, such as exposure +to cold and wet, hunger, and the irritation from vermin, +obviously aggravates the disorders we have described.</p> + +<p>We must not suppose, however, that the man who is +experiencing some or all of these mental and bodily conditions +is at this period necessarily displaying any obvious +<em>outward</em> signs of his trouble. There may be no tremor, +no twitchings, no loss of control of the facial or vocal +muscles which would indicate his state even to his neighbours. +He may, for a long time, “consume his own +smoke.” And during this process he may even appear +to his comrades to be steadier and more contemptuous<span class="pagenum" id="Page_8">[Pg 8]</span> +of danger than before. Dr. Forsyth<a id="FNanchor_9" href="#Footnote_9" class="fnanchor">[9]</a> has cited some +dramatic incidents, in which officers who imagined that +their instinctive fear was becoming apparent to the men +under their command took unnecessary risks in order to +impress these men with the idea that they were not +afraid.</p> + +<p>It must be understood that this suppression of the +external manifestations of an emotion such as fear is but +a partial dominance of the bodily concomitants of that +emotion. The only changes which can usually be controlled +by the will are those of the voluntary or skeletal +muscular system, not those of the involuntary or visceral +mechanism. While no signs of fear can yet be detected +in the face, the body, limbs or voice, these disturbances +of the respiratory, circulatory, digestive and excretory +systems may be present in a very unpleasant degree, +probably even intensified because the nervous energy +is denied other channels of outlet.<a id="FNanchor_10" href="#Footnote_10" class="fnanchor">[10]</a></p> + +<p>The suppression of fear and other strong emotions is +not demanded only of men in the trenches. It is constantly +expected in ordinary society. But the experience +of the war has brought two facts prominently before us. +First, before this epoch of trench warfare very few +people have been called upon to suppress fear continually +for a very long period of time. Secondly, men feel fear +in different ways and in very various degrees.</p> + +<p>The first fact accounts for the collapse, under the long +continued strain of trench warfare, of men who have +shown themselves repeatedly to be brave and trustworthy. +They may have felt intense emotions, obviously not of<span class="pagenum" id="Page_9">[Pg 9]</span> +fear alone, for a long time without displaying any signs +of them. But suppression of emotion is a very exhausting +process. As Bacon says, “We know diseases +of stoppings and suffocations are the most dangerous +in the body; and it is not much otherwise in the mind.”</p> + +<p>The second fact mentioned above is of great importance +in the consideration of our problem. There are +undoubtedly men who seem to be immune to fear of +the dangers of warfare. But to them we can scarcely +apply the adjective “brave.” The brave man is one, +who, feeling fear, either overcomes it or refuses to allow +its effects to prevent the execution of his duty.</p> + +<p>Other emotional states however, besides fear, arise +and require suppression. The tendency to feel sympathetic +pain or distress at harrowing sights and sounds, +disgust or nausea at the happenings in the trenches, the +“jumpy” tension in face of unknown dangers such as +mines—all these, like fear, are or have been biologically +useful under natural conditions and, like it, are deeply +and innately rooted in man. But the unnatural conditions +of modern warfare make it necessary that they +shall be held in check for extraordinarily long periods of +time.</p> + +<p>The impossibility of regarding modern methods of +warfare in the same light as natural and primitive means +of fighting appears very clearly when we consider the +instinctive and emotional factors involved in the two sets +of circumstances. In natural fighting, face to face with +his antagonist, and armed only with his hands or with +some primitive weapon for close fighting, the uppermost +instinct in a healthy man would naturally be that of +pugnacity, with its accompanying emotion of anger. The +effect of every blow would be visible, and the intense +excitement aroused in the relatively short contest would +tend to obliterate the action of other instincts such as +that of flight, with its emotion of fear. But in trench<span class="pagenum" id="Page_10">[Pg 10]</span> +warfare the conditions are different. A man has seldom +a personal enemy whom he can see and upon whom he +can observe the effects of his attacks. His anger cannot +be directed intensely night and day against a trench +full of unseen men in the same way in which it can be +provoked by an attack upon him by an individual. And +frequently the assaults made upon him nowadays are +impersonal, undiscriminating and unpredictable, as in the +case of heavy shelling. One natural way is forbidden +him in which he might give vent to his pent-up emotion, +by rushing out and charging the enemy. He is thus +attacked from within and without. The noise of the +bursting shells, the premonitory sounds of approaching +missiles during exciting periods of waiting, and the sight +of those injured in his vicinity whom he cannot help, +all assail him, while at the same time he may be fighting +desperately with himself. Finally, he may collapse when +a shell bursts near him, though he need not necessarily +have been injured by actual contact with particles of the +bursting missile, earth thrown up by its impact, or gases +emanating from its explosion. He may or may not be +rendered unconscious at the time.<a id="FNanchor_11" href="#Footnote_11" class="fnanchor">[11]</a> He is removed from +the trenches with loss of consciousness or in a dazed or +delirious condition with twitchings, tremblings or absence +of muscular power.</p> + +<p>Upon recovery of consciousness, which may take place +after periods varying between a few minutes and a few +weeks, the immediate disorders of sensation, emotion, +intellect, and movement, are often very severe. It may<span class="pagenum" id="Page_11">[Pg 11]</span> +be presumed that at the beginning of the war they must +have appeared far more serious to most of the doctors +who saw them in their early stages than they would now. +This speculation is suggested by the evidence of the +case-sheets sent with the men from France in the early +period of the campaign. Such diagnoses as “delusional +insanity,” and other similar terms taken from the current +classifications of advanced conditions of insanity, appear +very frequently as descriptions of cases which on arrival +in England had almost entirely lost every sign of mental +unusualness. In fact, one of the most cheering aspects +of work amongst this type of case has been the rapidity +with which men who have presented quite alarming symptoms +have subsequently recovered.</p> + +<p>It may seem almost unnecessary to enumerate the +bizarre phenomena which constitute the immediate results +of shell-shock, for our newspapers have naturally +seized upon such unusual details and have made the most +of their opportunities in this direction. But the reader +will obtain a clearer idea of the facts if they are catalogued +once more.</p> + +<p>The most obvious phenomena are undoubtedly the +disturbances of sensation and movement. A soldier may +be struck blind, deaf or dumb by a bursting shell: in rare +cases he may exhibit all three disorders simultaneously +or even successively. It should be added that these +troubles often vanish after a short space of time, as +suddenly and dramatically as they appeared. Thus one +of the blinded soldier survivors of the <em>Hesperian</em> +recovered his sight on being thrown into the water. Other +blind patients have had their sight restored under the +action of hypnosis. Mutism is often conquered by the +shock of a violent emotion, produced accidentally or +purposely. Examples of such “shocking” events taken +at random from our experience were the sight of another +patient slipping from the arms of an orderly, the “going<span class="pagenum" id="Page_12">[Pg 12]</span> +under” chloroform, the application of a faradic current +to the neck, the announcement at a “picture house” of +Rumania’s entry into the war (this cured two cases +simultaneously), and the sight of the antics of our most +popular film comedian. The latter agency cured a case +of functional deaf-mutism, the patient’s first auditory +sensations being the sound of his own laugh.</p> + +<p>The muscular system may be affected in an equally +striking manner. Contractures often occur in which a +man’s fist may be immovably clenched for months; or +his back may be bent almost at right angles to his +lower limbs, there being in neither case any bodily change +discoverable by the neurologist which can account for +such a condition. These contractures, though curable, +often prove very obstinate, and at present their nature +remains somewhat of a mystery. Other distressing and +long continued disturbances take the form of muscular +twitchings and tremors or loss of power in the limbs.</p> + +<p>Not every nerve-case, however, presents such striking +and objective signs as those which we have just been +describing. The <em>subjective</em> disturbances, which are apt +to go undiscovered in a cursory examination of the +patient, are frequently more serious than the objective,<a id="FNanchor_12" href="#Footnote_12" class="fnanchor">[12]</a> +and are experienced by thousands of patients who to the +mere casual observer may present no more signs of +abnormality than a slight tremor, a stammer, or a depressed +or excited expression. These afflictions: loss of +memory, insomnia, terrifying dreams, pains, emotional +instability, diminution of self-confidence and self-control, +attacks of unconsciousness or of changed consciousness +sometimes accompanied by convulsive movements resembling +those characteristic of epileptic fits, incapacity to<span class="pagenum" id="Page_13">[Pg 13]</span> +understand any but the simplest matters, obsessive +thoughts, usually of the gloomiest and most painful kind, +even in some cases hallucinations and incipient delusions—make +life for some of their victims a veritable hell. +Such patients may have recovered from sensory or motor +disturbances and yet may suffer from any or all of +these afflictions as a residuum from the original “shock-complex;” +they may suffer from them as a complication +of the discomfort attending upon a wound or an illness, +or, on the other hand, they may have no overt bodily +disorder: their malady then being usually given the simple +but all-inclusive (and blessed) description “neurasthenia.”</p> + +<p>Now the happiness and welfare of such men obviously +is bound up to no small extent with the character of the +hospital or hospitals (for the plural number is commonly +to be used in writing the history of these patients) to +which they are sent. In the general military hospitals +the medical officers have neither the time nor, in many +cases, the special knowledge, necessary to deal with cases +of this kind. Such patients may recover of themselves +without any treatment, but a large number of them tend +to get worse, and if they are left without attention their +symptoms are apt to become stereotyped into definite +delusions and hallucinations. Moreover, in a general +ward such men may become a constant source of disturbance +and annoyance to other patients and to the +nurses. One of the symptoms of their illness is a morbid +irritability; they tend to become upset and to take +offence at the merest trifles<a id="FNanchor_13" href="#Footnote_13" class="fnanchor">[13]</a>—and this leads to trouble +with patients, nurses, and the medical officers responsible +for discipline. But if special consideration is shown +them by the nurses the other patients are apt to misunderstand +it and even to complain of favouritism. In +other words, when mixed with wound-cases in a general<span class="pagenum" id="Page_14">[Pg 14]</span> +hospital, these nervous patients are apt to be regarded +as a nuisance—which is bad for them and for the proper +working of the hospital. Another consideration, too, is +that the subjection of such men to irksome regulations +of military discipline, and the usual penalties for infringing +them, is often so potent a factor in producing +disturbances as to be quite fatal to any hope of +amelioration.</p> + +<p>These considerations have led the military authorities +to establish special hospitals for nerve-cases.<a id="FNanchor_14" href="#Footnote_14" class="fnanchor">[14]</a> In +such institutions the patients can be nursed and attended +to by a staff which, being used to the idiosyncrasies of +such illnesses can make conditions more suitable to them.</p> + +<p>A man’s particular nervous malady is likely to be of +common occurrence in the nerve-hospital; it does not +render him conspicuous, and therefore an object of fussy +solicitude, galling pity, or suspicious contempt, as is too +often the case in other institutions. If unwounded, he +need not suffer the taunt of “having nothing to show” +as his reason for staying in hospital. Further, while in +the special hospital, more importance is attached to some +of the patient’s symptoms, less disturbance is produced +by others. The occurrence of a “fit” is viewed by the +rest of the men in this class of hospital in a truer +perspective, and the patient does not find himself a +nine-days’ wonder, as he so easily may do in a small<span class="pagenum" id="Page_15">[Pg 15]</span> +auxiliary hospital full of straightforward wound cases.</p> + +<p>Up to this point we have discussed the various troubles +subsumed under the term shell-shock in what may be +termed its initial and middle stages. In the middle stage, +the patient having recovered from the severe and acute +symptoms constituting the former phase, is left with a +motley residuum of troubles, the chief of which we have +enumerated on pages 12, 13. In distinguishing between +this middle stage and that which follows it, we may perhaps +ask the reader to assist us by recalling the difference between +a mechanical mixture and a chemical compound. In +the former the ingredients of the mixture remain unaltered +and unaffected by the proximity of other substances, as for +example when sugar is mixed with sand. In the compound, +on the other hand, chemical action and reaction +occur between the components so that not one of the +substances is immediately recognisable in the complex, +as for example when carbon, hydrogen and oxygen +combine to form alcohol, which resembles none of them.</p> + +<p>Now it would be distorting the facts of mind to suggest +that while the third stage of shell-shock is a compound +(as it undoubtedly is) the middle stage is a mixture. +For the very essence of mind is its compound nature. +But what we wish to point out is that in this middle stage +the abnormalities have had very little time to react +upon each other, with the result that there is some +resemblance to a state of mixture, the phenomena existing +temporarily side by side, so to speak. In this stage a +patient may be troubled simultaneously by several unusual +mental occurrences, such as terrifying dreams +during very light sleep, loss of memory for certain periods +of his past, and inability to understand or to carry out +complex orders. For a short time in his “bowled-over” +state he may be worried by the separate attacks, +of these various troubles at different periods of the day +and he may be too overwhelmed to try to understand<span class="pagenum" id="Page_16">[Pg 16]</span> +or to attempt to see relations between them. This state +of mind, in which the patient is still his “old self,” +though a somewhat overturned self, resembles the +mechanical mixture in our illustration. The reader may +obtain some idea of this condition if he recalls any one +day in his own experience when “everything seemed to +go wrong”; when at one moment he was turning to +face this difficulty, at another, that, but still retained to +a great extent his usual attitude towards the world.</p> + +<p>As has been pointed out, however, the state of +“mechanical mixture” is utterly alien to the normal +mind, which tends rapidly to interpret, in the light of +its own experience, and to integrate as far as possible, +its events, however incongruous they may be. The mind +cannot, for any length of time, allow a new experience +to remain strange or undigested. It must gather in and +assimilate that event to the systematised complex which +we call its own past experience. It follows that the +ultimate result upon any particular mind of a new experience, +if it be of a personally significant nature, will +depend almost entirely upon the past history of that +mind.</p> + +<p>Thus for example the question whether the patient +can or cannot satisfactorily stand up to his new troubles +will be determined not only by his disposition, temperament +and character, but also by his previous personal +experience.</p> + +<p>It is thus obvious to anyone who gives the matter +any serious consideration, that the manifestation of a +severe psychical shock must necessarily be determined +in a large measure by the nature of the mind upon which +the injury falls. It would be idle to pretend therefore, +that, in diagnosis, the story of the patient’s past experience +can be left out of account, for the manifestation +of the injury will obviously depend largely upon the +individual patient’s “mental make-up.”</p> + +<p><span class="pagenum" id="Page_17">[Pg 17]</span></p> + +<p>Faced by the existence of a number of unusual mental +phenomena the patient will inevitably succeed in time in +inventing for himself, explanations of their co-existence. +This “rationalisation,”<a id="FNanchor_15" href="#Footnote_15" class="fnanchor">[15]</a> as it is called, is a perfectly +normal process which is constantly going on in every +individual, yet it plays a great part in complicating +the mental disorders of the middle stage, and thereby +intensifying the patient’s ultimate distress. For instance, +he may not be more than temporarily disturbed by the +unusual experiences we have mentioned<a id="FNanchor_16" href="#Footnote_16" class="fnanchor">[16]</a> if they assail +him separately. But, given time, he will soon begin to +connect their appearances, and will argue to himself that +these phenomena can have only one meaning: that he +is mad or rapidly becoming so. And in this completely +erroneous procedure he will be aided and abetted, not +only by his own ignorance of the relation of mental +normality to abnormality, but also by the general tendency +of the uneducated to class everything unusual in +the mental sphere as “mad.” Once he is convinced that +he is in this state he may easily lose all hope of getting +better, thereby increasing enormously the gravity of his +case. Completely illogical, but to him entirely satisfactory +explanations of his condition will then multiply.</p> + +<p>As we have mentioned, this rationalisation is no unusual +phenomenon in ordinary life. It will be clear +to anyone who gives the question a moment’s thought +that few of the non-scientific<a id="FNanchor_17" href="#Footnote_17" class="fnanchor">[17]</a> beliefs held by even a +highly educated person have ever been logically reasoned +out from fundamental principles. In fact such principles<span class="pagenum" id="Page_18">[Pg 18]</span> +frequently cannot be reached, for the very good reason +that they have never been consciously conceived by +the individual. One’s views on religion, politics, or the +relations and rights of the sexes may exhibit in their +outer casings a semblance of rational structure: their +core, however, is not reason but emotion. As James +expresses it:—</p> + +<div class="blockquot fs90"> + +<p>“In its inner nature, belief or the sense of reality is a +sort of feeling more allied to the emotions than to anything +else ... reality means simply relation to our +emotional and active life. This is the only sense which the +word ever has in the mouths of practical men.... Whenever +an object so appeals to us that we turn to it, accept it, fill our +mind with it, or practically take account of it, so far it is real +for us and we believe it. Whenever, on the contrary, we ignore +it, fail to consider it or act upon it, despise it, reject it, forget +it, so far it is unreal for us and is disbelieved.... Whatever +things have intimate and continuous connection with my life +are things whose reality I cannot doubt.”<a id="FNanchor_18" href="#Footnote_18" class="fnanchor">[18]</a></p> +</div> + +<p>Few people, however, realise this truth so clearly, or +express it so lucidly, as Professor James. Often we +believe that we are logically convinced when in reality +we have been convinced first, and have invented reasons +for our conviction afterwards. But many of our beliefs +and attitudes have been implanted in us in childhood +or early youth by processes which could not by the +wildest stretch of imagination be called logical. And +not the least important of those beliefs are those held by +the average Briton with regard to insanity.<a id="FNanchor_19" href="#Footnote_19" class="fnanchor">[19]</a></p> + +<p>For the patient, then, his mental troubles, having +intimate and continuous connection with his life, +become very real indeed. But the longer he is left +alone to “cheer up,” the longer he broods over his<span class="pagenum" id="Page_19">[Pg 19]</span> +troubles in isolation, the longer he is allowed to build +theories upon his inadequate and inaccurate data, the more +intimately and continuously connected with his life will +the abnormalities become. They may come to be so +integrated with each other that his very personality +becomes tinged. Then he is no longer a normal person +battling with his separate enemies, but one who has +made terms, and those often disastrous ones, with his +closely allied foes. An attempt to cure him at this stage +will then necessitate the analysis of a highly complex +compound, while in the early and middle stages merely +the attack upon separated elements is necessary.</p> + +<p>We are concerned at present with the facts of shell-shock, +but this is perhaps a suitable place in which to +deal with an opinion about this set of phenomena, which +is not uncommon, especially perhaps in people above +military age. That judgment, expressed sometimes +bluntly, but oftener in a more subtle fashion, is that +shock or neurasthenia are polite names for nothing else +but “funk.” It is not easy to take a dispassionate view +of this question, but to persons holding this opinion the +following points are worthy of consideration.</p> + +<p>First, the most severe and distressing symptoms +occur to a surprising extent in the case of those patients +whose past history shows that, far from possessing even +the normal quota of timidity, they had been noted for +their “dare-devilry” and had been specially chosen as +despatch-riders, snipers and stretcher-bearers in the firing +line. Secondly, it is not uncommon for patients to ask to +be sent back to duty because they feel that they have +been too long with nothing to do, while it is quite obvious +to the doctor that they are as yet unfit to bear any great +strain. Thirdly, the seasoned regular, officer or N.C.O.,<a id="FNanchor_20" href="#Footnote_20" class="fnanchor">[20]</a><span class="pagenum" id="Page_20">[Pg 20]</span> +as well as the young soldier of only a few months’ service +may display precisely the same symptoms as those we +have described. Such men have frequently been in the +army for many years, and have fought on previous +occasions with great success. Their strength of +mind and body has been demonstrated over and over +again, yet at last they have broken down. And they +manifest the greatest concern at their unusual symptoms.</p> + +<p>It will be readily granted, of course, that there exist +among the nerve patients returned from the front cases +in which there is genuine fear of the war, arising from +memories of the experiences which they have undergone. +Even this state of mind, however, is usually expressed +by the patient in some such phrase as “I don’t want to +go back, but I’ll go quite willingly if I’m ordered to.” +It should not be forgotten, moreover, that not a small +number of instances are known in which these men prove +to have made repeated attempts at enlistment after +having been rejected several times, or even discharged +from the army, changing their medical examiner until +they have succeeded. One case, presenting a great +number of the symptoms of shell-shock in a very +intense form, including, beside the ordinary neurasthenic +troubles, blindness, deafness, and mutism at successive +times, was that of a man who had been discharged from +the army as medically unfit and had re-enlisted.</p> + +<p>Two cases may be quoted here in illustration of some +of these assertions:</p> + +<p>The first is that of a non-commissioned officer who +went through the initial eleven months of the war in +France and Flanders, was subjected to every kind of +strain, physical, mental and moral, which that stricken<span class="pagenum" id="Page_21">[Pg 21]</span> +field provided; and in addition was wounded twice, +gassed twice, and buried under a house, on all five +occasions being treated in the field ambulance and then +returning to the trenches. After all this experience he +had not qualified for sick leave, but was granted five +days ordinary leave to return home, apparently in a good +state of health. After reaching England and while +waiting for a train in the railway station, he suddenly +collapsed, became unconscious, and for months afterwards +was the subject of severe neurasthenia. Apparently at +the front the excitement, the sense of responsibility and +especially the example that he felt he should set his men, +seem to have kept him right. These stimuli removed, +he broke down. The whole of his trouble seemed to +be due to the dread lest on his return to the front, the +added responsibilities which would fall upon his shoulders +(because most of his own officers had been killed and +there would be new men to replace them) might be too +much for him. His intelligence seemed (to himself) to +have become numbed by his experiences, and he became +conscious of the unreliability of his memory and of his +inability to understand not only complex orders, but, +as he put it, “even the newspapers.” It was this that +excited in him the dread lest he should be incompetent to +discharge adequately the duties which would fall upon +him. There was nothing of malingering or shirking in +his case. There was no fear of physical injuries or of +returning to the front; on the contrary, he was anxious +to go back. His fear lest the possibility of his failure +would be bad for his platoon was wholly due to that +admirable sentiment of regimental loyalty, which comes +out so strikingly in the nervous troubles of the non-commissioned +officer.</p> + +<p>This class of case demands a great deal of patient and +sympathetic attention before the real cause of the trouble +is elicited, and then months of re-education may be<span class="pagenum" id="Page_22">[Pg 22]</span> +required to build up anew the man’s confidence in himself.</p> + +<p>The second case is that of a soldier who had suffered +from severe shock symptoms and had recovered. In +conversation with the medical officer the soldier expressed +his willingness, and even his desire, to return to the front, +in full knowledge of the fact that the officer’s report +in that sense would lead to his being sent back to fight. +That night the patient was awakened by a terrifying +dream, the true significance of which was certainly not +adequately appreciated by him. Although he dreamt +that he was afraid to go back to the front, apparently he +did not realise that he was actually afraid—<em>i.e.</em>, that the +dream had any meaning. On examination it proved to +be a detailed forecast of the imaginary incidents of his +return to his regiment, and of his attempt to commit +suicide when ordered to go to France. Here was a man +who of his own initiative had asked his doctor to certify +him as ready to go back, yet in his sleep the train of +thought, started by the discussion of the possibility of +his return, working subconsciously, had stirred up images +of what this implied, and reinstated emotions of so +terrifying a nature that in his dream he preferred suicide +to facing the ordeal again.</p> + +<p>It may perhaps be allowable to quote in this connection +the view of a German neurologist, Prof. Gaupp, on +the “shock-cases” which have been sent back from the +German front.<a id="FNanchor_21" href="#Footnote_21" class="fnanchor">[21]</a> At the same time it is important +to remind our readers that Gaupp is writing of a +conscript army, the authorities in which are certainly +not notorious for lenity to the individual; further, that +up to the time of writing the present chapter, all the +“shock” patients in Great Britain have been men who +voluntarily elected to serve their country, the majority of<span class="pagenum" id="Page_23">[Pg 23]</span> +them having enlisted in the earliest stages of the war.</p> + +<p>In discussing cases where nervous trouble, uncontrollable +in nature and intensity, had led to the patients +being kept in German hospitals for months, it was +sometimes found that the mental foundation which was +a causal factor of these troubles was a more or less +conscious anxiety concerning the possibility of a return +to the front.</p> + +<div class="blockquot fs90"> + +<p>“There is no justification,” says Gaupp, “for calling +every instance of this a case of malingering or simulation. +There are quite capable men of irreproachable character whose +nervous system is positively unfitted for the hardships and +horrors of war. They have enthusiasm and the best of intentions +but these cease to inspire them when the horrors and +terrors come. Their inner strength rapidly decreases, and it +only requires an acute storm to break upon the nervous system +(such as the explosion of a shell or the death of comrades) for +their self-control to vanish completely. Then automatically +their condition changes into what is popularly called ‘hysteria.’ +The exhausted mind then feels that it is no longer master of +the situation, and therefore ‘takes refuge in disease.’ At first, +as a rule, obvious signs of terror and anxiety (trembling, +twitching, etc.) manifest themselves; if these are cured there +still remain chronic symptoms of hypochondria and despondency. +Time, however, has its effect in many of these cases.”<a id="FNanchor_22" href="#Footnote_22" class="fnanchor">[22]</a></p> +</div> + +<p>If a patient comes into the hands of a physician before +the processes of rationalisation and systematisation have +become established, the medical officer should be able +to meet his difficulties, and help him correctly to interpret +his unusual experiences by explaining to him their origin +and nature.</p> + +<div class="blockquot fs90"> + +<p>“The application of discreet sympathy and tact by a physician +who endeavours to discover something of the man’s past +mental history may be able to reassure a patient upon his +particular trouble with the happiest of results. To a man quite<span class="pagenum" id="Page_24">[Pg 24]</span> +unacquainted with text-books or speculation on psychology +there can be no darker mystery than the working of other +people’s minds. To such a man the natural conclusion is that +his own mental processes are universal and normal. But if, +as a result of some nerve-shattering experience of warfare his +mind suddenly develops a trick which was quite unknown to +him before, though this development may be far from abnormal, +to the troubled patient it may seem to be an unquestionable +symptom of madness.”<a id="FNanchor_23" href="#Footnote_23" class="fnanchor">[23]</a></p> +</div> + +<p>Many of the cases in which a patient has merely +needed reassuring have been of this type. A short and +very simple explanation of some elementary facts of +psychology is often sufficient to bring about an immense +change in the man’s condition, which has led to his +curing himself. And this is the ideal method of cure.</p> + +<p>It may seem that an inordinate amount of space has +been devoted to the demonstration of a simple truth, +that mental, like bodily disorder, should be treated +early, or complications may ensue. But there are reasons +for giving so much prominence to this aspect of the +subject. The chief is that in our own country, mental +disorder is seldom treated in its early stages. Nearly +all our elaborate public machinery for dealing with this +distressing form of illness is devised, and in practice is +available, only for the advanced cases. This war has +shown clearly a truth which, of course, was already +known before to many doctors, but never adequately +appreciated by the general public, that a case of +advanced mental disorder may pass not only through +various milder stages on its way, but that if intercepted +at these earlier stages, it may frequently be cured with +ease.</p> + +<p>Another point which should be emphasised is this: +shell-shock involves no <em>new</em> symptoms or disorders.<span class="pagenum" id="Page_25">[Pg 25]</span> +Every one was known beforehand in civil life. If by +any stretch of the imagination we could speak of a +specific variety of disease called shell-shock, it would +be new only in its unusually great number of ingredients. +And the most gratifying truth of all is that even this +hydra-headed monster, if caught young, can be destroyed.</p> + +<p>From the fact that shell-shock includes no new disorders +the important inference may be drawn that the +medical lessons taught by the war must not be forgotten +when peace comes. The civilian should be offered the +facilities for cure which have proved such a blessing to +the war-stricken soldier.</p> +<br> + +<div class="footnotes"><h3>FOOTNOTES:</h3> + +<div class="footnote"> + +<p><a id="Footnote_1" href="#FNanchor_1" class="label">[1]</a> There are no sicknesses, there are only sick people.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_2" href="#FNanchor_2" class="label">[2]</a> This subject has been lucidly discussed by C. Burt, “Psychology +and the Emotions,” <cite>School Hygiene</cite>, May, 1916.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_3" href="#FNanchor_3" class="label">[3]</a> Such as for instance, D. Forsyth, <cite>Lancet</cite>, Dec. 25th, 1915, +p. 1399; C. S. Myers, <cite>Lancet</cite>, Mar. 18th, p. 608; R. G. Rows, +<cite>Brit. Med. Jour.</cite>, Mar. 25th, 1916, p. 441; G. Elliot Smith, +<cite>Lancet</cite>, April 15th and 22nd, 1916; H. Wiltshire, <cite>Lancet</cite>, June +17th, 1916.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_4" href="#FNanchor_4" class="label">[4]</a> Wiltshire, <em>op. cit.</em>, p. 1210.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_5" href="#FNanchor_5" class="label">[5]</a> On pp. 4, 5.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_6" href="#FNanchor_6" class="label">[6]</a> The reader who is interested in these important distinctions +should consult McDougall, <cite>Social Psychology</cite>, London, 1915, +p. 116.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_7" href="#FNanchor_7" class="label">[7]</a> <em>Cf.</em> the statements of two experienced neurologists:—Déjerine +and Gauckler (written before the war), “Overwork +and fatigue are no more a cause of neurasthenia than they are +of tuberculosis. Without emotion there are no psychoneuroses.”</p> + +<p>(<cite>The Psychoneuroses and their Treatment by Psychotherapy</cite>, +Jelliffe’s translation, 1913, p. 232.)</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_8" href="#FNanchor_8" class="label">[8]</a> An experimental investigation of the mental effects of loss +of sleep has been carried out by Miss May Smith of the Oxford +Psychological Laboratory. A short account of these experiments +and their results is given in “Some Experimental +Investigations of Fatigue,” by T. H. Pear, <cite>Proceedings of +London County Council Conference of Teachers</cite>, 1914.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_9" href="#FNanchor_9" class="label">[9]</a> <em>Op. cit.</em>, p. 1402.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_10" href="#FNanchor_10" class="label">[10]</a> In his book, “Bodily Changes produced by Fear, Pain, +Hunger and Rage,” Professor Cannon has given a striking +demonstration of the importance of emotion in producing +such bodily disturbances.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_11" href="#FNanchor_11" class="label">[11]</a> Capt. Wiltshire, as a result of recent experience near the +firing line in France thinks that the men’s accounts of the +duration of unconsciousness are often exaggerated, owing to +their faulty memory of the time at which it occurred. He also +says that in his opinion the actual individual shell-shock which +prostrates the man is but the final precipitating cause. (<em>Op. +cit.</em>, p. 1207.)</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_12" href="#FNanchor_12" class="label">[12]</a> This fact is in danger of being overlooked by members of +the public whose knowledge of “shock” is obtained from the +newspaper reports.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_13" href="#FNanchor_13" class="label">[13]</a> R. G. Rows, <em>op. cit.</em>, p. 441.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_14" href="#FNanchor_14" class="label">[14]</a> For particulars of these hospitals, see W. Aldren Turner’s +Report, <cite>Lancet</cite>, May 27th, 1916, p. 1073. The reports published +in the special war numbers of the <cite>Revue Neurologique</cite> (and +especially Nos. 23, 24, November and December, 1915) bear +ample testimony to the magnificent work being done by the +French in this direction. Not only has special provision been +made in each military district for dealing with neurological and +mental cases, but also admirable accounts of the work are +being published, and those responsible for the care of such +patients have been afforded many opportunities for discussing +their difficulties and learning from each other.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_15" href="#FNanchor_15" class="label">[15]</a> Or “seeking conscious and rational grounds for actions” (and +beliefs) “whose motives are largely unconscious and perhaps +irrational.” (A description borrowed from Burt’s article, <em>q. v.</em>)</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_16" href="#FNanchor_16" class="label">[16]</a> On pp. 12, 13.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_17" href="#FNanchor_17" class="label">[17]</a> (and, obviously, the same may be said of not a few ‘scientific’ +beliefs.)</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_18" href="#FNanchor_18" class="label">[18]</a> <cite>Principles of Psychology</cite>, II., 283-324.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_19" href="#FNanchor_19" class="label">[19]</a> The opinions of Dr. Bedford Pierce upon this matter are +highly important. <cite>British Medical Journal</cite>, January 8th, 1916, +p. 4.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_20" href="#FNanchor_20" class="label">[20]</a> Our personal experience has been of privates and non-commissioned +officers only, but there is no <i lang="la" xml:lang="la">a priori</i> reason for +supposing that these remarks do not apply to the commissioned +ranks. It has been found that in the French Army the cases +of neurasthenia amongst officers have been very numerous.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_21" href="#FNanchor_21" class="label">[21]</a> “Hysterie und Kriegsdienst” (Hysteria and War Service), +<em>Münchener Medizinische Wochenschrift</em>, March 16th, 1915.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_22" href="#FNanchor_22" class="label">[22]</a> The translation is very free, but it fairly represents the +sense of the German original.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_23" href="#FNanchor_23" class="label">[23]</a> From a leading article on “War-Shock and its Treatment,” +in the <cite>Manchester Guardian</cite>.</p> + +</div> +</div> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> +<p><span class="pagenum" id="Page_27">[Pg 27]</span></p> + +<h2 class="nobreak" id="CHAPTER_II">CHAPTER II.<br> +<span class="fs120">Treatment.</span></h2> +</div> + +<p class="drop-cap"><span class="upper-case">In</span> discussing the question of treatment we do not +propose to deal with general therapeutic measures +which every physician in charge of nervous or mental +patients is hardly likely to neglect.<a id="FNanchor_24" href="#Footnote_24" class="fnanchor">[24]</a> The importance of +a generous and easily digested dietary is generally recognised: +as also is the need for quiet and congenial +surroundings, and for shielding patients from disturbances, +such as noises and the sight of wounded, which +are likely to evoke painful emotions and vivid memories +of their experiences at the front. It is also obviously +important that the physician should deal promptly and +discreetly with any bodily ailments from which the patient +is suffering, being careful neither to minimise their gravity +and so give him any reason for the grievance that he +is not receiving proper attention, nor by exaggerating +them to add this anxiety to his other troubles.<a id="FNanchor_25" href="#Footnote_25" class="fnanchor">[25]</a> These +are questions which may confidently be left to the discretion +of the physician in charge.</p> + +<p><span class="pagenum" id="Page_28">[Pg 28]</span></p> + +<p class="no-indent"><em>Firmness and Sympathy.</em></p> + +<p>But there are certain other therapeutic measures commonly +recommended in text-books for application in the +cases of patients suffering from neurasthenic and hysterical +troubles, which cannot be thus summarily dismissed. As +many of these patients are irritable and childishly peevish, +it is necessary that they should be treated with sympathetic +firmness, tact and insight. But, unfortunately, +the words “firmness” and “sympathy” are interpreted +in a great variety of ways. While it is important, for +purely therapeutic reasons, that discipline should be +maintained, and that when the physician has decided +what he considers the proper treatment for the patient +this should be rigorously carried out, it is manifestly +disturbing and injurious in many cases for the officer +to insist upon all the exacting details of military rules +and regulations. For the mentally healthy soldier, +obedience to stern and even harshly rigid regulations is +often vitally important; but an attempt by a medical +officer to treat a ward of neurasthenic patients in this way +usually has disastrous results.</p> + +<p>Quite apart, however, from the military aspects of the +case, the physician, without really investigating the history +of a patient, may label his trouble “hysteria” and forthwith +adopt a course of “firmness.” He may assume +the attitude of doubting the genuineness of symptoms +which are very real to the sufferer. Under the plea of +helping to cure the patient the officer may assure him +that there is nothing much the matter with him and that +if he tries he will soon be all right. Such advice may +be justifiable if based on a real insight into the state +of the individual sufferer, but this knowledge can be +gained only by a patient investigation of the cause of +his trouble. If the advice is given without this insight, it +is a mere shot in the dark. The fact that the device +succeeds in a certain number of cases is no excuse for its<span class="pagenum" id="Page_29">[Pg 29]</span> +general adoption. And when it “misfires” no one +realises the fact more quickly than the patient himself. +He realises that the officer does not appreciate his condition +and his confidence is thereby destroyed.</p> + +<p>It is useful, too, to consider for a moment the nature +of treatment by “sympathy.” When we used the phrase +“sympathetic firmness” we intended to indicate the +insistence upon a strict observance of such methods of +treatment as a real insight into the patient’s condition +may suggest. The word “sympathy” was used in its +literal sense of “feeling with” the sufferer. But there +is no class of patients upon whom sympathy of the injudicious +kind is more prone to work serious harm than +the psychoneurotic. The knowledge of this fact is often +the excuse for the adoption of the opposite attitude and +the prescription of “firmness” which, as we have seen, +may be equally unintelligent and injudicious.</p> + +<p>But sympathy of the injudicious kind is not <em>real</em> +sympathy. For unless the sympathiser has a true +appreciation of the patient’s condition, and can look at +things from his point of view, he cannot really feel <em>with</em> +the sufferer. The latter may arouse in the would-be +sympathiser tender emotions and sympathetic “pain,” +but unless the sympathiser have insight, the pain, to put +it crudely, is not likely to be “in the same place” as +that of the patient. Such misplaced emotion and false +sympathy, whether on the part of the doctor, the nurse, +or the patient’s relations, may do much harm.</p> + +<p>In mild cases of mental trouble, however, where the +patient still retains a goodly portion of self-confidence +and self-respect, this “petting” variety of sympathy may +sometimes be effective. Such a patient may be cheered +up by the presence of people sufficiently interested in him +to be sorry for his condition; and it may help him to +look on the brighter side of things and to forget his +worries and anxieties. But often it is apt, by suggestion,<span class="pagenum" id="Page_30">[Pg 30]</span> +to aggravate his troubles or even to discourage him from +trying to recover.<a id="FNanchor_26" href="#Footnote_26" class="fnanchor">[26]</a> Perhaps it would be more accurate +to say that such treatment gives him no inducement to +get better.</p> + +<p>There are still not a few physicians who regard the +group of functional troubles commonly labelled “hysteria” +as something closely akin to malingering. If it +would not be considered invidious we could quote the +opinions of well-known physicians published within the +last five years, suggesting that there is no real line of +demarcation. (It is not uncommon to meet the expression +“<em>detecting</em>,” instead of <em>diagnosing</em> hysteria.)</p> + +<p>But even among those who regard these serious affections +as something more than mere simulation there is a +tendency to look upon any form of sympathy as a dangerous +pandering to the patient’s lack of will power.<a id="FNanchor_27" href="#Footnote_27" class="fnanchor">[27]</a></p> + +<p>This attitude often finds expression in leaving the patient +alone to get better by his own efforts, or in suggesting to +him that he is not so ill as he thinks he is, and that all +he needs is some work to occupy his attention.</p> + +<p>The attempt is often made to justify such methods by +the plea that it is “bad for the patient to talk to him of +his worries.” But how a physician is to rid a patient +of the very root of all his trouble without first discovering +and then discussing it with him is not apparent. Nor, +again, is it any more rational merely to tell a man who is +weighed down with some very real anxiety to “cheer up,” +or to “work in the garden,” or “take a walking tour.”</p> + +<p>We are not maintaining that such methods do not +often meet with success in the case of many patients who<span class="pagenum" id="Page_31">[Pg 31]</span> +are only mildly affected and earnestly want to get better. +But experience shows that such advice is often fraught +with danger, and, in severe cases of mental affection is +worse than useless. The experience of those physicians +who have been treating such patients with sympathetic +insight during the last two years affords a striking condemnation +of the theory that it is generally “bad to talk +to them of their worries.” It has repeatedly happened +that as soon as the patient was asked about his troubles +he made a full statement of all that was troubling him +and was obviously relieved to confess his worries to +someone who took an intelligent interest in his welfare.</p> + +<p>In many cases the mere unburdening of this weight +of anxiety and the removal by the physician of quite +trivial misunderstandings which were the original causes +of it, were sufficient to cheer up the patient and to start +him on the way to complete recovery. Yet many of +these men had been inmates of a series of hospitals in +which no attempt had been made to discover what was +the real source of all the trouble. Thus to their other +worries and anxieties was added the real additional +grievance that they were being neglected and were of +no account. In many cases this constituted a serious +aggravation of the patient’s mental disturbance and +encouraged him to believe that his state was already +beyond help.</p> + +<p>Those physicians who look upon such milder psychoses +as varieties of simulation should be reminded that the +methods we have just mentioned are not often likely to +be effective in cases of real malingering.</p> + +<p>In discussing the therapeutic use of “firmness” we +have not thought it necessary to mention those applications +of this method which at times are practised by +combatant officers at the front. The use of military +authority to suppress the minor manifestations of nervousness, +or the resort to such expedients as unexpectedly<span class="pagenum" id="Page_32">[Pg 32]</span> +firing off a gun alongside a man afflicted with functional +deafness, are merely examples of the application of +“suggestion.” They are akin to the use of “firmness” +by the physician who has not investigated the cause of +the patient’s trouble. The results of such expedients +are as erratic in the one case as in the other. But there is +no need for us to discuss this practice further, except to +add that the knowledge that such “treatment by military +authority” has been tried before, still further diminishes +the justification for resorting to such measures when the +patient reaches the home hospital.</p> +<br> + +<p><em>Isolation.</em> Many physicians regard isolation as an +appropriate method of treatment for soldiers suffering +from shock, and they urge in justification of such a +procedure the success which often attends its use in civil +cases. We do not deny the utility of isolation for suitable +cases, and success has attended its use when the patient’s +condition obviously required it. But the circumstances +which were responsible for causing the mental disturbance +in the soldier may be of a totally different nature from +those which have upset the civilian; and therapeutic +measures which may be appropriate in eliminating the +civilian’s sources of irritation might be wholly unsuitable, +if not positively harmful, in the case of soldiers.</p> + +<p>It cannot be too strongly emphasised in connection +with this subject that most of the theory and practice +of treating hysteria by isolation has been developed in +civil life, and in very many cases with reference to well-to-do +women living in the lap of luxury. When such +persons develop hysterical symptoms, some sources of +irritation in the home or the social environment are often +responsible. By isolation the patient is removed from +the noxious influence of both domestic worries and mistaken +sympathy; his or her whims and fancies are +compulsorily subordinated by self-discipline and consideration<span class="pagenum" id="Page_33">[Pg 33]</span> +for others. At home it is impossible satisfactorily +to enforce such measures and the attempt to +do so will almost inevitably fail, because sympathy, +curiosity and anxiety on the part of various relatives +hinder the attainment of these objects. By isolation the +patient is removed from these unfavourable psychical +influences. Through the freedom from such disturbing +stimuli, the abnormally intense reaction of the mind is +reduced. And in many patients of this class the desire +to be cured or to be active, which is produced by the +boredom of isolation, works favourably.<a id="FNanchor_28" href="#Footnote_28" class="fnanchor">[28]</a></p> + +<p>But in most soldiers the circumstances are altogether +different. In the first place, the patient secures the +change of surroundings by his removal from the +trenches to the hospital. Isolation, therefore, can hardly +be justified on that score. At the same time, the +removal to a military hospital at any rate should obviate +all danger of his being pestered by foolish relatives and +friends with their mistaken sympathy or excessive attention. +And as regards the importance of discipline and +routine, the soldier is in a position very different from +that of the wealthy society lady, for he has already been +subjected to such training.</p> + +<p>In some instances, however, just as in the civil cases, +the boredom of isolation may produce the good effects +noted above. But there is the corresponding disadvantage +that if you isolate a man and put a special nurse to look +after him it is impossible to convince him that his case +is not serious. It may, indeed, help him to persuade +himself that he is really going insane. As a matter of +experience, it is found that very many men cannot stand +isolation for long; they feel that they must break out, +even if they realise that punishment is certain for doing<span class="pagenum" id="Page_34">[Pg 34]</span> +so. The conversation of patients who are undergoing +treatment by isolation is often perfectly frank about it. +They tell the medical officer they will break out at the +first opportunity; that the few hours of freedom would +more than compensate for the punishment which would +come afterwards. Again, it must be apparent that, when +the trouble is due in any considerable measure to the re-awakening +of emotions linked up with some painful earlier +experience, isolation is not likely to be effective in many +cases, and may be definitely harmful. Neither should it +be forgotten that such measures fail to isolate the patient +from his worst enemy, himself.</p> + +<p>Even in those cases in which it is useful, isolation, +if unduly prolonged, may spoil its own good effects. It +may so accustom the patient to a solitary mode of +existence that the presence of other persons may make +him irritable when at the end of his time of seclusion +he is compelled to associate with his fellows.</p> + +<p>There is another fact which has to be taken into consideration—and +this applies especially in civil practice, +where the patient or his family have to pay for the +treatment. We refer to the expensiveness of treatment +by isolation. Unless it can be shown that it is the best +or the only hopeful method to adopt, the physician must +feel some hesitancy in the majority of cases, in prescribing +such costly measures.<a id="FNanchor_29" href="#Footnote_29" class="fnanchor">[29]</a></p> + +<p>Déjerine and Gauckler<a id="FNanchor_30" href="#Footnote_30" class="fnanchor">[30]</a> have given an admirable +account of the use of isolation in the treatment of +neurasthenia and hysteria. They are careful to point +out, however, that even in the case of civilian patients, +with whom of course their treatise is concerned, “isolation,<span class="pagenum" id="Page_35">[Pg 35]</span> +even accompanied by rest and overfeeding, is +never enough.” It is merely an adjunct, though, under +certain circumstances, a necessary one, of the treatment +by persuasion. But “it would be irrational to look upon +the isolation of neuropaths as a therapeutic necessity from +which one might never depart. It only applies to particular +cases.” In proceeding to define the class of +civilian patients for whom such methods are appropriate +they emphasise the value of isolation for those whose +troubles are due to, or aggravated by, “a bad family +environment.” In most cases the circumstances of the +war-stricken soldier do not come within the categories +which they suggest as justifying isolation. Moreover, +most of the benefits which they attribute to this therapeutic +measure, <em>i.e.</em>, removal from home surroundings +and from the particular worries and anxieties which have +caused the mischief, are attained (as we have already +pointed out) when the soldier is an inmate of a special—or, +in fact, of any—hospital.</p> + +<p>When Déjerine and Gauckler proceed to define the +different degrees in which the method of isolation may be +practised; <em>viz.</em>: (1) strict isolation; (2) absolute isolation +from one’s family circle and environment, and (3) +isolation from one’s family circle alone, or from one’s +usual environment alone—it becomes clear that the +treatment of every soldier who enters any hospital +inevitably comes within the scope of categories 2 and 3.</p> + +<p>Even when writing of hysterical women these French +physicians tell us that—</p> + +<div class="blockquot fs90"> + +<p class="no-indent">“to show how slightly (their) experience has inclined (them) +towards any systematic treatment of the psychoneuroses by +isolation,” isolation has not seemed (to the doctors) to be +necessary for “at least a third of the neuropathic women who +have been cared for at the Salpêtrière. Again, it must be added +that, of the patients admitted, a certain number have been +received at the hospital and naturally submitted to the discipline<span class="pagenum" id="Page_36">[Pg 36]</span> +which belongs to an isolation ward much more for +humanitarian and social reasons than because absolute isolation +seemed to be formally indicated.”<a id="FNanchor_31" href="#Footnote_31" class="fnanchor">[31]</a></p> +</div> + +<p>From the completely different nature of the circumstances +of the nerve-stricken soldier and civilian respectively +it is clear that such total isolation can be considered +necessary for soldiers only in very few cases, even though +the modified forms of isolation, to which reference has +been made, may be useful for most of such patients. +The important point that emerges from this discussion +is the necessity which is laid upon the physician of determining, +in the case of each individual patient, whether +isolation of any kind is desirable, what form it should +take, and especially when it should be used, modified or +discontinued.</p> +<br> + +<p><em>Suggestion and Hypnosis.</em> We have already touched +briefly on the need for sympathetic firmness and +for inspiring the patient with confidence that he will +recover. But such firmness can be useful only when +it is supported by respect for and confidence in the +physician. In most cases such respect can be gained +only by acquiring a real insight into the patient’s condition +and by treating him tactfully and reasonably. It +is too often forgotten that the neurasthenic patient’s +continual and intense criticism of himself makes him +especially quick at intuitively becoming conscious of the +physician’s failings. Under such circumstances, if the +doctor does not secure the patient’s respect and convince +him that he really understands his condition, the former’s +firmness and confident assurances will avail him nothing: +he has shown his hand; his failure will excite contempt; +and the patient’s intractable, <em>enlightened</em> stubbornness<span class="pagenum" id="Page_37">[Pg 37]</span> +will be fatal to any further hope of influence on the part +of that particular physician.</p> + +<p>Ever since mankind first sought help from his fellows for +his afflictions of body or mind, confidence in the efficiency +of the adviser’s ability has been an essential factor in +leech-craft. To be able to convince a patient that he is +going to recover and that medical advice will help +towards that end is certainly not the least of the +physician’s qualifications. But unless the assurances given +him are based upon real insight and understanding, +the process of securing the patient’s confidence is not +very different from the charlatan’s blatant boasting. In +other words, it is analogous to the confidence trick.</p> + +<p>The confidence which is inspired in the patient by +his conviction of the physician’s real understanding of +his condition is an altogether different matter. Such +“suggestion” necessarily enters into all successful treatment +and this applies in a very special manner to the +cure of mental ailments.</p> + +<p>But the question arises, is it useful or desirable to +supplement these measures of suggestion which are incidental +to all human intercourse, by more positive measures +of induced “suggestion” or hypnotism? There are wide +discrepancies of opinion with regard to this matter. +And, in endeavouring to come to a conclusion concerning +it, it is important to eliminate as far as possible the +emotional tone which the warm discussion of this question +has aroused in the past.</p> + +<p>The positive usefulness of hypnosis in relieving many +of the acute symptoms in recent cases of shell-shock has +been fully demonstrated by the important series of articles +by C. S. Myers, in the <cite>Lancet</cite>.<a id="FNanchor_32" href="#Footnote_32" class="fnanchor">[32]</a> When it is possible by +such means to restore to the patient his lost memory or<span class="pagenum" id="Page_38">[Pg 38]</span> +speech or banish his despondency it often proves that +the only hindrance to the complete restoration of his +normal personality has been removed.</p> + +<div class="blockquot fs90"> + +<p>“It may be argued,” to quote Myers’s own account, “that +mutism, rhythmical spasms, anæsthesia, and similar purely +functional disturbances disappear after a time without specific +treatment. But no one who has witnessed the unfeigned +delight with which these patients, on waking from hypnosis, +hail their recovery from such disorders can have any hesitation +as to the impetus thus given towards a final cure. More +especially is this the case in regard to the restoration of lost +memories. Enough has already been said here about the +striking changes in temperament, thought, and behaviour +which follow on recovery from the amnesia... The +restoration to the normal self of the memories of scenes at +one time dominant, now inhibited, and later tending to find +occasional relief in abnormal states of consciousness or in +disguised modes of expression—such restoration of past +emotional scenes constitutes a first step towards obtaining that +volitional control over them which the individual must finally +acquire if he is to be healed.</p> + +<p>Thus the minimal value that can be claimed for hypnosis +in the treatment of shock cases consists in the preparation and +facilitation of the path towards a complete recovery.”<a id="FNanchor_33" href="#Footnote_33" class="fnanchor">[33]</a></p> +</div> + +<p>Even if we admit that other measures, such as the +administration of chloroform for the cure of hysterical +mutism, may in some cases effect similar improvements, +this should not blind us to the incontrovertible fact that +hypnotism has been proved to be a valuable therapeutic +agent in the early stages of shell-shock.</p> + +<p>As a cure for certain patients who have passed the +acute stages of shell-shock or other forms of war-strain, +its use requires great discrimination in the selection +of suitable cases and extreme care in its practice. +It is very probable, too, that hypnotic suggestion by +itself should never be regarded as sufficient treatment<span class="pagenum" id="Page_39">[Pg 39]</span> +for these cases, though undoubtedly it may be of great +use as a part of such treatment.</p> + +<p>A view endorsed by some well-known physicians is that +all psychotherapy should be addressed to the functions +of consciousness, and that hypnosis, which is addressed +to the functions of automatism, is therefore undesirable. +As a general statement this is undoubtedly true of a +great number of cases, but there occur instances in which +it seems that this sensible rule may be wisely and +judiciously broken. In some cases hypnosis helps in +more quickly breaking down resistances, which occur +in patients too beset by their own auto-suggestion and +false beliefs to be able easily to grasp the arguments +and persuasions which the physician may have spent days +and weeks in vainly endeavouring to get accepted. Thus +assistance may be sought without in any way interfering +with subsequent treatment of the patient by psychological +analysis and re-education.</p> + +<p>The following instance illustrates the use of hypnotic +suggestion in the manner described above.</p> + +<p>The case was one of violent spasmodic tremor in the +right arm of a soldier. When in a state of convalescence +from a wound and shell-shock he suddenly encountered +his company officer, to whom he was greatly +attached. This officer had lost his right arm since he was +last seen in France by the patient. The shock of +suddenly meeting the officer in this condition set up +the man’s tremor. The case came under psychotherapeutic +treatment some weeks later, when the patient, +who was an extremely emotional individual, had lost all +hope of recovery. Any attempt at purposive movements of +the right hand and arm threw all the muscles of the right +side of the body into a violent state of jerky tremor.</p> + +<p>Long continued treatment by persuasion failed to effect +any improvement whatsoever. The medical officer in +charge of the case therefore decided to try hypnotic<span class="pagenum" id="Page_40">[Pg 40]</span> +suggestion. This was easily carried out; the hypnotic +state being moderately deep, though the patient was still +in touch with his environment. Hope, courage and assurance +of recovery <em>following his own effort</em>, together with +determination to make every endeavour, were suggested +to him. The patient was assured at each sitting that his +nerves and muscles would every day respond more and +more to his efforts at self-control. After a very few short +sittings the man’s hopeless attitude became changed to +one of hope, effort and attention in the waking stage, +and there was a slight but decided improvement in his +voluntary power. Hypnotic suggestion was then given +up, and the treatment was continued by means of +encouragement, exercises and explanation of his trouble, +with the result that two months later he was fit for discharge +from the hospital.</p> + +<p>It may reasonably be doubted whether methods of +persuasion alone would have cured this man. In any +case, it is clear that it would have taken a very long +time. It is also probable that hypnotic suggestion alone, +if continued, would very quickly have removed the +symptoms. It may be doubted, however, whether it +would have effected a permanent cure in a person so +open to auto-suggestion. It seems, therefore, that a +judicious combination of methods was advisable.</p> + +<p>We are of the opinion that hypnotic treatment, when +used with skill, discretion, and discrimination, has its +place in the treatment of shell-shock and similar conditions, +both in the acute and chronic stages.</p> + +<p>In the majority of cases of some considerable duration, +however, and in practically all those in which the trouble +is due to some ante-war worry or emotion, it may be +regarded as provable that hypnosis <em>alone</em> will be of +relatively slight use and in many cases may be positively +harmful, for under such circumstances, even with the +most favourable conditions, it would result merely in<span class="pagenum" id="Page_41">[Pg 41]</span> +the removal of symptoms; and the removal of one +may be followed by the appearance of another, which +may even be induced by the process of hypnosis. Moreover, +in cases where there is a tendency to the development +of a double personality hypnosis may have the +effect of increasing the risk. Further, if the patient +has sufficient of his own will-power to enable the process +of re-education to be carried out, it is clearly undesirable, +both on psychological and ethical grounds, for the doctor +to impress his influence from without.</p> + +<p>In considering the possibility of the usefulness of +hypnotic suggestion it is important to bear in mind that +various factors may come into play in impressing an +event upon the patient’s memory, or in determining the +effect of the shock from which he is suffering when he +arrives in hospital. In the first place there is the +vividness or intensity of the stimulus; in the second, +the degree of recency; in the third, the frequency of the +stimulus; and in the fourth its relevancy. By the latter +is meant the extent to which a given event appeals to +the individual’s past experience, and becomes integrated +into his personality.</p> + +<p>A patient who has recently received a severe shock, +the effects of which alone represent the real trouble, +without the disturbance of any antecedent experience, +might quite well be relieved by hypnotic suggestion from +sleeplessness, pain, or amnesia; and in some cases this +removal of the acute symptoms which determine the +persistence of the shock effects may lead to complete +recovery. A single and sudden wholly irrelevant experience, +such as the bursting of a shell, which has no +relationship whatever to the patient’s past experience, +and produces effects by its vividness and its recency, +might quite well be neutralised by another kind of wholly +irrelevant intrusion, such as hypnotic suggestion. This +argument may perhaps be made more intelligible by a<span class="pagenum" id="Page_42">[Pg 42]</span> +homely analogy. A temperate man walking along the +street might be thrown temporarily into a condition of +faintness or collapse by seeing some ghastly accident, +but by taking a “brandy and soda,” which to such a +man would be a wholly irrelevant experience, the +physiological expressions of his emotions might be controlled +and he might be able to proceed on his way, and +to overcome completely the effects of the transitory +occurrence. But in the case of a man who, for example, +had been greatly worried by monetary troubles for a +number of years, the “brandy and soda” would not +produce anything more than a temporary alleviation of +his troubles. The latter illustration represents the +chronic psychosis which, as Déjerine has so admirably +explained, is quite unsuitable for hypnotic treatment. +But the distinguished French neurologist’s statements do +not seem to apply to the former type of case, due to a +vivid recent shock, in the symptomatology of which +troubles before the shock play no part. In such cases +the results of hypnotic suggestion are often brilliant, if +erratic, as is the “brandy and soda cure” for the man +who is overcome by a sudden terrible experience in the +street.</p> + +<p>There are, however, patients who have not sufficient +will-power or intelligence to be properly re-educated, to +whom a certain amount of suggestion may be of some +use.</p> + +<p>Those who have used hypnosis in civil practice are +aware that in certain individual cases of long-standing +trouble, such, for example, as chronic alcoholism, hypnotic +treatment is of unquestionable value. Among +soldiers suffering from the long-standing effects of shell-shock, +hypnosis may be able in some cases to help in +the restoration of health with an effectiveness that no +other method can rival.</p> + +<p>Both the danger and the possible usefulness of hypnotism<span class="pagenum" id="Page_43">[Pg 43]</span> +may be illustrated by an actual case. It is that of +a man all of whose companions were destroyed by the +bursting of a shell, and who suffered for months afterwards +from complete loss of memory. A medical man hypnotised +him, and perhaps with undue tactlessness, brought back +the memory of the critical incident at the front, stripped +of all the episodes which led up to or followed it. +This excited in him the most violent emotions, and +he became sick with terror; for the revived incident seemed +perfectly real to him, or, as he described it afterwards, “it +jumped up against him,” and for weeks he was so utterly +terrified that he would not go near the doctor. Even +though he could not retain the memory of any other +recent events the horror of that experience seemed to +have made him remember his dread of a particular +medical man. But by making use of the information +gained during that revival under hypnosis of an incident +unknown to anyone but the patient, which his amnesia +up till then had kept sealed up, it became possible for +another medical officer to bridge the gap between his +memory of previous events and the experiences which +the patient was known to have had in the military +hospitals.</p> + +<p>In speaking of the results of hypnotic treatment as +being brilliant but erratic, it is important to remember +that the same observations apply to suggestion without +hypnosis. For instance, the application of electricity to +the vocal cords in cases of hysterical aphonia affords +an admirable illustration of the treatment by suggestion, +even if the method savours of charlatanism. An excellent +demonstration of the part which psychical factors play in +such cases is afforded by the story of a sailor on the +German battle-cruiser <em>Derfflinger</em>, recorded by Blässig.<a id="FNanchor_34" href="#Footnote_34" class="fnanchor">[34]</a></p> + +<p><span class="pagenum" id="Page_44">[Pg 44]</span></p> + +<div class="blockquot fs90"> + +<p>“A seaman from the <em>Derfflinger</em> was brought into a naval +hospital with loss of voice on Dec. 22nd, 1914, and could +speak only in a whisper. He said that he had always had +good health, with the exception that as a child he had diphtheria, +but recovered without tracheotomy or any complication. +His voice had always been clear and well under control. +At the beginning of December he had a slight cold, which he +attributed to sentry duty on deck in very stormy and wet +weather. While in the ammunition chamber of the big guns +he was greatly upset during the firing and suddenly lost +his voice. After fourteen days he recovered his speech. +On Feb. 12th, 1915, he returned to hospital with complete +loss of voice, immediately after the naval engagement in the +North Sea. On Feb. 15th he was treated with electricity, +directly applied to the vocal cords, and on March 20th he +was discharged with complete recovery of his speech. But on +returning to duty, as soon as he went on board his ship his +voice was suddenly lost for the third time, and he remained +aphonic.”</p> +</div> + +<p>This is clear evidence of the fact that his trauma was +psychical. His previous history perhaps contains the +clue explaining why, in his case, it was his voice which +was affected. The application of the faradic current was +suggestion pure and simple.</p> + +<p>In emphasising the limited usefulness and possible +danger of suggestive therapeutics in many cases that +are not quite recent, we have not been referring to that +method of suggestion which is involved to a greater or less +degree in all successful treatment of disease—the process +of gaining the patient’s confidence and impressing him +with the idea that he is going to recover.</p> + +<div class="blockquot fs90"> + +<p>“The conversational attitude, the familiar manner of talking +things over, the heart-to-heart discussion, where the physician +must exert his good sense and feeling, and the patient +be willing to be confidential” is the method which Déjerine +calls ‘psychotherapy by <em>persuasion</em>.’ “It consists in explaining +to the patient the true reasons for his condition, and [for] the +different functional manifestations which he presents, and +above all, in establishing the patient’s confidence in himself +and awakening the different elements of his personality, so as<span class="pagenum" id="Page_45">[Pg 45]</span> +to make them capable of becoming the starting-point of the +effort which will enable him to regain his self-control. The +exact comprehension of the phenomena which he presents must +be gained by the patient by means of his own reasoning.... +The part that the physician plays is simply to recall, awaken, +and direct....”<a id="FNanchor_35" href="#Footnote_35" class="fnanchor">[35]</a></p> +</div> + +<p>No one who has not had the experience of guiding +mental patients in the way so lucidly expounded by the +French physicians can form any adequate conception of +the remarkable efficacy of these common-sense methods +in restoring to those who are afflicted a normal attitude +of mind. It is certainly saving considerable numbers +of soldiers from the fate of insanity. These methods are +not novel, even if the fuller comprehension of their mode +of operation is only dawning upon us now. This point +has been admirably expounded by Déjerine and Gauckler, +from whose book we must quote once more:—</p> + +<div class="blockquot fs90"> + +<p>“May we be permitted to quote a few lines in which +Bernardin de St. Pierre has defined, more exactly and better +perhaps than we could do, and with a sort of prescience of +what is needed, the very rôle that we would like to [see our +physicians adopt towards their patients].</p> + +<p>I wish that there might be formed in large cities an establishment, +somewhat resembling those which charitable physicians +and wise jurists have formed in Paris, to remedy the +evils both of the body and of one’s fortunes; I mean councils +for consolation, where an unfortunate, sure of his secret being +kept and even of his incognito, might bring up the subject of +his troubles. We have, it is true, confessors and preachers +to whom the sublime function of offering consolation to the +unfortunate seems to be reserved. But the confessors are not +always at the disposition of their penitents. As for the +preachers, their sermons serve more as nourishment for souls +than as a remedy, for they do not preach against boredom, +or unhappiness, or scruples, or melancholy, or vexation, or +ever so many other evils which affect the soul. It is not easy +to find in a timid and depressed personality the exact point +about which he is grieving, and to pour balm into his wounds<span class="pagenum" id="Page_46">[Pg 46]</span> +with the hand of the Samaritan. It is an art known only to +sensitive and sympathetic souls.</p> + +<p>Oh! if only men who knew the science of grief could give +unfortunate people the benefit of their experience and +sympathy, many miserable souls would come to seek from +them the consolation which they cannot get from preachers +or all the books of philosophy in the world. Often, to comfort +the troubles of men, all that is necessary is to find out from +what they are suffering (<cite>Etude de la Nature</cite>, 1784).”</p> +</div> + +<p>Déjerine and Gauckler add:—</p> + +<div class="blockquot fs90"> + +<p>“One could not express any better, or any more directly, +what we never cease to maintain, however lacking in science +it may seem at the first—namely, the real therapeutic action +of kindness.</p> + +<p>Liberated morally, and having regained consciousness of +self, and freed in addition from his functional manifestations +by the appropriate processes ... the patient is cured. He +is cured from his actual attack. But his mental foundation, +his psychological constitution, still remains in the same condition +which permitted him under emotional influences to +become a neurasthenic. The rôle of the physician is, therefore, +not ended. He must still build up his patient’s life, +still practise prophylaxis, and get the patient into a condition +where his character will be established.”<a id="FNanchor_36" href="#Footnote_36" class="fnanchor">[36]</a></p> +</div> +<br> + +<p><em>Rational Treatment.</em> So far in this chapter we have +been discussing what may be described as general +methods of treatment, which do not <em>necessarily</em> involve +any attempt to probe into distinctive individual symptoms +and to discover the real fundamental cause or causes +of the trouble. The measures so far considered are +empirical rather than rational. But they are the only +methods of treatment discussed in most of the text-books.</p> + +<p>It is an axiom in medicine that correct diagnosis is +the indispensable preliminary to the rational and intelligent +treatment of disease. This fundamental principle +is universally recognised in dealing with bodily affections;<span class="pagenum" id="Page_47">[Pg 47]</span> +but it is the primary object of this book to insist that +<em>it is equally necessary to observe the same principle in +the case of mental illness</em>.</p> + +<p>It may seem ironical to stress this elementary consideration, +but it is notorious that accurate diagnosis is +too often ignored in cases of incipient mental disturbance. +It is idle to pretend that such a procedure is unnecessary, +or to urge in extenuation of the failure to search for +causes that many patients recover under the influence of +nothing more than rest, quiet, and ample diet.</p> + +<p>Many mild cases of illness, whether bodily or mental, +may and do recover even if undiagnosed or untreated. +But on the other hand many mild cases get worse; and +it is the primary duty of the physician correctly to +diagnose the nature of the trouble and to give a prognosis—to +decide whether the illness is mild or severe. +Some of the most serious cases of incipient mental +trouble are those of patients who do not seem to be +really ill, and are easily overlooked by a visiting physician. +They are quiet and inoffensive and display no obvious +signs of the insidious processes that are at work in them. +But all the time they may be, and often are, brooding +over some grievance or moral conflict, worrying about +their feelings, misinterpreting them and gradually +systematising these misunderstandings until they become +set as definite delusions or hallucinations. If, acting on +the belief that it is bad to talk about a patient’s worries, +the physician leaves such a man alone, he is clearly +neglecting his obvious duty. For the whole trouble may +be due to some trivial misunderstanding which he could +easily correct.</p> + +<p>In the severer forms of mental disease, precise diagnosis +is even more intimately related to treatment than in the +case of bodily illness. For when a patient’s illness is +recognised as some bodily affliction, such as pneumonia +or appendicitis, certain general lines of treatment are laid<span class="pagenum" id="Page_48">[Pg 48]</span> +down as soon as the appropriate label has been found +for the complaint, though, in the case of the latter +illness, there is added the further problem of whether or +not surgical interference is indicated.</p> + +<p>In cases of mental disturbance, however, the general +lines of treatment cannot thus arbitrarily be determined +merely by finding an appropriate label. It is true that +as in the treatment of bodily disease, certain general +principles must be observed, such as the provision of +abundant and suitable food, and the protection of the +patient from all disturbing influences. But the essence +of the mentally afflicted patient’s trouble is some particular +form of anxiety or worry which is <em>individual and +personal</em>. The aim of the diagnosis, therefore, should +be not merely to determine the appropriate generic +label for the affliction, but rather to discover the particular +circumstances which have given rise to the present +state. The special object of the physician should be to +remove or nullify the exciting cause of the disturbance; +and in order to do this it is essential that he should +discover the precise nature of the trouble. The diagnosis, +therefore, must be of a different nature from that +demanded in case of physical illness, where the condition +may be adequately defined by some such generic term +as “lobar pneumonia” or “acute appendicitis,” and its +gravity estimated by the general condition and physique +of the patient. In the case of mental trouble, the +physician has to make an individual diagnosis, based not +only upon an insight into the personality but also into +the particular anxieties of each patient.</p> + +<p>But even when it is recognised that exact diagnosis of +the particular circumstances of each individual patient is +essential, if the trouble is to be treated rationally and +with insight, there still remain many difficult problems +as to procedure.</p> + +<p>Amongst those whom experience has convinced of the<span class="pagenum" id="Page_49">[Pg 49]</span> +efficacy of psychological treatment for this class of case, +there are indications of a divergence of opinion in the +matter of procedure. Some believe that it is sufficient +if the medical man has discovered the real cause of the +trouble and explained it to the patient. Other workers +look upon a preliminary psychical examination merely as +a means of diagnosis, the unveiling of the hidden cause of +the trouble; and consider that the treatment should be the +laborious and often lengthy process of re-educating the +patient, and so restoring to him the proper control of himself. +It is of the utmost importance to emphasise the +undoubted fact that those who maintain either of these +views to the exclusion of the other are committing a +grievous and dangerous error, for there is no sharp line +of demarcation between the two procedures.</p> + +<p>A sensible and intelligent man, once the cause of his +trouble has been made clear to him, may be competent to +continue to cure himself, or, in other words, to re-educate +himself, and completely to conquer the cause of his +undoing. But the duller and stupider man may need a +daily demonstration and renewal of confidence before he +begins to make any progress. It is precisely analogous to +the experience of every teacher of a class of students; +the brilliant man will seize hold of a principle at once +and learn to apply it without further help, whereas the +dull man needs repeated and concrete demonstrations +before it sinks into his understanding.</p> + +<p>In dealing with soldiers, and this applies with especial +force to the regular army, the conditions in many of the +cases differ considerably from those of the civilians. +Trifling forgetfulness in the civilian would perhaps not be a +serious cause of worry, but in the soldier, inured by years +of training to strict discipline, forgetfulness of even trivial +instructions, or any difficulty in understanding complex +orders, is likely to bring down upon his head condign +punishment. Such lapses are regarded by the soldier as<span class="pagenum" id="Page_50">[Pg 50]</span> +extremely serious offences, because years of training and +discipline have inculcated this idea. When as the result of +shock such soldiers are afflicted by even slight forgetfulness, +they become worried by it much more than would the +civilian and exaggerate its importance until it becomes a +real terror to them. As the result of their training they may +regard such phenomena as altogether abnormal; and by +a process of rationalising what to them is a novel experience, +they are apt to imagine that they are going mad. +Such patients often dream about incidents in their army +life when they had been forgetful and got into trouble; +they become obsessed with the haunting fear that they +are likely to get into perpetual difficulties, are worried +by the thought that they are incompetent for the duties +to which they have been accustomed, and may imagine +themselves debarred from all useful work. However, +they are easily reassured when the medical attendant +explains to them that in ordinary life civilians are frequently +subject to such experiences, and that it is only +the special circumstances of army life which make such +trivial lapses seem serious to them. Not only is the +soldier much more scared by such things than the +civilian, but it is also a very remarkable phenomenon, +and certainly one which came as a surprise, that the +neurasthenia of a soldier is apt to be very much more +serious than that of the civilian. For when a really brave +man is stricken by fear he is more seriously affected by +the terror of an experience which to him not only has a +larger element of novelty than in the case of the civilian, but +also wounds him more deeply by convincing him that he +is lacking in that very quality which is most essential +for his professional work.</p> +<br> + +<p class="no-indent"><em>The Therapeutic Value of Work.</em></p> + +<p>It should be unnecessary to emphasise the desirability +of preventing the neurasthenic from dwelling upon his<span class="pagenum" id="Page_51">[Pg 51]</span> +subjective troubles by occupying his mind with other +things. This end may often be achieved by the provision +of suitable occupation, and where possible, for many +obvious reasons, this occupation should take the form of +useful work. The worker then feels that he is not a +mere burden upon the hospital which is treating him: +the institution in its turn benefits materially. But it is +necessary to sound a note of warning against the indiscriminate +prescription of work as a panacea. First of +all it should be certain that the work is of such a kind +as really to interest the patient and to occupy his mind. +There are many varieties of work, especially of manual +labour, which can be performed mechanically, and do not +succeed in distracting the attention from worries +and anxieties. But more important even than this is +the consideration that there are some mental troubles from +which no form of work will distract the patient. Especially +is this the case in many of the psychoneuroses caused by +the war. The sufferer is often haunted day and night by +memories which torture him not merely by their horror +but also by another aspect which is even worse: the ever-increasing +moral remorse which they induce. A patient +may be troubled not only by the terrible nature of the +memory but by the recurring thought, “If I had not done” +this or that, “it might never have happened.” The reader +will easily see how such a thought may arise in the mind, +especially of a nerve-stricken officer or “N.C.O.” after +weeks of brooding in private upon the memory of a +disaster. Now, such self-reproaches are frequently based +upon entirely insufficient evidence, and if the medical +officer is given the opportunity of calmly discussing their +foundations with the patient, the result is often to reassure +him and to enable him to view his past in an entirely new +light. It is then, and not before then, that he will be able +cheerfully to enter upon useful occupation and to benefit +by it. To suppose that the mere physical fatigue induced<span class="pagenum" id="Page_52">[Pg 52]</span> +by a day’s hard work will banish all forms of insomnia +betrays an ignorance of one of the most important causes +of this malady; <em>viz.</em>, mental conflict. It is well known +that bodily fatigue in the case of a mentally excited +patient may merely increase his unrest at night. Again, +anyone who has had a few months’ experience of receiving +the confidence of these nerve-stricken soldiers will know +that some of their troubles are so poignant that the +attractions of the (apparently) most interesting kinds of +occupation leave them cold.</p> + +<p>To sum up, the physician may confidently prescribe +work when, by investigating the history of any particular +case, he has satisfied himself that such occupation will be +likely successfully and profitably to distract the patient’s +mind from his worries. But the prescription of work for +the patient must be regarded as a sequel to, not as a +substitute for, the performance of work by the doctor.</p> +<br> + +<div class="footnotes"><h3>FOOTNOTES:</h3> + +<div class="footnote"> + +<p><a id="Footnote_24" href="#FNanchor_24" class="label">[24]</a> Such, for example, as those set forth in the series of +articles in Vol. VIII, of Sir Clifford Allbutt’s <cite>System of +Medicine</cite>, 1899, pp. 88-233.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_25" href="#FNanchor_25" class="label">[25]</a> The part played by bodily disease in the causation of +mental disturbance has been concisely summarised by Sir +G. H. Savage in the introductory chapter on Mental Disease +in Vol. VIII, of Allbutt’s <cite>System of Medicine</cite>, pp. 191-195.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_26" href="#FNanchor_26" class="label">[26]</a> Or in some mild cases, to encourage him to wish to +remain an invalid under such pleasant conditions.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_27" href="#FNanchor_27" class="label">[27]</a> In his careful studies of these conditions, C. S. Myers +has called attention to the mistaken notion of regarding these +troubles as “fundamentally due to disordered volition,” <cite>Lancet</cite>, +Sept. 9th, 1916, p. 467.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_28" href="#FNanchor_28" class="label">[28]</a> This explanation of the reasons for the use of isolation is taken +from Mohr’s article in Lewandowsky’s <cite>Handbuch der Neurologie</cite>.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_29" href="#FNanchor_29" class="label">[29]</a> As Sir Clifford Allbutt has pointed out (<em>op. cit.</em>, p. 158).</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_30" href="#FNanchor_30" class="label">[30]</a> <cite>The Psychoneuroses and their Treatment by Psychotherapy</cite>, +translated from the French by Jelliffe, 2nd Edition, +1913, p. 311.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_31" href="#FNanchor_31" class="label">[31]</a> <em>Op. cit.</em>, p. 315.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_32" href="#FNanchor_32" class="label">[32]</a> Feb. 13th, 1915 (p. 316); Jan. 8th, 1916 (p. 65); Mar. +18th, 1916 (p. 608); and Sept. 9th, 1916 (p. 461).</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_33" href="#FNanchor_33" class="label">[33]</a> <em>Op. cit.</em>, p. 69.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_34" href="#FNanchor_34" class="label">[34]</a> <cite>Münchener Medizinische Wochenschrift</cite>, June 15th, 1915, +p. 335.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_35" href="#FNanchor_35" class="label">[35]</a> Déjerine and Gauckler, <em>op. cit.</em>, p. 283.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_36" href="#FNanchor_36" class="label">[36]</a> <em>Op. cit.</em>, pp. 302-3.</p> + +</div> +</div> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> + +<p><span class="pagenum" id="Page_53">[Pg 53]</span></p> +<h2 class="nobreak" id="CHAPTER_III">CHAPTER III.<br> +<span class="fs120">Psychological Analysis and<br> +Re-education.</span></h2> +</div> + +<p class="drop-cap"><span class="upper-case">The</span> methods of treatment which have been +described in the foregoing pages: sympathy, firmness, +isolation, suggestion in its various forms, and +hypnosis; while all useful in their proper place, often prove +to be of no avail in cases of psychoneurosis. Where the +distressing symptoms lie on the surface so that both they +and their causes are easily discoverable by the physician—if, +indeed, they have not been known from the beginning, +to the patient himself—it is sometimes possible to bring +about a complete cure without any very penetrating +analysis by the doctor of the mental antecedents of the +patient’s present condition. Thus, for example, a courageous +and keen soldier who, suffering from loss of sleep +and from the harassing experiences of the battlefield, +eventually breaks down, the precipitating cause perhaps +being shell-shock, may need little more to set him on +his legs than the comfort, assiduous attention, and pleasant +distractions of a Red Cross hospital. For the civilian +whose chief trouble is the irritability caused by a multiplicity +of minor business worries, or family jars, a few days +of isolation, giving perhaps, among the other benefits +which we have mentioned, the opportunity to think things<span class="pagenum" id="Page_54">[Pg 54]</span> +out, may have excellent results. The beneficent action of +hypnosis in removing the acute disturbances caused by +shell-shock has already been illustrated. But a large +number of cases fall into none of these categories. +Sympathy merely annoys them, isolation tortures them, +for besides letting them think—usually in a very unwise +way—it helps to confirm their impression that they are +seriously ill, just because it involves the treatment of +them as special cases. Suggestive measures may be to +them like water on a duck’s back, and hypnosis may +prove of no avail. Firmness may have merely the effect +of proving to the doctor that there exist patients firmer +than himself. But, fortunately, psychical methods are not +exhausted. There still remains at least one—that of +psychological analysis and re-education.</p> + +<p>The employment of psychological analysis in medicine +means the resolution of the patient’s mental condition into +its essential elements, just as by chemical analysis it is +possible to determine that water, for example, is composed +of certain definite proportions of oxygen and +hydrogen combined in a particular way. Re-education is +the helping of the patient, by means of the new knowledge +gained by analysis, to face life’s difficulties anew.</p> + +<p>It is sometimes urged that if this be all that is meant +by psychological analysis, alienists have been doing this +ever since insanity was first treated, nay, further, doctors +have been practising it since the time of Hippocrates. +It is pointed out that when a patient is first interviewed +by the physician, an inquiry is always made into his mental +state and behaviour, and into the presence of delusions +and hallucinations or other unusual mental phenomena. +His relatives are questioned concerning the relation of +his recent behaviour to that at the time when he was +considered normal. Now the answer to this assertion is +that such an investigation is useful, indispensable in fact, +but it cannot be called psychological analysis.</p> + +<p><span class="pagenum" id="Page_55">[Pg 55]</span></p> + +<p>The point may become clearer to the untechnical +reader if he will imagine for a moment that a carver, +skilled in separating the legs and wings from the body +of a bird, should claim to be practising anatomy. The +anatomist would at once object that while such separation +of limbs from trunk is a small detail which sometimes +forms part of the anatomist’s task, it can scarcely +be called more than a preliminary to his study. For +first of all, while to a carver a leg is an ultimate unit, +to the anatomist it is, for the naked eye, a collection of +bones, muscles, tendons, skin, nerves, veins, arteries, +nails and the rest, and, seen through the microscope, a +tremendous organisation of infinitely more complex structures. +Furthermore, it might be pointed out that merely +to separate these more minute structures into their constituent +parts and to name them, by no means constitutes +the whole of the work of the intelligent anatomist. He +wishes to study the inter-relations of these parts, the +way in which they work together for the common good +of the leg. And lastly, the leg must not be studied only +in separation from the trunk, for its functions are subordinate +to the requirements of the body as a whole.</p> + +<p>So, in the same way, to record that a man is suffering +from a delusion of persecution or an unreasonable fear +of open spaces is merely to “carve up” the condition +of his mind. First of all it must be ascertained how +far that delusion has interpenetrated with the rest of his +mental life; whether, for example, his false belief is +restricted to a specific kind of persecution from a particular +person, or is a general delusion that everybody +and everything in the world is against him. And again, +if the delusion is strictly specific, it is important to know +whether it has been the cause of secondary false beliefs, +produced by rationalisation, to buttress the primary +delusion against the inevitable contradiction from facts +which it would otherwise suffer.</p> + +<p><span class="pagenum" id="Page_56">[Pg 56]</span></p> + +<p>Further, the nature of the delusion must be analysed. +Why is it of this and not of that persecution? Why is +this particular person feared or hated? Is it a constant +factor in the patient’s existence, or does it break out +at certain times? If so, the patient’s life at these critical +periods must be carefully examined. The doctor must +discover where the patient was at the time, what he was +doing and thinking, who were his companions, and so on.</p> + +<p>Next comes the important inquiry into the history of +the delusion. And here, just as the anatomist is able +nowadays to mobilise for service all his knowledge of +comparative anatomy and evolution, so if the physician +has really scientific knowledge, not only of the delusions +in other patients, but also of the development of ordinary +beliefs in sane people,<a id="FNanchor_37" href="#Footnote_37" class="fnanchor">[37]</a> he will be immensely helped in +his search, and may be enabled thereby to make many +short cuts to the essential facts. He will endeavour +to date the important stages of development of the +delusion; to find a time when, so far as the patient +knows, his mind was free from it.</p> + +<p>Thus we may say that a psychological investigation of +a case of mental disorder dissects its normal as well as +its abnormal phenomena into their functional elements. +Compared with the procedure which merely records such +gross units as delusions or hallucinations, it is as anatomy +to mere carving, however skilful the latter may be.</p> + +<p>But the psychological investigation is not merely comparable +to anatomical dissection. We have also compared +the mind to a chemical compound, rather than a +mechanical mixture. Especially is this true not only of +the normal but also of the abnormal mind, when the +latter has had time to settle down into its new<span class="pagenum" id="Page_57">[Pg 57]</span> +position of relative equilibrium and integration; when, +for example, a delusion has become so fixed that the +patient’s life is entirely ordered in obedience to it, and +he has ceased to have any doubts as to its reality or to +struggle against its domination.<a id="FNanchor_38" href="#Footnote_38" class="fnanchor">[38]</a> It is only when the +warring elements in the mind are relatively independent, +and before they have succeeded in “making terms” +with each other, that the mind even remotely resembles +a mechanical mixture. It follows, therefore, that psychological +analysis of a case of mental disorder is usually +comparable to <em>chemical analysis</em> as well as to anatomical +dissection.</p> + +<p>Now the most striking result of chemical analysis is +to show that the appearance and general properties of +the elements composing a compound are different from +the appearance and properties of the compound itself. +This is exactly the case, too, with mental analysis. A +mere dissection of an abnormal condition is sometimes +sufficient in the milder cases to serve as the basis for +curative measures,<a id="FNanchor_39" href="#Footnote_39" class="fnanchor">[39]</a> but in more advanced cases, or those +of longer standing, real analysis is necessary in order +to get at the unknown factors.</p> + +<p>It is just at this point that a number of investigators +of mental disorder decline to go any farther on the +path of research. Up to this stage, they say, one is +relying upon ascertained facts, for one has the warrant +of the patient’s own memory for the data obtained. +Further analysis of a mental phenomenon must inevitably +involve appeal to unconscious factors. And, once one<span class="pagenum" id="Page_58">[Pg 58]</span> +has called in the unconscious as a means of explanation, +psychology becomes a mere “tumbling ground for +whimsies.”</p> + +<p>Probably there are few people to whom this statement +does not appear to express the universal verdict of +common sense. That is precisely what it does. But it +should be unnecessary to point out that common sense +alone is not always the most reliable guide to the +discovery of fact. Unaided common sense not only informed +men for centuries that the sun moved round the +earth, but told them so with such finality and conviction +that extraordinarily unpleasant consequences ensued for +those who did not believe in such an obvious fact. And +the old belief, wholly false as it is, has still to be unlearnt +by every child.</p> + +<p>In the same way, the ‘common sense’ point of view +which we have described is not flawless. It assumes +that a patient is able not only to surmount the great +difficulties of translating his experiences and beliefs +precisely into words—a difficult task even for the well-educated +person—but also to account for and explain +them truthfully.</p> + +<p>It may, however, be pointed out that, though this +last-mentioned misleading assumption is widespread, +it is by no means so universal or so tenacious in man as +the “belief of his own senses” that the sun goes round +the earth. In fact, quite apart from the teachings of +modern psychology, we frequently find well-founded suspicions +in the lay mind that a man is not always competent +to give the basis of and reasons for his mental +condition. This view is summed up in the famous advice to +the future judge, “Give your decision, it will probably +be right. But do not give your reasons, they will almost +certainly be wrong.”<a id="FNanchor_40" href="#Footnote_40" class="fnanchor">[40]</a></p> + +<p><span class="pagenum" id="Page_59">[Pg 59]</span></p> + +<p>What ordinary man, unversed in the subtleties +of theology or comparative religion, could give to an +agnostic a satisfactory account of the reason why—being +let us say, a Christian, and a Protestant Christian—he +is a Primitive Methodist or an English Presbyterian? +Let us complicate the matter further by supposing that +this sect to which he now belongs is not that in which +he was brought up by his family! Many of the factors +which have contributed to his present religious beliefs +may have been entirely forgotten now, recallable only +with the greatest difficulty<a id="FNanchor_41" href="#Footnote_41" class="fnanchor">[41]</a> and with the help of a +second person skilful in such investigation.</p> + +<p>We may take as a good example of the historical complexity +of significant attitudes and actions in life, the +process of falling in love—especially if it is not, or at +least seems not to be, love at first sight. It is generally +admitted that, in the development of this psychological +phenomenon, onlookers see most of the game. In other +words, the actions of the two persons who are gradually +becoming more and more attracted to each other are +partly determined by motives, which, unknown to them, +are patent to their observant relations and friends.</p> + +<p>Further examples may be given to illustrate this important +and oft-disputed point. Let us suppose that a musical +critic, after hearing a new symphony by an unconventional +composer, immediately writes a lengthy appreciation of +the performance. It is clear that nobody would expect +him to be able to give, off-hand, an account of his reasons +for every sentence of the criticism. But it is obvious<span class="pagenum" id="Page_60">[Pg 60]</span> +that a single phrase in this account may be but the apex +of a whole pyramid of memories emanating from the +critic’s technical training, his attitude towards the new +departure, experiences highly coloured with emotion +which a few notes of the music may have evoked, and +his mental condition at the time he heard the performance. +Nobody denies that these may have shaped +or even determined his criticism. But who believes +either that they were all conscious at the time of writing +the article, or that he could resuscitate them without +much time and trouble and perhaps the help of a cross-examiner?</p> + +<p>Again, there are occasions when society expects that +a man shall be unconscious of the reasons for some of +his actions. He is expected, for example, to behave +politely, attentively and chivalrously to ladies, not because +at the moment of taking the outside of the pavement +he remembers why he does so, but simply because he +has been brought up in this way. And conversely, too +conscious politeness in a man arouses in others—and +often rightly—the suspicion that it is a recent acquisition.</p> + +<p>We see then that it is rare for a man to be able to +give a true account, even to himself, of the reasons +underlying his important acts and beliefs, when his +mental condition is relatively calm and his social relationships +are normal. But when a case of mental disorder is +in question it becomes quite obvious that the patient is +frequently not in a position to give, either to himself or +to another, anything like a complete or true enumeration +and description of the antecedent experiences which have +brought about his present condition.</p> + +<p>It therefore becomes necessary to admit that unconscious +factors of great importance may play an influential +part in the production of mental disorder and that, +therefore, some way must be found of tapping these submerged +streams.</p> + +<p><span class="pagenum" id="Page_61">[Pg 61]</span></p> + +<p>The most direct way into the complexities of the +unconscious mental processes of a person is afforded by +a study of his more “unusual” actions and thoughts. +For few persons are so completely adapted to their +environment or so perfectly balanced that moments never +arise in which their mental behaviour is not surprising, +either to themselves or to others. And even the +Admirable Crichtons of our acquaintance are not entirely +immune from errant moments—at least in their sleep. +The dream, then, is the chief gate by which we can enter +into the knowledge of the unconscious. For in sleep, the +relatively considerable control which most of us in waking +life possess over the coming and going of mental events +is almost if not entirely abrogated. Thoughts and desires, +which, if they attempted to dominate consciousness in +waking life, would be promptly suppressed, arise, develop +and expand to an astounding extent in the dream.</p> + +<p>This statement, of course, is entirely independent of the +implications of any one “theory of dreams.” Its truth is +evident to anyone who has honestly recorded or considered +his own dreams for even a short period.</p> + +<p>Other unusual mental processes are manifested in such +events as “slips of the tongue,” “slips of the pen,” the +mislaying of important objects, the forgetting of significant +facts, or conversely the inability to get an apparently +unimportant memory out of one’s mind. All these +phenomena, common enough in the normal individual, are +usually more frequent in the abnormal mind. Besides the +patient’s voluntary account of, and comments upon, these +events,<a id="FNanchor_42" href="#Footnote_42" class="fnanchor">[42]</a> other methods of obtaining data are possible to<span class="pagenum" id="Page_62">[Pg 62]</span> +the physician. He will note the matters about which in +conversation the patient is apt to become silent, embarrassed +or inexplicably irritated, to hesitate, to say he has +forgotten, or even to lie. All these sidelights upon the +mental make-up are carefully noted by the physician and +the deductions from them compared, not only with the +patient’s accounts of himself on different days—narratives +which when put together may show important discrepancies +and thin places—but also with the information +obtainable from his family. These devices serve to bring +to light in an extraordinary manner a whole number of +memories, many of them of immense significance for the +comprehension of the patient’s present mental state, +which it would be utterly impossible to discover in mere +conversation or even by cross-questioning.</p> + +<p>It is sometimes felt that these methods which savour +strongly of catching the patient tripping, while they may +unearth some interesting details of his past life, do no +more than exhibit under a strong magnifying glass a few +minute excrescences upon his otherwise fair mental countenance. +But it should be pointed out that nobody who +has ever honestly collected together and compared the +memories which have coalesced to compose a dozen of +his dreams—especially if he has done so with the help +and under the cross-examination of a candid friend who<span class="pagenum" id="Page_63">[Pg 63]</span> +knows him well—will maintain that the material thus +found is unimportant. As Professor Freud says, “The +dream never occupies itself with trifles.” It is probably +just because the thoughts and desires underlying the +dreams have been refused their normal outlet, that they +express themselves in such bizarre forms.</p> + +<p>Moreover, the fact should not be overlooked that in +other sciences—including the most exact, the physical +sciences—the most profoundly important general conclusions +are often arrived at by the examination of unusual +phenomena, of nature “caught tripping.” The study of +the thunderstorm was the foundation of our present +knowledge of that great force which is active not only in +thunderstorms but throughout all matter. Observation of +the sporadic and relatively unusual volcanic eruptions of +the mind may prove to be an important foundation of our +future knowledge of general psychology. As in the +inorganic, so in the organic world, there is no sharp line +dividing normal from abnormal, and the unusual phenomenon +is sometimes simpler and more easily studied +than the usual, as “Sherlock Holmes” was so fond of +demonstrating.<a id="FNanchor_43" href="#Footnote_43" class="fnanchor">[43]</a> From a scientific standpoint, then, we +have every justification for pressing to the utmost our +study of the unusual mental phenomena exhibited by the +patient, and for our belief that their nature is not unimportant, +but highly significant for therapeutical purposes.</p> + +<p>Another objection, however, is frequently levelled<span class="pagenum" id="Page_64">[Pg 64]</span> +against such a procedure, from quite a different direction, +or rather from a number of directions. This objection +can be expressed simply in words, such as “One ought not +to probe so deeply into a patient’s innermost mental life,” +and is not to be met by a single argument. The reason is +that it is polyhedral in form, and that each of its faces +or aspects must be considered separately. For it should +be obvious to everyone that such an objection cannot +be flippantly waved away.</p> + +<p>The aspects of this question which seem to have more +particularly appealed to the critics of the method which +we are describing, are at least four in number, which +we may describe as the æsthetic, social, medical and +moral.</p> + +<p>The origin of the first, the æsthetic aspect, is easily +seen. It is quite clear that in the investigation of the +inmost secrets of a person’s life (and particularly of a +life which has become so entangled and complicated that +the help of another is sought for its restoration to ‘mental +tidiness’) there must emerge frequently much that the +patient finds unpleasant to relate. When we remember +that a neurosis often (perhaps always) occurs as a result +of the patient’s inability to adjust his instinctive demands +to the opportunities of his environment, it becomes clear +that in the investigation of his history discussion is +inevitable of mental events in which the fundamental +instincts have played a great part. Now, of those important +instinctive impulses, it is obvious that in a civilised +community few are so often thwarted, deliberately repressed, +or otherwise obstructed as the powerful one of +sex. It therefore follows that in a large number of cases +the discussion of sexual matters becomes unavoidable. +Some critics have seized on this point as the weak spot +against which to launch their attacks, descanting upon the +unpleasantness, even the nauseousness, of such discussion. +Not all of them, however, make it clear whether in their<span class="pagenum" id="Page_65">[Pg 65]</span> +opinion it is the patient or the doctor who should be +shielded from such unpleasant experiences. If the latter, +the verdict of society would probably be that the sooner +a man requiring such protection was excused not only +from these uncongenial duties, but from all medical +obligations whatever, the better for the community. If +the former, it may be pointed out that every reasonable +person will agree that the man who does not tell the +whole truth to his doctor or his lawyer is a fool. Furthermore, +even under present conditions, if it be considered +advisable in the interests of the patient’s bodily health, +the doctor does not hesitate to ask, and the patient to +answer, questions about the most intimate matters, some +of them literally and not merely metaphorically nauseous.</p> + +<p>We may therefore dismiss the æsthetic objection as +unworthy of the consideration either of a conscientious +doctor, or of a reasonable patient.</p> + +<p>We may turn now to what we have designated the +social aspect of the objection. It should need little explanation. +There has arisen a convention, subscribed to +consciously or unconsciously by many, that the doctor +shall ask and the patient answer quite freely questions +relating to the patient’s bodily well-being, but that any +unusual mental occurrences must be considered the +patient’s private affair into which it is not the business +of the doctor to pry.</p> + +<p>It would be rash to deny that up to a certain point this +convention is susceptible of defence. But, carried too far, +it is productive of disastrous results. Moreover, it is +impossible for a doctor to treat many varieties even +of physical disease without becoming to a great extent +the confidant not only of the patient but often of his +family. And there is no doubt that the present unwritten +law that the doctor should confine himself to the +patient’s physical ills is often judiciously disobeyed by +very many successful practitioners. Yet it must be<span class="pagenum" id="Page_66">[Pg 66]</span> +recognised that the convention exists, and like all social +usages is extremely tenacious.</p> + +<p>The chief medical objection, which we shall now consider, +is usually expressed in some such form as the assertion +that “it makes the patient worse to talk about his +worries” and that one should rather “try to make him +forget them.” Let us examine these statements, both of +which contain a certain amount of truth, but if applied +without qualification to serious cases of incipient mental +disorder can by their respective negative and positive +tendencies do an incalculable amount of harm. They are +often the result of applying experience acquired by the +successful reassuring of a certain type of “malade imaginaire,” +to the consideration of far more complicated cases +in which such easy and straightforward treatment is +impossible. A man, let us say, visits a doctor and confesses +to him his fear that he is suffering from some +organic disease. The physician after a careful examination +proves to the patient by objective means that there is +nothing the matter with him; the sufferer is reassured +and returns to his daily business and in due course forgets +about this worry or ceases to be troubled by the +memory of it. Here the diagnosis, treatment, and cure +may be uncomplicated and “on the surface.” But even +here it should be emphasised that in one sense, far from +“making the patient worse” to talk about his trouble, +the talking about it was the <i lang="la" xml:lang="la">sine quâ non</i> of cure; +otherwise the doctor would never have known of the +fear. In another sense, however, talking about the trouble +did make the sufferer worse—but for a short time only, +during a confession of his apprehensions, or perhaps even +for a few days, if more than one visit to the consulting +room were necessary before the doctor’s verdict could +be obtained.</p> + +<p>But not all visits to the doctor end so briefly or so +easily as this. The patient’s trouble, on examination, may<span class="pagenum" id="Page_67">[Pg 67]</span> +prove to be organic and of long standing. Does the +doctor consider then that it is his duty to emulate the +Christian Scientist or to “make the patient forget it?” +On the contrary, he does not flinch from the employment +of the most searching methods of investigation, lengthy +and often painful treatment, and, if it seems necessary +in the patient’s interest, he will carry out or arrange for +operative interference which may be difficult, expensive, +by no means free from danger, and is quite likely to +“make the patient worse,” perhaps for a considerable +time, before its beneficial results appear.</p> + +<p>It is therefore idle to argue that on the one hand +psychological methods of treating mental disorder are +unnecessary because some patients get better without +their application; while, on the other, they are dangerous +because they may make a patient worse. The same remarks +could be applied to most of the successful operative +methods of present-day medicine. All of them are fraught +with grave potentiality for harm if applied by unskilled +persons.</p> + +<p>The degree to which the doctor is medically justified +in probing the patient’s intimacies is obviously dependent +upon the individual case. Not all patients require such +drastic incisions; a fact which has been clearly shown in +the special military hospitals. An intelligent man of +strong will, whose social relations have hitherto been +normal and happy, might be temporarily “bowled over” +by the emotional stress of the campaign, but after a few +inquiries into the causes of his mental anguish and a few +explanations, he is often set on his feet again.</p> + +<p>We must not forget, however, the other side of the +picture. There are many patients, who, far from being +made worse by the confidential recital and discussion of +their mental troubles to a suitable person, experience +great relief as a result of this unburdening. Men in the +military hospitals have expressed this over and over<span class="pagenum" id="Page_68">[Pg 68]</span> +again, in such phrases as, “I have been bursting to tell +this to someone who would understand,” or, “I have seen +many doctors since I left the front, but you are the first +who has asked me anything about my mind.” Frequently +the troubles prove to be caused by their ignorance of the +great individual differences in minds, so that the appearance +in them of a new but by no means pathological +mental phenomenon frightens them unduly. We have +already referred to cases of this kind in Chapter I.<a id="FNanchor_44" href="#Footnote_44" class="fnanchor">[44]</a> +Another frequent cause of the most intense and continuous +mental anguish is the exaggerated self-reproach which the +patients attach to some real, but in the judgment of +others, comparatively trivial defect or delinquency in +themselves. To borrow an expressive phrase, the neurasthenic +has “lost his table of values.” It is in such cases +that a talk with a tactful, sympathetic, broad-minded +physician may produce the happiest results.</p> + +<p>To assume that one can make the patient forget such +worries as these without first discovering what they are, +is obviously fatuity at its grossest. Moreover, as we +have seen, it is quite insufficient merely to discover that +the patient is “suffering from hallucinations” or delusions +and then to tell him to dismiss them from his mind. +To suppose that, without understanding the nature of and +the specific reasons for the development of a particular +hallucination, one can “make the patient forget” his +interpretation of a real experience which has appealed to +him night and day for weeks, or banish a delusion which +is gradually becoming systematised and rationalised—<em>i.e.</em>, +intimately interwoven into the tissues of the whole of his +experience—is an assumption which has no foundation in +fact.</p> + +<p>The point cannot be too much emphasised that many +of these patients are quite sane, if conduct be regarded<span class="pagenum" id="Page_69">[Pg 69]</span> +as the criterion of sanity; but they are growing afraid of +the appearance of these abnormal phenomena, and take +them for signs of incipient—or, more usually perhaps, of +established—insanity. Hence follows the important +corollary that while treatment by isolation has obvious +advantages in certain cases, in the particular group of +patients which we are now discussing it is often dangerous, +for the reasons already emphasised in the last chapter. +The presence of such mental phenomena is usually confided +to the physician only after great hesitation, and +such worrying experiences are common in cases of +insomnia and other disorders, which, though troublesome, +do not appear to be grave. It is therefore possible that +isolation may have serious effects in many cases in which +its net result seems merely to be that the patient is no +better.</p> + +<p>It is granted then that in some instances (by no means +all), the patient may be temporarily pained by the +dragging into daylight of the causes of his worry, but it +is usually a case of <i lang="fr" xml:lang="fr">reculer pour mieux sauter</i>. This +procedure is often inevitable in the medical treatment of +many disorders which have become complicated to any +considerable extent.</p> + +<p>We pass now to a difficult task; the consideration of +the moral objections to the procedure of psychological +analysis. The difficulty obviously lies in the circumstance +that, while in the discussion of the other objections one +could continually point to facts upon which at least, the +great majority of civilised people are in cordial agreement, +such unanimity is not so complete upon moral +questions. Some of the varieties of the moral objection, +however, are not based on such disputable grounds. For +example, there is the argument that it is bad for the +patient that he should have his inmost mental life dissected +and analysed in the thoroughgoing way which we +have described, since it is important for the preservation<span class="pagenum" id="Page_70">[Pg 70]</span> +of his self-regard that, as far as possible, he should +consider himself “master of his soul.” With the latter +sentiment no reasonable person would quarrel. And where +it is possible (as it often is) for a slight mental tangle +to be straightened out without an extensive and lengthy +inquisition, we hold that it is urgent in the patient’s +interest that his privacy shall be respected. It should +be pointed out, however, that since this procedure is +equally in the interests of the honest physician—for it +will save him time and trouble—it is likely to be adopted +wherever possible. In the special military hospitals, for +instance, it was often found unnecessary, in mild cases, +to press the inquiry very far; the patient “learning his +lesson” successfully at an early stage of the proceedings.</p> + +<p>But it obviously does not follow that the fact of a man +having for very sufficient reasons, admitted the physician +into his confidence, must necessarily bring as a consequence +a diminution in his self-respect. On the contrary, +he often emerges from such an examination with +increased confidence and a better opinion of himself, +especially if, as so often happens, his self-reproaches +have been unfounded. The civilised world contains +a relatively large proportion of people who habitually +confess their shortcomings to priests. One may recognise +that the confessional has its defects, but the assumption +that to have recourse to it inevitably promotes mental +flabbiness is obviously unfounded. The business man +who, when faced with the necessity of successfully meeting +an entirely new situation, consults his legal adviser, is not +usually blamed for his lack of self-reliance. Conducting +one’s own legal transactions, like doctoring oneself, may +appear (to the vulgar) to show independence, but its +results are not always happy.</p> + +<p>It is therefore perfectly fair to claim that none of the +arguments against the use of psychological analysis have +any very great significance. In some cases, however,<span class="pagenum" id="Page_71">[Pg 71]</span> +they express valuable reminders that this delicate and +powerful instrument, like all others with these attributes, +must be used with care and discretion.</p> + +<p>We may now proceed to take stock of our present +position and briefly to summarise the contents of the +foregoing remarks. Many cases of “functional nervous +disorder” or “neurosis” exhibit as their most important +characteristics symptoms, the underlying factors of which +are demonstrably <em>mental</em>. A neurosis may be regarded +as the failure of an act of adaptation.<a id="FNanchor_45" href="#Footnote_45" class="fnanchor">[45]</a> The resultant +mental disturbances do not seriously affect the “reason” +or the “intellect” as was formerly supposed, but are +in character predominantly instinctive and emotional. +The neurotic’s behaviour in the face of an insurmountable +difficulty presents a considerable resemblance to that of +a child. The reasons why this analogy is not always +obvious (though often it is quite plain) is that while in +the child one can usually appreciate the cause of the +emotional disturbance and watch its progress, these +possibilities are often excluded in the case of the civilised +neurotic adult. Both his insurmountable difficulty and +the historical circumstances which have made it unconquerable +may (they do not always) lie within his inmost +mental life. Further, the child’s difficulty usually is +caused simply by his inability to adjust himself to his +environment; or perhaps more often to adjust his environment +to himself. The adult neurotic, on the other hand, +adds to these difficulties the further significant one of +a lack of inner harmony. There are warring elements inside +as well as outside him: he is trying to fight the +enemy with an army which has mutinied.</p> + +<p>It follows then that any attempt to restore equilibrium +between himself and his social environment must be +accompanied by a similar endeavour to bring about his<span class="pagenum" id="Page_72">[Pg 72]</span> +inner harmony. Therefore, in such cases, a certain +amount of psychological analysis is indispensable. Without +such investigation the application of physical or +psychical methods of treatment must inevitably be a shot +in the dark.</p> + +<p>The task of psychological analysis is rendered difficult +by the fact that not all the motives of the patient’s +present beliefs, attitudes and actions are conscious; the +entry into consciousness of some of the unacceptable +motives and memories is obstructed by various mental +processes. When the action of these shielding mechanisms +has been subverted by various means the real significance +and history of the patient’s present mental condition +becomes clear to him. In the light of this new self-knowledge +he begins to cure himself. In a few cases he +may require little or no subsequent assistance, but usually +a process of re-education<a id="FNanchor_46" href="#Footnote_46" class="fnanchor">[46]</a> is necessary. He may still +require to be helped over some of the obstacles which he +meets, and he may need more or less frequent encouragement +and advice to an extent determined by his disposition, +temperament, and character. By these means +he is “freed from himself,” liberated from the exaggerated +emotional tone which has become attached to so many +of his memories, and so enabled to face life anew with a +harmonious and integrated mind.</p> + +<p>The procedure which we have discussed is precisely +that which the sensible mother adopts towards a child +who exhibits sudden and unreasonable fear, anger, or +any socially undesirable emotion. The same method<span class="pagenum" id="Page_73">[Pg 73]</span> +is adopted towards the man who, having muddled his +financial affairs, appeals for advice to an experienced +and judicious business friend. “Firmness”—of the unsympathetic +and unintelligent order—may occasionally +produce good results in both these instances, but +usually it only makes matters worse. Paying for the +commercial muddler a few of his chief debts may remove +his embarrassment for the time, but if unaccompanied by +an attempt to reform his business methods, the result will +usually be merely that such a treatment will enable him +to incur fresh liabilities. So it is when a symptom or +set of symptoms in a neurosis is unintelligently removed: +new troubles frequently break out in fresh places.</p> + +<p>We believe that there exist and can exist no serious +arguments against the procedure of psychological analysis +and re-education which we have just described. But +now we come to speak of a procedure introduced +during the last few years which has certainly not escaped +criticism both of the most flattering and the most hostile +kind. This is the method of “psychoanalysis” which we +owe to Professor Sigmund Freud, of Vienna, who +developed it as an extension and elaboration of the +pioneer work of his former master, Professor Pierre Janet<a id="FNanchor_47" href="#Footnote_47" class="fnanchor">[47]</a>, +of Paris.</p> + +<p>Perhaps few terms in medicine have aroused so much +misunderstanding, so much criticism, well-informed and +ill-informed—and so much enmity as this word “psychoanalysis.” +This latter fact alone, however, should not +prejudice the reader for or against it. He will probably +remember that it is the exception, rather than the rule, +for an innovation to be received without hostility, not +only from the general public, but also from experts who +work in provinces bordering upon the field in which the +new method is introduced.</p> + +<p>It should be pointed out that much of the heated +discussion which has raged around this word psychoanalysis<span class="pagenum" id="Page_74">[Pg 74]</span> +is due to the fact that the term has different +meanings, as used, not only by its enemies, but by its +friends. Psychoanalysis, according to Dr. Jung, is a +<em>method</em>; “a method which makes possible the analytic +reduction of the psychic content to its simplest expression, +and the discovery of the line of least resistance in the +development of a harmonious personality.”<a id="FNanchor_48" href="#Footnote_48" class="fnanchor">[48]</a></p> + +<p>Psychoanalysis is therefore a method of psychological +analysis. Why, then, have we not used the term psychoanalysis +in the earlier part of the book? It was purely +to avoid unnecessary and acrimonious discussion on any +particular doctrinal aspect of the question which this term +may be taken to imply.</p> + +<p>It is clear to every thinking person that, in analysing +a mental state the physician should use every legitimate +means at his disposal. If these means include, as they +do, the valuable assistance derived from the study of the +patient’s dreams, his “associations” whether free or +constrained,<a id="FNanchor_49" href="#Footnote_49" class="fnanchor">[49]</a> and other mental phenomena, the doctor +may use them freely without thereby subscribing to any +one “doctrine of psychoanalysis.”</p> + +<p>The term psychoanalysis has been widely applied, not +only to the diagnostic method, but also to the theories +which underlie and determine the subsequent process of +re-education. This seems to be a misuse of the useful +word “analysis.” It may be objected that in all scientific +analysis there is some directive hypothesis to be confirmed +or disproved, and that in this sense all analysis is +based on theory. This is true, but it seems inadvisable +to confuse the analytic process with the theory which +directs one form of it.</p> + +<p>When we come to consider the theoretical presuppositions +which underlie the different methods of re-education<span class="pagenum" id="Page_75">[Pg 75]</span> +adopted by various physicians, it is not +surprising, at this early stage of our knowledge, to +discover differences of opinion. The physician will find +at every step that in “tidying up” the disentangled +functions of the patient’s mentality he will need not one +theory but many, for his problem is life itself.</p> + +<p>All his own human sympathy, with its indispensable +basis, a knowledge of his own strength and weaknesses, all +his learning in physical science and psychology, all his +knowledge of morality and religion must be available +for immediate and efficient use. In one interview he may +have to lay down the law for the benefit of some ignorant +and distressed patient who is desperately anxious to +follow his advice unquestioningly; in the next he may be +at close grips with a mind more flexible and independent +than his own, knowing well that his every little victory +must be consolidated, and that every position won may +be subsequently counter-attacked by his patient. He must +be ready to suggest, discuss, persuade as the time and +the conditions indicate.</p> + +<p>While, therefore, the ultimate lines on which an ideal +diagnostic analysis and curative re-education will be +possible are as yet undefined, it would serve no good +purpose in a book of this length to raise discussion on +the question of psychoanalysis. Its future will be settled, +not in the heated atmosphere of the debate, not in the +acrid polemics of the correspondence columns, but in the +calm, careful examination by the individual worker of his +own actual findings and the honest comparison of them +with those of others.</p> +<br> + +<div class="footnotes"><h3>FOOTNOTES:</h3> + +<div class="footnote"> + +<p><a id="Footnote_37" href="#FNanchor_37" class="label">[37]</a> Such development involves a complicated set of processes +the nature of which is by no means obvious to unaided +common sense.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_38" href="#FNanchor_38" class="label">[38]</a> “... for example, a patient may maintain that he is +the king, but that an organised conspiracy exists to deprive +him of his birthright. In this way delusions are sometimes +elaborated into an extraordinarily complicated system and +every fact of the patient’s experience is distorted until it is +capable of taking its place in the delusional scheme.” Bernard +Hart, <cite>The Psychology of Insanity</cite>, Cambridge, 1914, p. 32.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_39" href="#FNanchor_39" class="label">[39]</a> <em>Cf.</em> p. 15<em>f.</em></p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_40" href="#FNanchor_40" class="label">[40]</a> <em>Cf.</em> Hart, <em>op. cit.</em>, p. 66<em>f.</em></p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_41" href="#FNanchor_41" class="label">[41]</a> The reader may pass an interesting time in trying to give +himself or others an historical account of the events +in his life which caused him to choose his present profession. +He will probably find that memories emerge of incidents +and conversations which have been forgotten for years. Yet +he may find that they have influenced his present life and +his action at any moment of the present, to a very great extent. +Their present action clearly has been unconscious.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_42" href="#FNanchor_42" class="label">[42]</a> It should not be forgotten that when a patient in an early +stage of mental disorder voluntarily seeks the doctor, his +<em>active co-operation</em> in the task of tracing the causal factors of +his trouble is of the greatest value. This assistance cannot be +relied upon after the patient has been certified as insane and +removed to an asylum, or even after he has been taken to the +doctor at the instance of others. For obvious reasons he is +then more likely to hide than to reveal his eccentricities. The +simulation of insanity is comparatively rare: it is difficult +and usually easily detected. It is dissimulation—the concealment +of symptoms of disease—which is the doctor’s greatest +enemy. The deluded man may hide his delusions because +“everyone knows that these beliefs are mad:” the melancholic +may pretend for the time to be cheerful in order that +his liberty may not be interfered with. (<em>Cf.</em> K. Jasper’s +<cite>Allgemeine Psychopathologie</cite>, Berlin, 1913, p. 317.) Such +attitudes of the patient are obviously strengthened by our +present custom of delaying the treatment of mental disorder.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_43" href="#FNanchor_43" class="label">[43]</a> In his account of the wonderful exploits of “Sherlock +Holmes,” Sir Arthur Conan Doyle was merely applying, with +inimitable skill and literary resourcefulness, the methods of +clinical diagnosis in medicine to the detection of imaginary +crimes. The unusual phenomenon in medicine or in crime +often affords the most obvious clue to the expert who can +appreciate its significance, whereas a simple dyspepsia or a +commonplace murder may present insoluble problems, because +they reveal no distinctive signs to guide the investigator.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_44" href="#FNanchor_44" class="label">[44]</a> p. 17<em>f.</em></p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_45" href="#FNanchor_45" class="label">[45]</a> Dr. C. G. Jung’s view, <cite>Analytic Psychology</cite>, p. 234.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_46" href="#FNanchor_46" class="label">[46]</a> It is of importance to remember that successful re-education +utilises the emotional factors in the patient’s mental make-up, +by helping him to realise the value of the things which will +make life once more attractive and worth living. In this process +the more the physician knows of the patient’s social, moral +or religious relations, the earlier and more satisfactory will be +his success.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_47" href="#FNanchor_47" class="label">[47]</a> CORRECTION.</p> + +<p>An unfortunate error in the second paragraph on page +73 escaped our notice during the correction of proofs. +Professor Pierre Janet was not formerly the teacher of +Professor Freud, but his fellow pupil when they were +studying under Charcot in Paris.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_48" href="#FNanchor_48" class="label">[48]</a> <em>Op. cit.</em>, p. 256<em>f.</em></p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_49" href="#FNanchor_49" class="label">[49]</a> <em>Cf.</em> Hart, <em>op. cit.</em>, p. 69<em>f.</em>, Jung, <em>op. cit.</em></p> + +</div> +</div> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> + +<p><span class="pagenum" id="Page_77">[Pg 77]</span></p> +<h2 class="nobreak" id="CHAPTER_IV">CHAPTER IV.<br> +<span class="fs120">Some General Considerations.</span></h2> +</div> + +<p class="drop-cap"><span class="upper-case">It</span> is instructive to compare the public attitude towards +insanity with that adopted in the case of another +serious disease, tuberculosis.</p> + +<p>There is nowadays a general conviction, not only +amongst the medical profession but also amongst a large +proportion of the educated public, that tuberculosis is a +curable disease. It may exist in a mild and incipient +form in many persons regarded as healthy, and, if +properly treated in its early stages, with due regard not +only to the actual disease in the bodily organism, but +also to the healthy environment of the individual, it is +almost certainly conquerable. Not many years ago, however, +this happy belief did not obtain. A person “in +consumption,” especially if “consumption was in the +family,” was regarded as being in a very serious and +almost hopeless condition. The patient, shielded from +fresh air, inappropriately and insufficiently fed, often +succumbed, supplying one more example to support the +unscientific conception then prevalent of the inheritance +of the disease. But such conditions are passing away. +In our medical schools and hospitals special attention is +paid to the diagnosis and treatment of early forms of +tuberculosis; the importance of preventive measures is +emphasised; the influence of the patient’s environment +in favouring or combating the disease is explained; and<span class="pagenum" id="Page_78">[Pg 78]</span> +the future medical practitioner is afforded frequent opportunities +for personal investigation of tubercular patients. +The old ideas about the “inheritance of consumption” +are greatly modified. No longer is a patient’s +disease explained as “in the family” and left at that. +Preventive measures, early treatment, an attempt justly +to appreciate the relative influence of heredity and environment +are the watchwords of the modern medical +attack upon tuberculosis.</p> + +<p>If, however, we consider the attitude of the general +public in this country towards the malady of insanity +we find a mixture of ignorant superstition and exaggerated +fear. From these there springs a tendency to ignore +the painful subject until a case occurring too near home +makes this ostrich-like policy untenable. The sufferer +is removed to a “lunatic” asylum, neither himself +nor his relatives being spared the gratuitous extra wrench +to their feelings aroused by this name, which has long +struck terror into the uneducated mind. He is taken +away by the relieving officer of the district, often under +the pretence of being given “a few weeks in a convalescent +home at the sea-side,” and eventually finds +himself under lock and key. Here, as is well known, he +is treated with great kindness. Neither public money nor +the exertions of the staff are stinted in the effort to +render his lot as pleasant as possible—“the asylum +to-day has become a model of comfort and orderliness.”<a id="FNanchor_50" href="#Footnote_50" class="fnanchor">[50]</a> +But the proportion of doctors to patients is on the +average, one to 400, and it is exceedingly difficult to +ensure that all patients, once inside the “lunatic” +asylums, shall be regularly visited by friends from the +outside world.<a id="FNanchor_51" href="#Footnote_51" class="fnanchor">[51]</a> The attitude of the general public is<span class="pagenum" id="Page_79">[Pg 79]</span> +not deliberately cruel, but it appears to be far more +benevolent than it really is. The community treats the +sufferer well, when, <em>but not before</em>, he has become a +“lunatic.” It allows his delusions to become fixed, his +eccentricities and undesirable acts to harden into habits, +his moods of depression to permeate and cement together +the whole of his life—and then interns him and treats him +kindly for the rest of his life, but does not give him +facilities for gratuitous treatment while he is still sane. +<em>That is the British procedure to-day.</em></p> + +<p>Lest we should be accused of exaggeration, or worse, +we will quote here from published articles and reports.</p> + +<p>Dr. Bedford Pierce says:—</p> + +<div class="blockquot fs90"> + +<p>“Let me state in a few words the defects of our present +system. At present, broadly speaking, no person unable to +pay its cost can receive adequate treatment until he is certified +as of unsound mind. This practically means that no special +treatment is possible until he has utterly broken down, and +is so seriously affected as to convince a magistrate that he +is decidedly insane. No general hospital will receive such a +patient; the public asylums are all closed to any one who +begs for protection or treatment, for county asylums cannot +receive voluntary boarders even when the cost of their maintenance +is forthcoming.</p> + +<p>Consequently there is no alternative but to apply to the +Poor Law authorities, who, under certain circumstances, provide +treatment for a period of two weeks in the workhouse +infirmary. The whole system is radically wrong. When the +wife of an artisan becomes depressed after confinement, surely +it is cruel in the extreme to make her a pauper and send +her to the workhouse infirmary, pending a decision as to +whether she is insane or no. It is obvious in such a case +that this course will not be adopted until the last possible +moment, and consequently much valuable time is lost.</p> + +<p><span class="pagenum" id="Page_80">[Pg 80]</span></p> + +<p>Every practitioner will be able to call to mind patients +travelling steadily towards insanity in unfavourable surroundings. +This question is brought even more prominently before +consulting physicians, especially those interested in nervous +and mental diseases.” (<em>Op. cit.</em>, p. <a href="#Page_42">42</a>.)</p> +</div> + +<p>In the words of the report of the Medico-Psychological +Association:—</p> + +<div class="blockquot fs90"> + +<p>“The present system, which compels all persons, except +those able to pay adequately for their maintenance, to apply +to the Poor Law authorities in order to secure treatment, is +unsatisfactory and unjust. In doubtful and undeveloped cases +temporary care can be given only in workhouses or Poor Law +infirmaries, which, with very few exceptions, lack proper +facilities for treatment.</p> + +<p><em>A system which artificially creates paupers in order to +obtain medical treatment necessarily acts as a deterrent, so +that too frequently there is serious and even disastrous +delay.</em>”<a id="FNanchor_52" href="#Footnote_52" class="fnanchor">[52]</a></p> +</div> + +<p>This is not exactly locking the stable door after the +horse has gone; it is double-locking him thoroughly, +expensively and often unnecessarily, in someone else’s +stable.</p> + +<p>Let us, for a moment, compare this state of affairs +with that existing in the case of tuberculosis. Nobody +now believes that the scientific way of treating this disease +consists in waiting until the patient has become a positive +danger to others, and then locking him up. This point +needs no elaboration. But another fact in this connection +should not be forgotten. The tubercular patient usually +seeks the doctor <em>of his own free will</em>, often obtaining +treatment in a relatively early stage of the disease.</p> + +<p>There are, however, many reasons that deter the +mental sufferer from seeking medical help. One of the +strongest of these is the wish to cure himself by his +own unaided efforts. This is a laudable desire and one<span class="pagenum" id="Page_81">[Pg 81]</span> +which is extremely helpful and important in mild and +uncomplicated cases of relatively recent occurrence, but +of which, as we have seen,<a id="FNanchor_53" href="#Footnote_53" class="fnanchor">[53]</a> the gratification is not always +possible. Another factor is the natural disposition which +the patient shares with the rest of conventional humanity, +to conceal his worries, not only from his friends, but +perhaps above all from those of his own household. +This tendency to concealment, however, often only +aggravates his mental distress. Particularly is this the +case in adolescents. As is well known, a talk with a +kindly, sympathetic and wise person, or even a confession +to such an adviser, frequently means the end of many +painful mental conflicts.</p> + +<p>But in addition to these very natural reasons for +deferring recourse to medical help, there are in our own +country special causes for delay. These are due to the +prospects imagined by the sufferer to be awaiting him if +he discloses his trouble.<a id="FNanchor_54" href="#Footnote_54" class="fnanchor">[54]</a> The treatment of incipient +mental disorder is often a long and complicated process +for which the average general practitioner has seldom +either the time or the special training. In very few +hospitals in this country is out-patient attendance for such +maladies practicable. For the mental sufferer whose +means are not considerable, there exists nothing if the +efforts of the general practitioners fail, but trying to +cure himself, or, if he becomes worse, admission to an +asylum. Unfortunately, however, the average asylum, +with its one doctor to 400 patients, does not and can +not meet his needs. The successful treatment of mental<span class="pagenum" id="Page_82">[Pg 82]</span> +disease usually requires individual care, often lasting over +long periods. When it is remembered that the asylums +contain a considerable percentage of patients whose +bodily diseases, apart from their mental troubles, require +the doctor’s attention, and further, that by the time the +patient reaches the asylum, his disorder has usually +passed through its initial stages, it is easily seen that +our asylum system in its present state—to put it mildly—is +far from conducive to recovery from mental disease. +Considering that, in spite of these drawbacks, 33 per cent. +of the patients are discharged,<a id="FNanchor_55" href="#Footnote_55" class="fnanchor">[55]</a> we can only gladly +recognise the efforts made by the asylums; we are, +however, bound to ask: <em>What percentage of the +inmates need ever have entered the asylum?</em> It may +be objected that it is easy, but unfair, to ask such a +question seeing that no satisfactory answer can be given. +To this objection there are two replies: first that, +judging from the present state of affairs, this question +cannot be publicly asked too often; secondly, that +materials for an answer are already forthcoming. It is +conclusively proved by the experience of other countries +that a large proportion of the patients might have been +cured without being sent into an asylum. Thus, for +example, in Germany, in the province of Hesse, by +reason of suitable treatment during the early stages of +mental illness the authorities were able to postpone +for ten years the erection of a new asylum.</p> + +<div class="blockquot fs90"> + +<p>“The Psychopathic Hospital at Boston, Massachusetts, ... +was built by the State expressly to deal with recent acute +cases. No fewer than 1,523 patients were received in its +first year, and of these 590 were received under a temporary +care law, which provides for a week’s detention only; large +numbers were also received on a voluntary basis, so that +during the year <em>48 per cent. of all patients escaped the usual +lunacy procedure</em>.</p> + +<p><span class="pagenum" id="Page_83">[Pg 83]</span></p> + +<p>On reading the reports of work done, one is struck with +the enthusiasm of the medical staff and the vast field of +research undertaken. During the two years eighteen +medical men describe their work covering almost every department +of psychiatry: juvenile crime, tests for feeble-mindedness, +incidence of syphilis, alcoholism, hydropathy in its influence +on red blood cells, treatment of delirium, prophylaxis, analysis +of genetic factors, salvarsan treatment, tests of cerebro-spinal +fluid, and last, but not least, the value of out-patients’ departments +and after-care. There is a special social service department +for the purpose of following up cases in their homes, +and it was found that of every 100 admissions 20 needed supervision +on discharge, 24 needed advice, 3 required assistance +in arranging their discharge, and 10 showed a need for +prophylactic work in their families.</p> + +<p>This bald statement of the activities of the Boston State +Hospital shows plainly what an important service it renders in +providing treatment apart from ordinary asylum associations. +It shows how it is possible at such a hospital to organise a +medical service which covers all departments of psychiatry; +and further, that when the mental symptoms clear up, a +patient need not be thrown back into old associations without +help or supervision.</p> + +<p>This hospital at Boston is but one of many that have been +established in the United States in recent years. Some of +the others are due to private munificence; in particular, reference +may be made to the Henry Phipps Psychiatric Clinic +at Baltimore, the medical staff of which consists of a director, +assistant director, a resident physician, two assistants, and five +[resident medical officers]. In addition to these are the heads +of three research laboratories dealing (1) with clinical pathology +and bio-chemical investigation, (2) with neurological research, +and (3) with psychopathology.” (Bedford Pierce, <em>op. cit.</em>, +p. <a href="#Page_42">42</a>.)</p> +</div> + +<p>In advocating the establishment of separate pavilions +for nervous and mental disease in direct association with +the general hospitals, Dr. Bedford Pierce says:—</p> + +<div class="blockquot fs90"> + +<p>“At La Charité Hospital in Berlin, the visitor enters a small +park, and Dr. Ziehen’s clinic is but one of many detached +buildings devoted to special diseases. It is as easy and simple +for the patient suffering in mind to get advice there as for +another with eye and lung trouble.”</p> +</div> + +<p><span class="pagenum" id="Page_84">[Pg 84]</span></p> + +<p>Let it be noted that none of these German patients, +on returning to their relatives and friends, suffer from +the stigma of having been to an asylum. In our country +some of those same friends during the patient’s absence +would often have been engaged in “sympathetically” +spreading the news of the sufferer’s absence and his +whereabouts to everybody in the district. To a certain +type of mind there is a ghoulish fascination in gloating +over the illnesses and afflictions of neighbours. Even +though people addicted to such habits may salve their +own consciences by exclaiming “poor fellow” at the +end of their narrative, the effect of their conduct is +none the less brutal and offensive. This is not the +place for the discussion of so remarkable and important a +phenomenon of social psychology. Nevertheless it plays +a great part in the causation of the prevalent dread of +treatment for mental disorder.</p> + +<p>For many reasons the psychiatric clinic is not regarded +by the public as a “lunatic” asylum. In the Giessen +clinic in Germany, for instance, both nervous and mental +diseases are treated. The patient afflicted with tremor +or a paralysed finger visits this institution as well as the +sufferer whose troubles if neglected might develop into +mental disease. Difficult medico-legal cases resulting from +such incidents as those arising from the claims by +workmen and others for compensation after accident are +sent to this clinic for observation and opinion. “Rest-Cures” +and similar treatment are also carried out there. +The official title of the institution, displayed at the +entrance, is “Clinic for Mental and Nervous Diseases.” +The institution is therefore regarded by most people +in quite a different light from the asylum, and it +is not spoken of by the general public with bated breath. +One of us, while working in the laboratory of a German +psychiatric clinic, was introduced to a visitor who made +some remark about “when I was here.” To the question,<span class="pagenum" id="Page_85">[Pg 85]</span> +“Were you on the staff, then?” the visitor answered +quite naturally, “Oh no, I was here as a patient.”</p> + +<p>With this experience may be contrasted another +incident, this time from our own country. Delegates +from a certain Board of Guardians paid a visit to the +county asylum to inspect the arrangements made for +the comfort of the inmates from their own district. In +the next week’s local newspaper a report of the visit +appeared in the form of the chief delegate’s speech at +the subsequent board meeting. This report consisted of +“funny” stories of the eccentricities of the patients the +visitors had seen, and of the delusions from which some +of the victims were suffering, with sufficient detail to +enable many of the relatives, and possibly some of the +friends, of these “lunatics” to identify the afflicted ones. +The newspaper account of this humorous effort was +punctuated at suitable intervals with “laughter.”</p> + +<p>It is obviously not claimed that these two accounts +are typical either of Germany or of England. But what +is claimed is that of these two public attitudes the clinic +system promotes the one, the “lunatic” asylum the +other.</p> + +<p>Before leaving the comparison of insanity with tuberculosis +we must remind the reader of some other facts that +are important in this connection. We have seen<a id="FNanchor_56" href="#Footnote_56" class="fnanchor">[56]</a> that +the scientific study of tuberculosis has materially modified +the earlier views concerning its hereditary transmission. +It is now held that tuberculosis is not inherited as such; +but that a child of tuberculous parentage may begin +life with a subnormal power of resistance to the disease +and perhaps greater risk of exposure to infection. If +later he develops the disease, it is traceable directly to +his environment. The corollary is that if his environment +be improved, and his body’s power of resistance increased<span class="pagenum" id="Page_86">[Pg 86]</span> +meanwhile by all the means in our power, he has a +considerable chance of living a life free from the disease. +Thus the old pessimistic view is replaced by a distinctly +optimistic one.</p> + +<p>In the mental disorders that are indubitably traceable +to organic disease of the central nervous system, heredity +doubtless plays a great role. But two points should be +remembered in this connection. First, among asylum +patients the number of mental disorders which cannot, +<em>post-mortem</em>, be traced to organic causes is very great +as compared with those that can be so related. For +example, of 1,325 patients received at the Burgholzi +Central Asylum and University Psychiatric Clinic, Zürich, +Dr. C. G. Jung states:—</p> + +<div class="blockquot fs90"> + +<p>“... in round figures a quarter of our insane patients show +more or less clearly extensive changes and destruction of the +brain, while three-fourths have a brain which seems to be +generally unimpaired or at most exhibits such changes as +give no explanation of the psychological disturbance.... +We must take into account the fact that those mental diseases +which show the most marked disturbances of the brain end +in death; for this reason the chronic inmates of the asylum +form its real population, and among them are some 70 to 80 +per cent. of cases of dementia præcox, that is of patients in +whom anatomical changes are practically non-existent.”<a id="FNanchor_57" href="#Footnote_57" class="fnanchor">[57]</a></p> +</div> + +<p>In a great number of mental disorders our present +knowledge of anatomy, physiology and pathology is of +little help as a means of throwing any light upon the +patient’s condition. While in no way attempting to +belittle the magnificent work in these subjects during +the past century, it should be pointed out that its very +success has brought about, especially in this country, an +unfortunate tendency to regard these methods as the only +ones suitable for attacking the problems of insanity. +But nothing is more certain than that in the psychoneuroses:<span class="pagenum" id="Page_87">[Pg 87]</span> +hysteria, neurasthenia, psychasthenia and the +rest, anatomical and physiological knowledge has not +yet passed beyond the theoretical stage<a id="FNanchor_58" href="#Footnote_58" class="fnanchor">[58]</a>. But it is +equally indisputable—and the statistics of shell-shock +cases have strengthened the evidence for this assertion—that +the psychological mode of attack, the treatment of +mental disorder by mental means, is now firmly established +as a practical method.</p> + +<p>It appears, therefore, that precisely in those cases of +psychoneurosis which yield to psychical treatment, there +is no anatomical, pathological or chemical evidence of +inheritance.</p> + +<p>But while the contributions of anatomy, physiology and +pathology to the treatment of psychoneuroses have not +yet gone beyond theoretical and mutually conflicting +suggestions, the psychological method of investigation +and treatment on the other hand has proved itself of +practical use in restoring patients to a normal state of +mental health. What scientific justification therefore have +we, when considering the action of heredity, for lumping +together the organic and the functional mental disorders? +The psychoneurosis is often simply a progressive state +of mal-adaptation to environment; a mental twist which +can be corrected if treated suitably at a sufficiently early +stage. Its specific nature is frequently explicable almost +entirely in terms of the peculiar educational, family or +social relations of the patient’s environment. The war +has shown us one indisputable fact, that a psychoneurosis +may be produced in almost anyone if only his environment<span class="pagenum" id="Page_88">[Pg 88]</span> +be made “difficult” enough for him.<a id="FNanchor_59" href="#Footnote_59" class="fnanchor">[59]</a> It has +warned us that the pessimistic, helpless appeal to heredity, +so common in the case of insanity, must go the same +way as its lugubrious homologue which formerly did +duty in the case of tuberculosis. In the causation of the +psychoneuroses, heredity undoubtedly counts, but social +and material environment count infinitely more.</p> + +<p>To some readers the above argument may seem so +obvious as to be superfluous. To ascribe a patient’s +entangled state of mind to heredity without attempting +to discover how far his own personal experiences have +tended to bring about that mental condition, would seem +as fatuous as attributing to heredity the financial muddles +of a son who has inherited from his unbusinesslike +father a badly managed estate. The trade-adviser called +in to help might for a moment consider the possibility +that the son may have inherited his father’s unpractical +character, but surely his first serious efforts would be +to discover where the business methods were wrong or +antiquated and to improve on them. So it is with the +mental patient; his own history is the important +desideratum. That of his parents may cast valuable +light upon his trouble, but even then it is often just +because their own difficulties have contributed to the +making of his environment.</p> + +<p>One of the most dangerous and misleading terms in +our language is the word “neuropathic;” for it is made +to signify so many things that it ends by meaning nothing. +Etymologically, it should mean “afflicted with disease +of the nerves,” a conception the precision of which we +shall discuss below. Yet on the return from the front +of patients afflicted with “shock” one heard the opinion +at first that the cases were those of “neuropathic” men: +that the soldiers who became affected by shock were<span class="pagenum" id="Page_89">[Pg 89]</span> +weaklings or were descended from mentally afflicted +or nervous parents. It is, of course, unquestionable that +in a large army there must be many soldiers with tainted +family histories; and it is probably equally certain that +such factors play some part in determining the greater +susceptibility of certain men to shock. But it would +be a gross misrepresentation of the facts to label all +the soldiers who suffer from mental troubles as weaklings. +The strongest man when exposed to sufficiently intense +and frequent stimuli may become subject to mental +derangement. It is quite common to find among the +patients suffering from shock senior non-commissioned +officers who have been in the army fifteen or twenty years +(much of which time has been spent in foreign service +under trying circumstances, such, for example, as the +South African War), and have stood this severe strain. +Such men can hardly be called weaklings or “neuropathic.”</p> + +<p>Even in those cases where there is a definite history +of a neurotic parent, it would be a mistake hastily +to conclude that when the son of such a man or +woman becomes a victim of shell-shock it is due to +heredity. For when the detailed history of such patients +is obtained the fact comes out quite clearly that the +social disturbances in the household of such a nervous +person may be amply sufficient to inflict severe psychical +injuries upon young children.</p> + +<p>Further, in many cases the histories themselves clearly +and definitely reveal the real etiology of the mental condition, +and point to emotional disturbances in children, +due to the cruelty of drunken parents, a rankling sense +of injustice, a terrifying experience, which may have been +an accident or deliberate maltreatment by some human +being, or again, to the appalling conditions created in +some of these homes by nervous and irritable parents, +as the real trauma which the “shock” has served to +re-awaken.</p> + +<p><span class="pagenum" id="Page_90">[Pg 90]</span></p> + +<p>But when we come to ask <em>what</em> disease of the nerves, +or, more strictly, of the nervous system, is implied in +speaking of the “neuropathic” we find no satisfactory +answer. Certainly no one disease is regarded as being +the causal factor. And the list of theories is overwhelming. +Disturbances of the genital, vaso-motor, or +digestive systems, demineralisation, chemical disturbances +of nutrition of hepatic or cholæmic origin, visceral ptosis, +cerebellar disturbance, thyroid disorder, complex disturbances +in functioning of the blood vessels, intoxication, +exhaustion<a id="FNanchor_60" href="#Footnote_60" class="fnanchor">[60]</a>: these are some of the numerous theoretical +suggestions proposed to account for neurasthenia only. +Whether the unfortunate neuropath is supposed to be +afflicted by one or all of these is a matter which we +certainly cannot decide; for the theories proceed from +many different sources.</p> + +<p>But we must not lose sight of another important fact +in this connection. The neuropathic person’s mental +troubles, or those at least for which he seeks relief from +the physician are by no means in the clouds of theory. +They are real enough, and as a rule not to the patient +only, but also to his relatives and friends, with whom he +finds it difficult to live amicably. Those troubles are +based upon fear, anxiety, anger, and excessive curiosity +concerning matters about which the normal person would +not bother his head. They find expression in outbursts +of pugnacity or of unusual self-assertion with its emotion +of elation, often followed by self-abasement and subjection, +inordinate desires either to be alone or never +to be alone, floods of tender emotion, possibly following +close on the heels of a mood of blatant self-assertion +with no regard for the feelings of others. These relatively +simple processes of mind, occurring sometimes in +comparative isolation, sometimes inextricably blended or<span class="pagenum" id="Page_91">[Pg 91]</span> +kaleidoscopically transient, are the real marks of the +so-called neuropath or neurotic. Bodily troubles may, +and often are, added to these. But as every physician +knows to his cost (and sometimes to the patient’s), and +as faith-healers know to their advantage, these bodily +diseases are usually exaggerated by the neurotic sufferer, +and frequently prove to have but a slight material basis. +In other words, the real marks of the “neurotic” are +mental.<a id="FNanchor_61" href="#Footnote_61" class="fnanchor">[61]</a> And one need not be a technical psychologist +to see that the above list is nothing but an enumeration +of the instincts and emotions possessed in common by +all men.<a id="FNanchor_62" href="#Footnote_62" class="fnanchor">[62]</a></p> + +<p>If then, the neuropath is merely displaying instincts +which are common to all mankind, what is the difference +between him and the normal human being? The +difference is psychologically slight, sociologically immense. +While his normal brother reacts instinctively and emotionally +to his physical and social environment in such +a way and to such a degree as to promote his own +welfare and that of others, the neuropath does not. +Nobody calls the townsman a neuropath who before +crossing the street waits on the pavement until the stream +of traffic has thinned. If he did not wait we should +rather call him a fool. But the instinct of fear is largely +at the bottom of his so-called intelligent caution—especially +if he has ever witnessed a distressing street accident. +But what do we say of the man who waits and waits +until finally he is too afraid to advance, eventually +stealing down to another place so that he may cross in +safety? He is very likely to be called a neuropath. Or<span class="pagenum" id="Page_92">[Pg 92]</span> +what shall we say of the unfortunate man whose caution +has gone so far that he cannot cross <em>any</em> open space +whatever, and is said to be suffering from agoraphobia?</p> + +<p>Or again, take the case of a man whose personality, +family or country, is grossly and publicly insulted. If +he strikes at the aggressor, do we call him neuropathic? +But we seldom hesitate to apply this term to the man +who is inordinately touchy, ever on the watch for the +least suspicion of insult towards himself or anything +even remotely connected with him. The emotion of fear +underlies both the attitude of caution and of “funk,” +that of anger, the righteous indignation of the stalwart +and the querulous, peevish irritability of the neurasthenic. +The difference between the behaviour of the normal +man and the neuropath lies primarily in the circumstances +that provoke emotion in them, and secondly in the +violence and duration of the emotion itself.</p> + +<p>We should remember also that many varieties of +animals display the kind of behaviour we have described, +and regard as so unusual, if not utterly eccentric, in +our friends. Professor William James reminds us of the +chronic agoraphobia of our domestic cats; and the tamer +of wild animals has good reasons to respect the incessant +touchiness of some species of the genus <em>Felis</em>. Do we +invoke theories of visceral ptosis, intoxication and the +rest to explain the behaviour of the average cat or +mule? Scarcely. We say that these animals are actuated +by instinct. Our arrogance makes it difficult for us to +suppose that our suffering human brothers are also +acting instinctively. Yet this is undoubtedly the case.</p> + +<p>It has been said of the neurasthenic with aptness and +truth that he behaves like a child. But if a child, normal +in its behaviour up to a certain day, suddenly manifests +fear of being left alone for a moment in a room with +closed doors, or in a street, do we rush for our “Liddell +and Scott” and forthwith proceed to babble of claustrophobia<span class="pagenum" id="Page_93">[Pg 93]</span> +or agoraphobia?<a id="FNanchor_63" href="#Footnote_63" class="fnanchor">[63]</a> Do we follow this up by +solemnly invoking complicated physico-chemical theories +concerning the state of his blood or other bodily fluids? +Finally, do we brand him as “insane” or at least +“neuropathic?” What we do in this case, if we have +any sense, is carefully to investigate the causes of the +emotional outbreak. We try sympathetically to understand +and re-educate the child to meet such situations +without fear. In other words, we use a method precisely +similar to that which proves to be of such great use in +treating the psychoneuroses.</p> + +<p>The analogy—if it be an analogy and not perhaps an +identity—between the two cases goes still farther. The +child who manifests extreme fear at “inadequate” causes, +such as we have described, not infrequently agonises +his mother—perhaps soon after his outburst of fright—by +an exhibition of foolhardiness which, if we did not +know of the previous sign of weakness, would cause one +to look upon him as fearless. In short, the child’s fear +is restricted to one or two special situations. So it is +with many neurasthenics. Some, for example, may be +driven through traffic in a fast motor car without experiencing +the slightest fear, though they cannot bring +themselves to enter an ordinary slow suburban train; +others may surprise us not only by their exhibition of +anger at what we should consider an absurdly slight +provocation, but by their tolerance and self-control in +other (to us) much more annoying situations. Their +exaggerated emotional reactions are excited not by +general but by specific stimuli; and a little tact, insight +and patience on the part of the physician often reveals +in their past experience, psychological factors which<span class="pagenum" id="Page_94">[Pg 94]</span> +explain the tremendous personal importance and overweighting +of these stimuli. If for neuropathic we write: +“unduly hampered by instinct and emotion”—and this +is all we have the right to do<a id="FNanchor_64" href="#Footnote_64" class="fnanchor">[64]</a>—we represent the matter +more truthfully.</p> + +<p>Among the laity, before the war, the justification of an +attitude of inertia towards the treatment of mental +disorder (more particularly of the psychoneuroses) was +often based upon two statements. The first was that many +of the phenomena reported were not real, but were the +imaginings of hysterical women. If to this it was +objected that men were not immune to hysteria<a id="FNanchor_65" href="#Footnote_65" class="fnanchor">[65]</a> one was +met by the retort: “But they are ‘neuropaths.’” This +war has, however, removed from honest people’s minds +the possibility of regarding these phenomena in such a +shamelessly unscientific light. In the military hospitals +there have been hundreds of patients suffering from +psychoneuroses, who are demonstrably neither women nor +neuropaths, in any of the legitimate senses of these terms. +And many of these men have suffered intensely. Their +fears and other emotional troubles are such as they +usually conceal as long as possible, until further endurance +is intolerable. Their troubles are real enough to +them. “But they are unreasonable,” the healthy philistine +may object. Some (by no means all) of the fears <em>are</em> +unreasonable, if by that is meant that the actual danger +(as the healthy man estimates it) and the emotion which +it evokes in the patient are entirely disproportionate.<span class="pagenum" id="Page_95">[Pg 95]</span> +But who among us has “sized up” life’s dangers so +accurately that he can say he knows the precise degree +of fear which each one <em>ought</em> to evoke?</p> + +<p>In some country places the inhabitants to-day are +more afraid of the presence in their houses of peacock’s +feathers or of hawthorn blossom than of scarlet fever. +Their fears are unreasonable. But we do not call these +people neurasthenics. As a matter of fact, neurasthenia +is one of the last diseases likely to attack these rustics. +If they vouchsafe any reason for their fear, it is safe +to assert that it will be a rationalisation, for its real +sources are hidden from them. And if we really wish +to discover the cause of their fear we turn for help to +the records of folk-lore and ethnology. In other words, +we investigate the history of the fear. This history may +go back many centuries and the process of recovering +it from a series of clues will prove a task of infinite +fascination. Now the history of the neurasthenic’s fear +is likewise obtainable and much more easily, for it is +of much more recent date. Its discovery often means the +freeing of a mind from torment, the restoration of a +useful member to society, and the enrichment of the +science whereby other similar liberations may become +possible. But how few investigators, as yet, have been +attracted by this tremendous unfilled field of knowledge!</p> + +<p>However, our philistine, while agreeing to this, may, +and often does, change his ground. He may add: +“When I said that the phenomena were not real I had +in mind rather the pains and the paralyses from which +the hysteric and neurasthenic suffer—or say they suffer.” +To this we may answer in the words of Dr. Purves +Stewart:—</p> + +<div class="blockquot fs90"> + +<p>“... we must recognise that the neuroses are real diseases, +as real as small-pox or cancer. A sharp distinction must be +drawn between a hysterical or neurasthenic patient and a +person who is deliberately shamming or malingering....<span class="pagenum" id="Page_96">[Pg 96]</span> +The hysterical or neurasthenic patient usually has no knowledge +of the disease which he or she may unconsciously simulate. +The various paralyses and pains from which hysterics and +neurasthenics suffer are as real to the patient as if they were +due to gross organic disease.”<a id="FNanchor_66" href="#Footnote_66" class="fnanchor">[66]</a></p> +</div> + +<p>There is a view which, while eminently useful and +sensible in so far as it concerns neurology alone, +is apt, by virtue of these good qualities, to retard the +progress of psychical treatment of the neuroses. For it +tends to focus the attention of the medical world on +their physical basis alone. Such a view is expressed by +Dr. Purves Stewart in the manual from which we have +just quoted. In his chapter on the neuroses he says:—</p> + +<div class="blockquot fs90"> + +<p>“The old definition of a neurosis as a nervous disease devoid +of anatomical changes is inadequate. <em>Disease is inconceivable +without some underlying physical basis.</em><a id="FNanchor_67" href="#Footnote_67" class="fnanchor">[67]</a> The lesion need not +be visible microscopically: it may be molecular or bio-chemical.”<a id="FNanchor_68" href="#Footnote_68" class="fnanchor">[68]</a></p> +</div> + +<p>Now from the purely material standpoint such a +statement is above reproach. But some important reflections +occur as one thinks over the paragraph, and +especially the statement: “Disease is inconceivable without +some underlying physical basis”—as applied for +example, to neurasthenia. What are the important signs +of disease in the neurasthenic, or what unusual +phenomena are there which cause him to seek the doctor? +Chiefly, as we have seen on p. <a href="#Page_91">91</a>, the undue dominance +in his mental happenings of instinct and emotion. But +we cannot say that this by itself is a sign of disease. +Otherwise we shall arrive at the paradoxical conclusion<span class="pagenum" id="Page_97">[Pg 97]</span> +that wild animals, savages and children form the diseased +class <i lang="fr" xml:lang="fr">par excellence</i>.</p> + +<p>The behaviour of the neurasthenic differs from that +of the normal person only in degree, and some sane men +might be unhesitatingly regarded as neurasthenic by one +class of society, normal by another.<a id="FNanchor_69" href="#Footnote_69" class="fnanchor">[69]</a></p> + +<p>Moreover, it is perfectly clear that if we adopt any of +the usual views as to the relation between body and +mind, not only disease, but health too is “inconceivable +without some underlying physical basis.” Yet of the +molecular or bio-chemical aspects of that basis we know +practically nothing which would help us to understand +even ordinary mental occurrences. So when a normal, +physically healthy mother bursts into tears of joy on her +son’s return from the front, is sleepless when she knows<span class="pagenum" id="Page_98">[Pg 98]</span> +he is in the trenches, forgets some of her daily duties in +perpetually thinking of him, is “on edge” and irritable +when she has had no letter from France—though we may +be perfectly justified in believing that there are molecular +or bio-chemical nervous changes underlying her behaviour, +we do not dream of invoking these as explanations of +her condition, for of them we know little. Neither do we +call her neurasthenic. We understand her condition in that +we correctly refer it to the action of instinct and emotion. +Its cause is clear to us, and if we attempted to treat it we +should know beforehand that the best cure would be the +restoration of her loved one, the next best, sympathetic +help in facing her worries, the removal of unfounded fears +and the production of a serener outlook on the future. +In other words, the diagnosis, the tracing of causes, and +the treatment would be entirely mental, with no reference +whatever to the physical basis, the existence of which +we obviously should not deny. Similarly, if a man is +troubled by a great moral conflict which produces in him +sleeplessness, irritability, abstraction and the rest, the +physical basis of his emotional condition may be +“materially” treated. His sleeplessness may be reduced +by bromides, his irritability and depression by alcohol; +but who, if he knew of the great mental conflict, would +dare merely to prescribe these?</p> + +<p>And this, in the case of many of the psychoneuroses +is the crux of the whole matter. The root of the trouble +is mental conflict, the complete details of which can +seldom be found on the surface of the complex of +symptoms. To palliate them one by one is often to +provoke new ones. The conflict is sometimes clearly +apprehended by the patient, but even then is often +jealously guarded from everyone else. Sometimes, however, +it is not clearly conscious in all its details, even +to him. This is especially the case, if as so often +happens, he habitually shuns the thought of it. Faced<span class="pagenum" id="Page_99">[Pg 99]</span> +with an inability to adapt himself to his circumstances, +he instinctively relapses into a more childish way of +meeting the situation—hence the tears, the irritability, the +mental distraction and the rest. This phenomenon, we +repeat, is not new. We all acknowledge its existence +when we say that the “nervy patient behaves childishly,” +though perhaps we do not realise what a true conception +of the matter we are expressing.</p> + +<p>To sum up, while it is indisputable that the psychoneuroses, +like all mental phenomena, have a material +basis, we should clearly distinguish between fact and +theory in our existing knowledge. Every doctor will +naturally seek to make the fullest use of his learning +in building up the bodily health of the neurasthenic. +But to sit with folded hands and wait for the advancement +of our knowledge of microscopic anatomy, physiology +or bio-chemistry would be fatuous when there are other +and more direct means of treating the numerous and +often pathetic cases, which urgently call for cure. The +view that “disease, like health, is inconceivable without +some underlying physical basis” is sound and useful, +but must not be allowed to blind us to the vital significance +of the mental factor and its corresponding +importance in the diagnosis and treatment of “functional” +disease.</p> + +<p>It is an indisputable fact that many modern physicians +are apt to concentrate their attention almost exclusively +upon the bodily ills of their patients. Yet the majority +of doctors, especially those who in general practice get +to know their patients intimately, admit readily, even +eagerly, that not a small number of the maladies which +come under their notice are seriously complicated, if not +dominated, by mental factors. To take a simple and +obvious example, insomnia may be caused by distressing +mental conflicts quite as often as by physical disease. +The doctor, however, even if he suspects this fact, often<span class="pagenum" id="Page_100">[Pg 100]</span> +hesitates to proceed further in the light of such knowledge.</p> + +<p>For this there are several reasons. In the first place, +his arduous, lengthy and expensive medical course has +usually never vouchsafed him five minutes’ specific training +concerning the manifold ways in which human nature +may succeed or fail in adapting itself to the complex +environment which we call civilisation. Any wisdom of +this kind that he has picked up is due to his own interest +and insight in social matters. The university’s contribution +to his psychological knowledge usually consists +in showing him a handful of comparatively hopeless +caricatures of mentality in his short series of visits to +the asylum.<a id="FNanchor_70" href="#Footnote_70" class="fnanchor">[70]</a> It is as if one tried to teach electrical +engineering by a few exhibitions of broken-down dynamos, +navigation by half-a-dozen cursory inspections of wrecks, +finance by a short series of visits to the bankruptcy +courts.</p> + +<p>The result of this strange conception of medical +education is different according to the mental make-up +of the particular physician. There are many whose +insight and sympathy enable them to penetrate successfully +for some distance into the Cimmerian darkness of +the patient’s mental troubles. But do we believe that +insight and sympathy alone are sufficient for the successful +diagnosis of disorder or disease of the heart or lungs? +Mental disorder is subtler, more varied than these, but +like them it proceeds along definite lines in definite +situations, and it is capable of description even as they +are. It is therefore insufficient even for the talented +doctor to rely entirely upon his natural gifts. But in what +other branch of science would it enter his head to do +so?</p> + +<p><span class="pagenum" id="Page_101">[Pg 101]</span></p> + +<p>But not all doctors happen to be of the type we have +described. There exist many excellent practitioners who +are temperamentally so constituted that to them these +unaided excursions into the investigation of mental +trouble would never suggest themselves. Predominantly +objectively-minded,<a id="FNanchor_71" href="#Footnote_71" class="fnanchor">[71]</a> “without a nerve in their bodies,” +calm and confident, practical and quick to apply their +knowledge in the physical sphere, they have no natural +inclination towards the study of such disorders as we +have mentioned; and their teachers have too seldom +done anything to supplement the exclusively materialistic +studies<a id="FNanchor_72" href="#Footnote_72" class="fnanchor">[72]</a> of their medical course. When, as not seldom +happens, he is faced by a case of hysteria or neurasthenia, +such a practitioner is inclined to regard +the malady, if it does not prove tractable by rest, +change, drugs and diet, massage, electricity, etc., either +as “fanciful” and requiring firmness unveiled or +veiled,<a id="FNanchor_73" href="#Footnote_73" class="fnanchor">[73]</a> or as the beginning of a lamentable and grave +attack of mental disorder. Unfortunately the number of +cases yielding to firmness is not gratifyingly large. The +hysterical patient, too, has a will of his own, and frequently +proves this fact in a disconcerting manner. The +neurasthenic, knowing long before the doctor tells him, +that he ought not to worry, that he ought to “buck up,”<span class="pagenum" id="Page_102">[Pg 102]</span> +frequently becomes acutely critical of his physician, and +his powers of judgment are all the keener for their +frequent whetting upon his own deficiencies. Not that +he should not worry, but <em>why and how</em> he should not +worry is what he wants to know.</p> + +<p>This criticism of the brusque, cheery way in which +such a physician may treat mental troubles is not meant to +be one-sided or unfair. For some patients, the “firmness” +treatment is the right one; others may be so +impressed by the doctor’s cheery personality that they +recover. But it is safe to say that these are seldom +serious cases. The intelligent, highly moral, over-worked +business man must not be given the same treatment as +the society lady suffering from lack of honest labour—and +nobody knows this better than the patient.</p> + +<p>This objective way of regarding cases of neurasthenia +readily tends on the one hand to make the physician +underrate their importance (as when he expects to cure +them with “firmness”) and on the other, when they +prove impregnable to such attacks, to cause him to +exaggerate their seriousness. For, he may argue to himself, +if they are beyond cure in this way, what is to be +the future of the patients except permanent eccentricity +or even insanity? Only a deeper knowledge of the +subject can save him from this top-heavy oscillation +from unfounded optimism to equally baseless pessimism.</p> + +<p>We have noted two of the common obstacles which +obstruct the path of the physician anxious to treat +mental disorder: his own lack of training and, in not a +few cases, his temperamental inclination to look exclusively +for visible and tangible material evidence of disease. +There is, moreover, at present another serious obstacle +consisting in a widespread social convention. This is +the unwritten law which commands a person to hide any +troubles of a mental nature not only from his friends, +but even from his doctor, though he may speak of his<span class="pagenum" id="Page_103">[Pg 103]</span> +physical disabilities to everybody with unblushing frankness. +Much could be written on this subject, but the +inconsistency of the current attitude has been satirised +with inimitable wit and humour by Samuel Butler.</p> + +<p>His whimsical fancy has created a civilised country +in which this convention does not exist; in which, in +fact, the opposite belief obtains. In that land, while a +man’s bodily ills are counted a disgrace, and not to be +mentioned, his mental troubles are regarded as physical +illness is with us. The name of that country is <em>Erewhon</em>. +In <em>Erewhon</em>, we are told, physical illness is not only +considered shameful but is punishable by imprisonment. +Mental trouble, on the other hand, even irritability or +bad temper, is regarded as illness requiring the attention +of physicians, known as “straighteners.” And the consequences +of this are that a man will dissimulate the +existence of indigestion, giving out that he is being +treated for dipsomania, while in answer to questions +about his general condition another will quite freely and +truthfully say that he is suffering from snappishness. +We in England, says the explorer,</p> + +<div class="blockquot fs90"> + +<p class="no-indent">“never shrink from telling a doctor what is the matter with +us merely through the fear that he will hurt us. We let him +do his worst upon us and stand it without a murmur, because +we are not scouted for being ill, and because we know that +the doctor is doing his best to cure us and that he can judge +our case better than we can; but we should conceal all illness +if we were treated as the Erewhonians are when they have anything +the matter with them; we should do the same as with +moral and intellectual diseases—we should feign health with +the most consummate art till we were found out....”</p> +</div> + +<p>This convention inevitably influences the “straightener’s” +attitude towards his patients, as we are told by +the traveller in a description of an interview between his +host and an Erewhonian doctor:—</p> + +<div class="blockquot fs90"> + +<p>“I was struck with the delicacy with which he avoided even +the remotest semblance of inquiry after the physical well-being<span class="pagenum" id="Page_104">[Pg 104]</span> +of his patient, though there was a certain yellowness about my +host’s eyes which argued a bilious habit of body. To have +taken notice of this would have been a gross breach of professional +etiquette. I was told, however, that a straightener +sometimes thinks it right to glance at the possibility of some +slight physical disorder if he finds it important in order to +assist him in his diagnosis; but the answers which he gets +are generally untrue or evasive, and he forms his own conclusions +upon the matter as well as he can. Sensible men have +been known to say that the straightener should in strict confidence +be told of every physical ailment that is likely to bear +upon the case, but people are naturally shy of doing this, for +they do not like lowering themselves in the opinion of the +straightener, and his ignorance of medical science is supreme. +I heard of one lady, indeed, who had the hardihood to confess +that a furious outbreak of ill-humour and extravagant fancies +for which she was seeking advice was possibly the result of +indisposition. ‘You should resist that,’ said the straightener, +in a kind, yet grave voice, ‘we can do nothing for the bodies +of our patients; such matters are beyond our province, and +I desire that I may hear no further particulars.’ The lady +burst into tears and promised faithfully that she would never +be unwell again.”</p> +</div> +<br> + +<div class="footnotes"><h3>FOOTNOTES:</h3> + +<div class="footnote"> + +<p><a id="Footnote_50" href="#FNanchor_50" class="label">[50]</a> Hart, <em>op. cit.</em>, p. 7.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_51" href="#FNanchor_51" class="label">[51]</a> <em>Cf.</em> Dr. Bedford Pierce’s statement, (<em>op. cit.</em>, p. 43), “I have +met persons otherwise level-headed who cannot be persuaded +to enter the grounds of an asylum. Not infrequently all sorts +of excuses are made to escape the duty of visiting a relative +who is under care, and so real is the danger of neglect that +the State has decreed that no order for reception shall be +granted without an undertaking that the patient shall be +visited at least every six months.”</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_52" href="#FNanchor_52" class="label">[52]</a> p. 5. The italics are ours.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_53" href="#FNanchor_53" class="label">[53]</a> pp. 77 and 78.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_54" href="#FNanchor_54" class="label">[54]</a> We have in mind throughout the discussion, not the richer +members of the community, for whom a relatively expensive +holiday or period spent in the nursing home is easily possible, +but the great majority of the public, to whom even the +ordinary doctor’s bill may be a source of financial embarrassment +for months or years.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_55" href="#FNanchor_55" class="label">[55]</a> R. G. Rows, <cite>Journal of Mental Science</cite>, January, 1912.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_56" href="#FNanchor_56" class="label">[56]</a> pp. 77 and 78.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_57" href="#FNanchor_57" class="label">[57]</a> <cite>Analytic Psychology</cite>, London, 1916, p. 318.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_58" href="#FNanchor_58" class="label">[58]</a> “Everybody agrees,” say Déjerine and Gauckler (<em>op. cit.</em>, p. +214<em>f</em>), “that neurasthenia is a neurosis, <em>i.e.</em>, a nervous disease +without any known lesions.... Neurasthenia is due wholly to +psychological factors which are essentially, if not exclusively +determined by emotion.” They then proceed to compare the +“materialistic” theories of neurasthenia, showing that they are +all still merely speculative.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_59" href="#FNanchor_59" class="label">[59]</a> <em>Cf.</em> pp. 19 <em>et seq.</em></p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_60" href="#FNanchor_60" class="label">[60]</a> <em>Cf.</em> Déjerine and Gauckler, <em>op. cit.</em>, p. 214<em>f.</em></p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_61" href="#FNanchor_61" class="label">[61]</a> As Professor Kraepelin says, “Nervenkranker sind Geisteskranker” +(“Those ‘suffering from nerves’ are <em>sick in +spirit</em>.”).</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_62" href="#FNanchor_62" class="label">[62]</a> The reader should consult Mr. W. McDougall’s excellent +treatment of this subject in his <cite>Introduction to Social +Psychology</cite>—especially pp. 45-89.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_63" href="#FNanchor_63" class="label">[63]</a> The remarks of Mr. George Bernard Shaw on Max Nordau’s +“Degeneration” (<cite>The Sanity of Art</cite>, especially p. 88) +might be consulted in this connection.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_64" href="#FNanchor_64" class="label">[64]</a> <em>Cf.</em> E. Régis, “Les Troubles Psychiques et Neuro-Psychiques +de la Guerre,” <cite>Presse Médicale</cite>, 23, p. 177, May 27th, +1915.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_65" href="#FNanchor_65" class="label">[65]</a> This term is derived from the Greek word for the womb. +Hysteria was once thought to be due to the wanderings of the +uterus about the body. The term well deserves its place beside +that other ornament of psychological medicine—the word +“lunacy.”</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_66" href="#FNanchor_66" class="label">[66]</a> <cite>The Diagnosis of Nervous Diseases</cite>, 3rd Edition, London, +1911, p. 355.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_67" href="#FNanchor_67" class="label">[67]</a> Italics ours.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_68" href="#FNanchor_68" class="label">[68]</a> p. 355.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_69" href="#FNanchor_69" class="label">[69]</a> This was seen repeatedly in the treatment of the relatively +uneducated soldiers who had become slightly neurasthenic as a +result of the war, especially of those whose life had been spent in +open-air manual work, or in the strict and healthy routine of +the regular army. They complained of emotional irritability, +minor lapses of memory such as the forgetting of relatively +unimportant names or of errands, disturbed sleep, soon +“getting fed up” with their amusements (<em>e.g.</em>, “jig-saws,” or +billiards for hours every day, month after month in a converted +schoolroom or outhouse!). Not only did these phenomena +disturb them, but in a great many cases they seemed to prove +to these unfortunate men that they were insane, or rapidly +becoming so. They would anxiously ask such questions as, +“What is it that makes me so irritable at a slight noise, or +at being brushed against by another patient? I used not to +be like that.” Their conduct was also regarded as unusual by +their companions. Now would not the head of a business firm, +an over-worked medical man, a university professor or an army +officer in a position of responsibility, confidently expect to be +allowed <i lang="la" xml:lang="la">ex-officio</i> a certain number of these eccentricities without +being called “diseased?” But let him drop the privileges +and shelter of his rank, live for a few weeks as a private in +a barracks with a number of high-spirited and thoroughly +healthy soldiers and his behaviour might certainly be considered +by them to be queer, if nothing worse.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_70" href="#FNanchor_70" class="label">[70]</a> Reform of this state of affairs is urgently needed. The +matter is of such fundamental and far-reaching importance that +we have devoted part of the next chapter to the further consideration +of its bearings.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_71" href="#FNanchor_71" class="label">[71]</a> “Tough-minded,” “matter-mongers,” modern writers have +called this type, contrasting it with that of the “tender-minded,” +“reason-mongers.”</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_72" href="#FNanchor_72" class="label">[72]</a> Of a brilliant teacher of physiology, one who was himself +intensely interested in the sciences bordering on his own +subject, it was related that when, in lecturing upon the +functions of the nervous system in man, he approached difficult +problems, he used to say, “But that is a matter for the +psychologist.” Whereupon the class heaved a sigh of relief and +prepared to take notes upon the next subject.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_73" href="#FNanchor_73" class="label">[73]</a> “... strong electric shocks, cold douches, and other decorous +substitutes for a sound birching.” W. McDougall, <cite>Psychology</cite>, +London, 1912.</p> + +</div> +</div> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> + +<p><span class="pagenum" id="Page_105">[Pg 105]</span></p> +<h2 class="nobreak" id="CHAPTER_V">CHAPTER V.<br> +<span class="fs120">Some Lessons of the War.</span></h2> +</div> + +<p class="drop-cap"><span class="upper-case">Are</span> we, as a nation, doing all that we should for +the mentally afflicted? This is the question—no +less urgent and important now than it was a +century ago—to which we call the serious attention of +the reader.</p> + +<p>It is no new discovery to recognise the immediate +importance of its proper consideration, of the honest +facing of the present conditions, and of the urgency for +such reform as shall lead to an affirmative answer to our +question. Already it has been the subject of considerable +discussion in recent medical literature, and in the medical +press numerous efforts have been made to bring it to +the attention of the general public. In July, 1914, the +Medico-Psychological Association of Great Britain and +Ireland, a body composed chiefly of the medical officers +of our asylums, issued the report of a special committee +which had been appointed, in November, 1911, to consider +the “status of Psychiatry as a profession in Great +Britain and Ireland, and the reforms necessary in the +education and conditions of service of assistant medical +officers.” Unfortunately, within a few weeks of its +publication, the outbreak of war prevented that discussion +of the question which would otherwise assuredly have +followed the publication of so momentous a statement. For +in the report stress was laid on the “absence of proper<span class="pagenum" id="Page_106">[Pg 106]</span> +provision for the early treatment of incipient and undeveloped +cases of mental disorder,” on the lack of +adequate “facilities for the study of psychiatry and for +research” and upon “the unsatisfactory position of assistant +medical officers” in the asylum service. Clearly +the stressing of such points by a committee, thoroughly +competent to form a judgment in such matters, compels +a negative answer to our leading question. The report +makes it perfectly clear that this country has grievously +lagged behind most of the civilised nations in the treatment +of mental disease.</p> + +<p>Yet all attempts in the way of important and far-reaching +reform have been frustrated, at least during +times of peace, by a strange state of indifference and +inertia and by lack of knowledge. Thus, even so recently +as January 15th, 1916, the <cite>British Medical Journal</cite> was +responsible for the statement “The only hope that our +present knowledge of insanity permits us to entertain of +appreciably diminishing the number of ‘first attacks’ +lies in diminishing habitual and long enduring drunkenness +and in diminishing the incidence of syphilis.”<a id="FNanchor_74" href="#Footnote_74" class="fnanchor">[74]</a> +This statement would have been sufficiently amazing if +it had been made three years ago; but when the hospitals +of Europe contain thousands of “first attacks” of insanity, +which are definitely <em>not</em> due either to alcohol or syphilis, +the only conclusion to be drawn is that its author must +have been asleep since July, 1914, or have become so +obsessed by a fixed idea as to be unable to see the +plain lessons of the war. Syphilis, no doubt, is responsible +for a considerable number of cases of insanity, and +drink perhaps for some more<a id="FNanchor_75" href="#Footnote_75" class="fnanchor">[75]</a>; but the incipient forms<span class="pagenum" id="Page_107">[Pg 107]</span> +of mental disturbance which the anxieties and worries of +warfare are causing ought to impress even the least +thoughtful members of the community with the fact +that similar causes are operative in peace as well as in +war, and are responsible for a very large proportion of +the cases of insanity. But—and this is still more important—it +is precisely these cases which can be cured if +diagnosed in their early stages, and treated properly. +The chief hope of reducing the number of patients in the +asylums for the insane lies in the recognition of this +fact, and in acting on it by providing institutions where +such incipient cases of mental disturbance can be treated +rationally, and so saved from the fate of being sent into +an asylum. We may refer the reader to p. <a href="#Page_82">82</a> <em>et seq.</em>, on +which was given a short account of the success of these +reforms. We reiterate some of the advantages of the +clinic system—treatment of the patient without the +necessity of the ordinary asylum associations and the +consequent social stigma; and the considerable reduction +in the number of patients requiring internment in +asylums which has followed upon the establishment of +the psychiatric clinic.</p> + +<p>In this country insuperable obstacles in the way of this +urgent reform have been raised by our distinctive national +obstinacy, and our blind devotion to such catch-phrases +as “the liberty of the subject,”—even when this involves +the eventual incarceration of the patient whose liberty +to escape treatment and to become insane, is the issue +jealously defended. Now, however, the stress of war has +compelled us to see matters in another light. The present +war, which has been responsible for destroying so many illusions, +has worked many wonders in the domain of medicine.</p> + +<p><span class="pagenum" id="Page_108">[Pg 108]</span></p> + +<p>The rational and humane treatment of early cases of +mental disturbance has now been inaugurated on precisely +those lines which have been so long urged, with such +little success, by the more far-seeing members of the +medical profession.<a id="FNanchor_76" href="#Footnote_76" class="fnanchor">[76]</a></p> + +<p>A good example of this reform is the splendid work +now being carried out, at the Maghull Military Hospitals, +near Liverpool, for officers and men, organised and +superintended by Major R. G. Rows. The institutions +are specially devoted to the treatment of soldiers suffering +from “shock” and other psychoses. The success +already achieved there is sufficient evidence of the great +value of these special hospitals for the treatment of +nervous and mental disorders in their early stages.</p> + +<p>But if the lessons of the war are to be truly beneficial, +much more extensive application must be made of these +methods, <em>not only for our soldiers now, but also for +our civilian population for all time</em>. We have before +us the practical experience of those countries which have +undertaken this great experiment in preventive medicine, +yet apart from the encouraging results of its treatment +practised in our special military hospitals, its present +position in this country is only too accurately described +in the report to which we have referred. With few +exceptions<a id="FNanchor_77" href="#Footnote_77" class="fnanchor">[77]</a> “the subject (of mental disease) is left severely +alone.”<a id="FNanchor_78" href="#Footnote_78" class="fnanchor">[78]</a> Our arm-chair writers direct their attention to +safer subjects, such as eugenics, for example, and here +they can be happy in feeling they are on secure ground,<span class="pagenum" id="Page_109">[Pg 109]</span> +because they are aware that their neighbour knows +little more about it than they do. Or they inspire +reports, and I quote a sentence from a recent report +as a contrast to the encouraging sound of the word +‘recovering.’<a id="FNanchor_79" href="#Footnote_79" class="fnanchor">[79]</a></p> + +<div class="blockquot fs90"> + +<p>In the <cite>Standard</cite> newspaper a few days ago, (<em>i.e.</em>, in 1914) +there was a reference to a report issued by the London County +Council in which one paragraph began with the statement, +‘Once a lunatic, always a lunatic.’ This is the message sent +in this country to our sufferers, a message as brutal as it is +unjustifiable. Again, in the <cite>Standard</cite> of February 11th in +the year of grace 1913, there appeared the statement that +‘the Camberwell Guardians have issued instructions that the +use of “anklets” on violent lunatics in their institutions is +to be discontinued.’</p> +</div> + +<p>With reference to the dictum “Once a lunatic always +a lunatic” we should like to call attention to another +statement in this report. “The fact that, <em>even under +the present conditions of delayed treatment, about +33 per cent. of those admitted to the asylums of +England and Wales are discharged recovered</em>, demonstrates +that the feelings of helplessness and hopelessness, +with which such illnesses are usually regarded, are +by no means justified. The evidence of many authorities +who have had practical experience of the value of +treatment during the incipient stages of the illness, shows +conclusively that the exercise of scientific care during +the early phases of mental disorder would save many +from such a complete breakdown as would necessitate +certification and removal to an asylum. In all other +branches of medicine facilities for dealing with disease +in its initial stages are recognised as indispensable and<span class="pagenum" id="Page_110">[Pg 110]</span> +therefore the Committee regard it as essential that, in the +large centres of population at any rate, means should be +provided to obviate the delay that now exists in providing +adequate treatment for mental disorders. It is, therefore, +recommended that psychiatric clinics should be +established.”<a id="FNanchor_80" href="#Footnote_80" class="fnanchor">[80]</a></p> + +<p>Again, at the International Congress of Medicine in +London, in August, 1913, an important discussion of +these problems was introduced by an account of the +Henry Phipps Psychiatric Clinic which has been established +in Baltimore for the treatment of mental disorders, +and for teaching and research in this subject. In the +course of the discussion special emphasis was laid upon +“the necessity for <em>teaching the medical profession and +the public</em> that many mental disorders are absolutely +recoverable, that good hospital and scientific treatment +save many, that the mere economy of our monster institutions +represents a sham economy paid for by the patients +and their families, and that psychiatry must extend +beyond the asylums.”<a id="FNanchor_81" href="#Footnote_81" class="fnanchor">[81]</a></p> + +<p>Emphasis was also laid upon the importance of making +these hospitals, for the care and cure of those suffering +from mental illness, centres for scientific education and +research and for the development of prophylactic +measures. For, unless medical students are provided +with facilities for the study of these early cases the +present deplorable condition of affairs will be perpetuated. +All honest medical work is essentially research; for every +individual patient presents problems which need investigation; +and facilities should be provided for making +such enquiries under the most favourable conditions. As +Dr. Flexner has well said,<a id="FNanchor_82" href="#Footnote_82" class="fnanchor">[82]</a> it is impossible “to develop<span class="pagenum" id="Page_111">[Pg 111]</span> +two types of physician, one to find things out, the other +to apply what has been ascertained. For the same +kind of intelligence, the same sorts of observation, +knowledge and reasoning power are needed for the +application as for the discovery of effective therapeutic +procedure.”</p> + +<p>This last consideration leads us to the examination of +another potent factor in the present situation, <em>viz.</em>:—</p> + +<p><em>The Attitude of the Medical Profession.</em> When it is +remembered that mental factors play an important rôle +in the causation and continuance not only of obviously +mental disorder but also of bodily troubles, and that +therefore successful diagnosis and treatment must +inevitably take these factors into account, it may seem +remarkable that the medical profession as a whole should +take so little interest in, and know so little of psychology. +Even when the psychological aspect of their problems +becomes the outstanding element in diagnosis and treatment, +the vast majority of medical practitioners show little +or no inclination to satisfy their scientific curiosity and to +endeavour to understand the condition of their patients.</p> + +<p>But this attitude becomes more comprehensible, and in +a certain measure more excusable, when we look into the +courses of instruction provided for students in our medical +schools. What training in psychiatry—to say nothing of +psychology and psychopathology—have they received in +the schools? How many hours have been spent in +lectures or demonstrations upon mental diseases? And +how has this modicum of time been spent? How many +hours are devoted to actual <em>personal investigation</em> of +patients suffering from early mental disorder? All the +instruction in such matters that our students get at +present in most of the medical schools is given in a few +hours during one term, when they visit an asylum where +demonstrations are given of <em>advanced</em> cases of mental +disease: “melancholia,” “mania,” “dementia,” etc.</p> + +<p><span class="pagenum" id="Page_112">[Pg 112]</span></p> + +<p>Lest we may be accused of wild statements, let us +quote again from the Medico-Psychological Association’s +report. (The italics are ours.):—</p> + +<div class="blockquot fs90"> + +<p>“... the attention given to mental diseases before qualification +is much less than that given in many other countries. +Owing to the absence of clinics, the medical student <em>has no +opportunity of observing borderland or undeveloped cases</em>.” +(p. <a href="#Page_6">6</a>.)</p> + +<p>“To this absence of teaching facilities is due the lack of +knowledge of the general practitioner, who should be competent +to recognise, and possibly to deal with, some of the +earliest symptoms; <em>to this we owe the lack of real equipment +in those who enter the lunacy service</em>.” (p. <a href="#Page_21">21</a>.)</p> +</div> + +<p>In this connection it is interesting to quote from a +comparatively recent report on medical education. Four +years ago the Carnegie Foundation for the Advancement +of Teaching published a report on “Medical +Education in Europe.” This work was remarkable both +for its perspicacity and thoroughness and for the frankness +and detachment with which its author, Dr. Abraham +Flexner, expressed the opinions he had formed after a +detailed study of the medical schools of this country +and on the Continent. This valuable and important +document was barely noticed by the medical press in this +country. But this is not the place for a discussion of the +psychology of this conspiracy of silence. For it certainly +does not imply any reflection upon the impartiality or the +thoroughness of Dr. Flexner’s research; on the contrary, +it is a silent tribute to the seriousness of the exposure +of the weaknesses of our medical schools. But the report +is also a most valuable appreciation of the strength of +our methods of medical education. It provides a minute +analysis and comparison of the methods of teaching +clinical medicine in Great Britain and on the Continent. +The summary clearly defines the distinctive merits of +the British system, and has such an important bearing<span class="pagenum" id="Page_113">[Pg 113]</span> +upon the questions we are considering in this book that +we will quote its most essential paragraph.</p> + +<div class="blockquot fs90"> + +<p>“The limitations by which medical education in Great +Britain is hampered have now been candidly exposed. It is +nevertheless true that in respect to the student, nowhere else +in the world are conditions so favourable. In our discussion +of Germany we pointed out that its clinical instruction was +overwhelmingly demonstrative; that the student <em>saw</em> and +<em>heard</em> but almost never <em>did</em>. Clinical education in England +has completely avoided this wasteful error. It is primarily +practical. It makes, indeed, the huge mistake of assuming +that a more scientific attitude towards the problems of disease +is in some occult way hostile to practicality; for it protests +against the adoption of modern methods of investigation, as +though practical teaching would be in some inexplicable fashion +endangered thereby. However, that may be, the English are +indubitably correct in holding that sound medical training +requires free contact of the student with the actual manifestations +of disease. It is the merit of English and, as we shall +also perceive, of French medical education that the student +learns the principles of medicine concurrently with the upbuilding +of a veritable sense-experience in the wards, and that +he acquires the art of medicine by increasingly intimate and +responsible participation in the ministrations of physician and +surgeon. The great contribution of England and France to +medical education is their unanswerable demonstration of the +entire feasibility of the method of instruction which the end +sought itself imposes.”<a id="FNanchor_83" href="#Footnote_83" class="fnanchor">[83]</a></p> +</div> + +<p>We have quoted at length this vivid and accurate portrayal +of the distinctive feature of British methods of +clinical instruction in order to emphasise the fact that in +the teaching of psychological medicine the British utterly +neglect this excellent method of instruction which Dr. +Flexner considered so admirable a feature of our +medical schools. The British method of teaching +psychological medicine, so far as the subject is taught +at all,<a id="FNanchor_84" href="#Footnote_84" class="fnanchor">[84]</a> is that of class-demonstration, but, as we have<span class="pagenum" id="Page_114">[Pg 114]</span> +seen, the avoidance of exclusive reliance upon this method +is the feature on which Dr. Flexner congratulates the +British schools. On the other hand, while the Germans are +criticised for their adherence to the class-demonstration, +it should be remembered that, although this source of +weakness appears in their undergraduate classes, it is they +and not we who provide facilities, in their clinics, to the +post-graduate student for free contact with patients in +incipient stages of mental illness.</p> + +<p>Therefore we have neglected to apply, in the case of +mental diseases, the very methods which in all other +branches of medicine have been so conspicuously +successful as to be selected by an impartial critic as the +distinctive merit of British medical training.</p> + +<p>We have indicated briefly the type of instruction in +psychiatry obtaining in our medical schools at present. +Its educational value is certainly very slight; and—what +is worse—it serves to give the future doctor a hopeless +outlook on insanity. For the instruction of students in +the nature and treatment of tuberculosis we do not send +them to some sanatorium to gaze upon patients dying +from the disease. They personally examine patients in +the early stages and learn to recognise the subtler +manifestations of the onset of the tubercular attack, when +there is some hope of giving useful advice and saving +the sufferer. Why cannot mental disease be dealt with +in the same way? Why cannot our students be afforded, +in general hospitals, the opportunity of personally examining +patients in the incipient stages of mental disturbance? +They would then not only acquire a knowledge of the +real nature of insanity, but would also learn, in the school +of experience, the individual differences which are exhibited +in the working of the normal mind, a lesson<span class="pagenum" id="Page_115">[Pg 115]</span> +which would be of the utmost value to them in dealing +with <em>all</em> their patients, whether their ailments be bodily +or mental. But in addition such a training would impress +on them, in a way that nothing else could do, the vitally +important fact that mental disease is curable, and is not +the hopeless trouble which is likely to be suggested by +the spectacle of a few asylum patients in advanced stages +of lunacy.</p> + +<p>Even, however, if the asylums afforded better facilities +for the proper study of mental disease than unfortunately +is the case in most institutions in this country, they are +usually not sufficiently near the medical schools to permit +the student properly to acquire his knowledge, as he does +of other diseases, by frequent and regular attendance +for a considerable period of time. Nor, as yet, have +many of the medical officers in our asylums sufficient +up-to-date knowledge of psychiatry to enable them usefully +to co-operate with the medical schools and the +teaching staffs of the general hospitals in achieving the +desired aim. We know that there are some exceptions +to this general statement, and fortunately they are +becoming more numerous. But viewing the condition of +affairs in the country as a whole, in respect of this +important matter, one can only accurately describe it as +deplorable. These are hard words, and we are well +aware that their use may expose us to the charge of +superficial, uninformed and even spiteful criticism. Let +us, therefore, turn to the gratifyingly frank and honest +statements of the asylum workers themselves, embodied +in the report from which we have quoted.</p> + +<div class="blockquot fs90"> + +<p>“<em>The tendency of routine to kill enthusiasm and destroy +medical interests.</em></p> + +<p>The promotion or advancement of a medical officer depends +so little upon his knowledge of psychiatry that he has no +inducement for that reason to devote himself to an earnest +study of the subject. His work is apt to begin and end with<span class="pagenum" id="Page_116">[Pg 116]</span> +the discharge of essential routine duties to the exclusion of +careful clinical and scientific investigation.</p> + +<p>The work assigned to junior medical officers is, in the +majority of cases, monotonous, uninteresting and without +adequate responsibility. For those whose personal enthusiasm +keeps alive in them the desire to extend their knowledge, such +opportunities as that of study-leave are rarely afforded them. +The existing system, therefore, leads to the stunting of ambition +and a gradual loss of interest in scientific medicine. It +tends, therefore, to produce a deteriorating effect upon those +who remain long in the service.”<a id="FNanchor_85" href="#Footnote_85" class="fnanchor">[85]</a> (pp. <a href="#Page_8">8</a> and <a href="#Page_9">9</a>.)</p> +</div> + + +<p class="no-indent"><em>Methods of Making Appointments.</em></p> + +<div class="blockquot fs90"> + +<p>“Appointments are made by lay committees, which, though +they are generally wishful to appoint the best candidate, are +in most cases without expert advice, and without adequate +knowledge of the factors involved. The results are, therefore, +generally haphazard in character, often dependent upon +influence or personal consideration, as they frequently bear out +little relation to the actual claims and qualifications of the +candidate.” (p. <a href="#Page_7">7</a>.)</p> +</div> + +<p>We submit then, that our expression of opinion is but +a paraphrase of the authorised report. The study +of this publication as a whole will only deepen this impression +in the reader.</p> + +<p>In the foregoing paragraphs we have pointed out the +vital importance of research in relation to mental disease. +All properly conducted clinical work is of the nature of +original investigation; and in the examination of patients +suffering from mental disturbance this is particularly +the case. But a vast amount of research work must be<span class="pagenum" id="Page_117">[Pg 117]</span> +carried out in properly equipped hospitals and laboratories +if we are to deal with the problems of lunacy in the same +efficient manner as we have learnt to treat tuberculosis. +In this connection it is important to emphasise the lack +of an adequate knowledge of normal psychology +among many of the medical officers and the absence of +psycho-pathological research in so many of our asylums.</p> + +<p>It must not, however, be inferred that the only reform +needed is an increase and improvement of the <em>mental</em> +treatment of mental disease. It is not merely the psychological +side that is neglected. The most depressing +aspect of the present state of affairs <em>is the comparative +absence of all research</em>. Investigations into the material +basis of mental disease, while certainly more numerous +than psychological investigations, are at present few in +number. Hosts of problems concerned with the nervous +system are awaiting investigation, and the admirable +results obtained by the small band of energetic workers +in our country serve to show how sadly our nation is +neglecting its golden opportunities for accomplishing +much more in this respect. Important problems in connection +with the normal and morbid anatomy of the +nervous system, its pathology and its bio-chemistry, +suggest themselves to the worker at every step. The +physiological and psychological effects of different diets, +of drugs like the hypnotics, <em>et cetera</em>, how little we know +of them! Are we to rest content in leaving this vast +unknown land to be charted by other nations?</p> + +<p>Original research is thus urgently needed in all those +departments which should be included in asylum work. +But it is also necessary for the researches to be co-ordinated. +Not a few individual doctors in our asylums, +usually members of the junior staffs, are endeavouring +to carry on original investigations; but in the majority +of cases the absence of any prospect of direct or +indirect personal benefit from this work damps their<span class="pagenum" id="Page_118">[Pg 118]</span> +enthusiasm, if it does not make such work wholly impossible. +And, of course, without the willing co-operation +of the asylum authorities co-ordinated researches cannot +be carried out.</p> + +<p>We shall again quote from the report of the Medico-Psychological +Association in justification of our statement:—</p> + +<div class="blockquot fs90"> + +<p>“Research is largely dependent on individual enthusiasm, +but can certainly be stimulated and maintained by the co-operation +of the senior medical staff. There is reason to fear +that such work is undertaken in some quarters without any +guidance or encouragement from seniors, and laborious original +investigations have received little or no recognition from those +in authority.... Although there is no uniformity of +practice, report is made that in many asylums junior medical +officers are placed in charge of chronic cases only, and have +no duties in reference to the treatment of newly-admitted cases. +This appears to be most undesirable. Junior medical officers, +in addition to their statutory routine duties, should be given +the opportunity of co-operation with their senior colleagues +in clinical work. Consultation between the various members +of the medical staff in doubtful and interesting cases is very +desirable....” (p. <a href="#Page_30">30</a>.)</p> +</div> + +<p>If the reader will pause for a moment, and in imagination +put himself in the position of a junior medical +officer, “<em>placed in charge of chronic cases only</em>,” he +will not only come to understand the “stunting of +ambition and the gradual loss of interest in scientific +medicine” of which he has read, but may admire the +self-restraint of a report which can speak in temperate +language of such a state of affairs.</p> + +<p>Another difficulty that stands in the way of this +urgently needed reform in medical education is the +inadequacy of the text-books available for the student. +In many of these text-books the introductory chapters +contain some, often irrelevant,<a id="FNanchor_86" href="#Footnote_86" class="fnanchor">[86]</a> morbid anatomy, and the<span class="pagenum" id="Page_119">[Pg 119]</span> +remainder deals with “psychology.” The latter frequently +consists largely of anecdotes, often “funny” and sometimes +more appropriate to the “after-dinner” hour than +the text-book, and enumerations of the mental <em>symptoms</em> +of the cases. In practically every available English text-book +the latter are depicted only as they appear after they +have become fixed, habitual, hardened and rationalised. +Such “units” of terminology as “delusions,” or “delusions +of persecution,” “hallucinations,” etc., are freely +used. In other departments of clinical medicine the text-book +writer does not describe a patient as suffering from a +cough, and leave it at that; yet the phrase “suffering from +delusions” is the veriest commonplace in the text-books. +Yet just as a cough may be due to tuberculosis of the +lung, pharyngeal irritation, hysteria, or a variety of +utterly different causes, each class of case requiring a +different treatment, so the causes of delusions are even +more infinitely varied.</p> + +<p>But the gravest defects of these text-books is that few +of them make any attempt whatever, except in the case +of such forms of disease as have an organic cause, to +explain the <em>development</em> of the trouble, the precise +nature of the primary cause or causes and the way in +which the disturbance of the patient’s personality has +been gradually effected.</p> + +<p>Unfortunately there are serious defects in many of +the works upon general psychology which render them +almost useless to the student of psychological medicine. +This may explain, if it does not excuse, the quaint selection +of subjects, often wholly irrelevant or inappropriate, +which form the contents of the psychological section of +many English books on mental disorders. But this +deficiency is not a sufficient excuse for the neglect of +the kind of instruction that is of vital importance for +the proper understanding of such disorders. When books +such as those written by McDougall, Stout, Hart, Shand,<span class="pagenum" id="Page_120">[Pg 120]</span> +and Déjerine and Gauckler, are available, it is possible +to use the facts of normal psychology as the natural, +rational and necessary means of explaining and interpreting +departures from the normal state.</p> + +<p>We may summarise here some of the chief defects of +our national system of treating mental disorder. First +and foremost is the serious waste of time which almost +invariably occurs before the mental sufferer comes under +medical care. This is due to a variety of causes—all of +them preventable. The chief is that, lying in the path +of patients who would <em>voluntarily</em> seek help, there is the +insurmountable obstacle of the asylum system and its +restrictions. The men in the asylum service, who have +the opportunity of acquiring an intimate knowledge of +mental diseases, are <em>forbidden</em> to carry that knowledge +into the outside world for the benefit of the mental sufferer. +If a patient, suffering from a mental disorder in its +earliest and easily curable stage, should voluntarily go to +an asylum and ask for advice, all that can be done for him +is to suggest that he should consult a medical man outside, +or to recommend him to call and see the relieving officer. +Now, unless the patient has considerable means, it is +practically certain that he will be able to consult no +medical man who is conversant with—much less expert +in—the treatment of early mental disorder. And, though +the relieving officer’s intentions may be of the best, it is +just his ‘help’ and all that it means, that the unfortunate +is so desperately striving to avoid. In short, all that the +officials under our present system can say to such a man +is, “Go away and get very much worse, and then we +shall be allowed to look after you!” Can stupidity go +farther than this?</p> + +<p>Even, however, if the doctor were allowed to help +such a person in the asylum, this would be far from an +ideal solution of the difficulty. Entry into such an +institution, even if voluntary, would entail the serious<span class="pagenum" id="Page_121">[Pg 121]</span> +social stigma which has been so often mentioned. Furthermore, +the asylum, with its associations and implications, +particularly the assumption of the irresponsibility of the +patients interned in it, would destroy one of the chief +therapeutic agents in the treatment of such cases. We +mean the conviction of the patient that he is still responsible +for his actions, and that he is still able, under +direction, to cure himself.</p> + +<p>The place to which such a patient should be able to +go is obviously one which is exempt from any stigma; +one in which of his own free will he may stay for a time +under care, or if this be unnecessary, as is very frequently +the case, which he may visit at frequent intervals for +advice and treatment. It should be staffed by skilled +specialists who are familiar with the diagnosis and treatment +of <em>early</em> and <em>incipient</em> mental disorder, not only +with that of advanced insanity. For years such institutions +have existed in other countries and form an important +part of their contribution towards the alleviation of human +suffering.</p> + +<p>The chief functions of such a psychiatric clinic would +be:—</p> + +<p>(1) Attendance on the mentally sick.</p> + +<p>(2) The provision of opportunities for personal intercourse +between patients and the psychiatrists in training.</p> + +<p>(3) The theoretical and practical instruction of students.</p> + +<p>(4) Advising general practitioners and others who are +faced with difficult problems arising in their daily work.</p> + +<p>(5) To serve as a connecting link between investigation +in the large asylums and that in the anatomical, +pathological, bacteriological, bio-chemical, psychological +and other laboratories of the universities.</p> + +<p>(6) The scientific investigation of the mental and bodily +factors concerned in mental disease.</p> + +<p><span class="pagenum" id="Page_122">[Pg 122]</span></p> + +<p>(7) The furtherance of international exchange of +scientific knowledge concerning mental disorder, by the +welcome accorded to visitors from other countries.</p> + +<p>(8) The dissemination of medical views on certain +important social questions and the correction of existing +prejudices concerning insanity.</p> + +<p>(9) When necessary, the after-care of the discharged +patient.</p> + +<p>We have already given some details of the activities of +a few of the clinics abroad<a id="FNanchor_87" href="#Footnote_87" class="fnanchor">[87]</a> and have pointed out their +valuable function in saving a high percentage of patients +from the fate of an asylum, while at the same time relieving +the community of the serious expense of keeping +these patients for life as pauper lunatics.</p> + +<p>We may quote from an article by Dr. R. G. Rows<a id="FNanchor_88" href="#Footnote_88" class="fnanchor">[88]</a> +describing the psychiatric clinics at Munich and Giessen:</p> + +<div class="blockquot fs90"> + +<p>“They are carried on upon the lines of ‘freely come, freely +go,’ as far as is consistent with the safety of the patient and of +the public. In neither of these clinics is any legal document +necessary for the admission or discharge of patients. But +where the character and severity of the mental disturbance +require the longer detention of the patient in the clinic or +in an asylum, such detention can be exercised only under a +legal procedure which carefully safeguards the rights of the +patients.</p> + +<p>In this way it is possible to avoid the stigma which is +attached to certification and seclusion in an asylum. That +this is appreciated by the general public is demonstrated by +the number of people who make use of the opportunities +offered them. To the clinic at Giessen, with its seventy beds, +between three and four hundred patients were admitted in +1907. From the report of the clinic at Munich for the years +1906-7 we learn that there were 1,600 admissions in 1905 (the +first complete year after it was opened), 1,832 admissions in<span class="pagenum" id="Page_123">[Pg 123]</span> +1906, and 1,914 admissions in 1907. At the present time +admissions go on at the rate of ten or twelve per day. It +should be mentioned that at Munich the clinic is open night +and day for the reception of patients, so that they can be +brought under the care of an expert at the earliest possible +moment, and the painful impressions produced often by detention +and restraint by unskilled persons and unsuitable surroundings +are reduced to a minimum. This immediate treatment +at the hands of men experienced in insanity is a matter of +the greatest importance, from the point of view of a favourable +termination of many of these cases.</p> + +<p>Let us now consider the actual treatment of those admitted +into these institutions. What most strongly impressed us in +these clinics was the absence of noise and excitement amongst +the patients; it was certainly an ample demonstration of the +value of the means of treatment adopted. It is recognised +in the first place that patients must not be crowded together: +none of the wards contain more than ten beds.... For +the patient who is too excited to be kept in bed or who +disturbs the others too much, experience has shown that prolonged +warm baths provide the best means of quieting him +and bringing him into such a condition as will allow of his +being kept in the ward. The extent to which the bath +treatment is employed may be judged from the fact that +besides the baths used for ordinary purposes of cleanliness +there are in the clinic at Munich eighteen baths for prolonged +treatment, five movable baths, one electric, and one douche +bath. The wet pack is occasionally used. The baths are so +arranged that the patient can remain in the bath for days or +weeks as the case demands, sleep there and take his food +there. The result of the treatment is that hypnotic drugs +and confinement to a single room have come to be regarded +as evils to be used only on rare occasions; in fact, the single +rooms are occupied by convalescent and quite quiet patients +and not by recent and acute cases.</p> + +<p>Treatment on these lines will of course necessitate the employment +of a large medical and nursing staff. At Giessen, +with 70 beds and between three and four hundred admissions +a year, there are five medical officers including the director. +At Munich, with one hundred and twenty beds and three or +four thousand admissions, there are fifteen medical officers to +carry on the work of examination and supervision of the +patients. The nursing staff must be provided in the proportion +of at least one to five. This is of course a high figure, but +there are two conditions to be remembered: first, the very<span class="pagenum" id="Page_124">[Pg 124]</span> +large number of admissions dealt with, and secondly, that +these clinics are established not for the housing of the insane, +but for the care and cure of those suffering from incipient +mental disturbances—a most important distinction, and one +not yet fully appreciated in this country.</p> + +<p>Besides the patients admitted into the clinics for treatment, +a large number obtain advice and help from the out-patients’ +department.”</p> +</div> + +<p>It should be mentioned that in Germany there is a +psychiatric clinic attached to every university.</p> + +<p>Among the most important functions of a clinic are instruction +and research. Each assistant in the Munich clinic +carries on some chosen line of study. In order that he +may have better facilities for becoming acquainted with +the literature on the subject and finishing his selected +work, he is given, besides his annual month’s leave, two +months of each year for this purpose. Frequent evenings +are set apart for discussions of original work carried on +in the clinic and elsewhere. Besides this, numerous short +courses in special subjects are provided, so that it is +possible to enter the clinic for instruction in matters +requiring a special knowledge of delicate technique and +diagnosis.</p> + +<p>Of very special importance in the Munich clinic is the +course for qualified medical men. In 1907 this was +attended by <em>sixty men, of whom one third were +foreigners</em>. What can we, in Great Britain, show in +comparison with this? Our physical, chemical, physiological, +and pathological laboratories attract distinguished +foreigners from the universities of other countries, though +twenty would be a number on which even our most +celebrated laboratories would pride themselves. But how +many foreigners come to us to study insanity? Very +few indeed, and the reason is not far to seek.</p> + +<p>In the Munich clinic, again, we find well equipped +rooms for clinical examination, for the deeper investigation +of mental life by experimental psychology, for<span class="pagenum" id="Page_125">[Pg 125]</span> +the study of morbid anatomy and pathology and for the +finer examination of the blood and other fluids of the +body. Furthermore, these laboratories are not only +spacious and well-equipped, but are occupied by busy, +keen and skilled workers. Testimony to their activity +is afforded in abundance by their frequent publications.</p> + +<p>We submit, then, that the clinic system is a decided +advance in the treatment of mental disorder which other +countries have adopted while for years we have stood by +with folded hands.<a id="FNanchor_89" href="#Footnote_89" class="fnanchor">[89]</a> From the humanitarian and the +scientific point of view there is everything to be said in +favour of the clinic. The practical Englishman will, +however, ask “What about the financial aspect? Are not +these institutions, with their heavy proportion of doctors +and nurses to patients, prohibitively expensive?”</p> + +<p>The answer to this question is that certainly the clinic +is relatively more expensive than the asylum. But since +the function of the clinic is to save as many patients as +possible from entering the asylum, it is obvious that its +expense must be judged from a special standpoint. The +maintenance of a repair shop is always comparatively +costly, whether the material to be mended be human or +not. The cost per day of repairing a motor car is +usually distinctly higher than the daily charge for garaging +it in its broken-down state. Yet we gladly pay the +higher charge for the simple reasons that a motor car in +its garage is of no use to us, and that the daily charge for +housing the car would amount to a colossal figure if paid +for many years. Cannot we apply the same reasoning to<span class="pagenum" id="Page_126">[Pg 126]</span> +the case of the mentally disordered human being? This +is to take the very lowest view of the value of the +individual to the community. Yet it would seem that the +British public, so far, has been impervious even to this +financial consideration.</p> + +<p>But, it may still be asked, cannot the doctors in the +asylums carry out the work suggested? The answer to +this is, that apart from the undesirability of allowing a +patient suffering from a mild mental disorder to be +associated with an institution housing the definitely insane, +it is a physical impossibility for the asylum doctors to do +this work so long as the present proportion of doctors to +patients remains unchanged. How many members of +the British public realise the fact that it is quite usual +for an asylum doctor to be in charge of at least 400 +patients, and that this number sometimes rises to +600? When it is remembered that insane patients are +even more prone than the average person to suffer from +physical ailments, and that their mental disorders are +infinitely complicated by the delay incurred before they +come under medical care, it becomes clear that the +doctor who would succeed in treating such patients +individually would require titanic energy and the addition +of at least twenty-four more hours to each of his working +days. We cannot therefore compare the staff of a clinic +with that of a British asylum, for the staff of the latter +is lamentably and obviously too small.</p> + +<p>Regarding the financial aspect of the question we may +quote again from Dr. Rows’ article:—</p> + +<div class="blockquot fs90"> + +<p>“... we shall no doubt be met with the objection that the +provision of such institutions will involve the expenditure of +such an immense sum of money. I believe we spend in +Great Britain about £3,000,000 a year on those suffering from +various forms of mental affliction. That, certainly, is an +immense sum to spend while getting so little in return. A +large proportion of this money is spent in housing, feeding, +clothing, and taking care of the 97,000 inmates of the county<span class="pagenum" id="Page_127">[Pg 127]</span> +and borough asylums of England and Wales. We learn from +the commissioners’ report, published in 1910, that 20,000 +patients were admitted into these asylums during the previous +year, and of these, over 30 per cent. were discharged after +a longer or shorter detention. Now it may safely be said +that very few of these 20,000 fresh admissions did obtain, +or could have obtained, any advice for their mental illness at +the hands of anyone who had had experience of mental +disorders, before they reached the stage when certification and +seclusion in an asylum became necessary. When we visited +Giessen we were informed by Professor Sommer that in the +province of Hesse, by reason of suitable treatment during the +early stages of mental illness they had been enabled to postpone +for some years the erection of a new asylum in the +province. Is it not therefore fair to assume that, if facilities +were provided whereby expert advice and treatment in a well-organised +psychiatric clinic could be obtained by those +threatened with a mental breakdown, we should save enough +of the £3,000,000 to justify the expenditure involved in the +establishment of such clinics? Further benefits would be +derived from them in that we should be able to avoid the +breaking-up of the home, which now, in so many instances, +follows the removal of the bread-winner of the family to an +asylum and his long detention there.”</p> +</div> + +<p>And</p> + +<div class="blockquot fs90"> + +<p>“... it may be suggested that we should attempt to +demonstrate the possibility of saving money in order to carry +the public with us in the matter. I do not think that is +necessary. The value of treatment of the early stages of +mental disorder cannot be expressed in pounds, shillings and +pence. Moreover, I submit that our duty as medical men is +to guarantee the satisfactory treatment of the patient, and we +have no right to allow our action to be dominated by monetary +considerations. I feel sure that the more this question is +placed before the public in an intelligent manner, the more +we insist upon the necessity for early treatment and for +scientific knowledge as a basis of any treatment, the less will +the public grumble about expense. We have ourselves +to thank if the public refers so constantly to money matters. +Do we ever encourage the public to regard the question from +any other point of view? Do we point out that insanity is a +product of civilisation? Do we encourage people to regard +insanity as an illness for which something can be done and +which should be treated with intelligent and humane consideration? +Do we not rather say with the public, “Lock him up,<span class="pagenum" id="Page_128">[Pg 128]</span> +put him where he can neither harm himself nor his neighbour?” +Do we not talk of sterilising the unfortunate sufferers +and preventing marriage and procreation before we have +made an honest effort to investigate what insanity really is, +what is the mechanism of its production, and how we can +teach those so afflicted to help themselves? How then can we +expect the public to do anything but grumble at the expense? +The public has not objected to spend money in other branches +of medicine when the necessity has been demonstrated, and +there is no reason, if the members of the lunacy service in +this country will develop confidence in themselves, why they +should not be able to instil confidence into those outside the +profession.”</p> +</div> +<br> + +<p><em>Suggested Reforms.</em> After the depressing picture of +the present state of affairs in this country it will be asked, +“What should be done to remedy it?” The answer to +this question is clear and definite.</p> + +<p>For the relief of the mentally afflicted amongst us, and +especially for the prevention of insanity, it is our bounden +duty as a nation to take measures such as most +civilised countries have adopted some time ago. For this +purpose it is necessary that there should be hospitals to +which patients in the early stages of mental disturbance +can go, without any legal formalities, and receive proper +treatment from physicians competent to diagnose their +troubles and to give them appropriate advice. It is +important that such special hospitals should be attached +to general hospitals, so that sensitive patients may not be +deterred from resorting to them by the fear of the stigma +which in this country, unfortunately, is so inseparably +linked with the idea of a “lunatic asylum.” It is also +important that such institutions should be affiliated to +medical schools, not merely to ensure the adequate education +of the coming generations of medical practitioners, +but also to afford the staffs of such hospitals the proper +opportunities for carrying on the work of investigation +which is essential for the success of the scheme we have +sketched out.</p> + +<p><span class="pagenum" id="Page_129">[Pg 129]</span></p> + +<p>No less important and urgent a reform than the foregoing, +however, is another consideration—the <em>legal</em> aspect +of the treatment of the mentally deranged.</p> + +<p>The glaring defects of the present system have been +well and briefly pointed out by Dr. Bedford Pierce in his +article from which we have quoted, published in the +<cite>British Medical Journal</cite> of January 8th, 1916.</p> + +<p>Again, Sir George Savage, writing in Allbutt’s <cite>System +of Medicine</cite> (Vol. VIII, p. 429) states:—</p> + +<div class="blockquot fs90"> + +<p>“The lunacy legislation of this country, despite the Acts of +1890 and 1891, remains in an unsettled state; and the care +and treatment of the insane are burdened with vexations and +unnecessary restrictions. Not only are the steps required for +the placing of a person of unsound mind under legal care +complicated and clumsy, but they result in many cases in a +delay of that early treatment which is so important in cases +of mental disease.”</p> +</div> + +<p>Dr. F. W. Mott writes:—</p> + +<div class="blockquot fs90"> + +<p>“There is yet one point which it is desirable to mention, +as the result of both hospital and asylum experience, and that +is the necessity of some earnest attempt being made to +establish a means of intercepting, for hospital treatment, such +cases of incipient and acute insanity as are not yet certifiable. +It is probable that many would not come into the asylums, +and a certain number of cases thus come under observation +willingly, and in time to retard the progress of the disease. +Practitioners could send doubtful cases for observation and +treatment to such hospitals, where, moreover, the opportunity +would be afforded of improving their own knowledge as to +the early signs of insanity.”<a id="FNanchor_90" href="#Footnote_90" class="fnanchor">[90]</a></p> +</div> + +<p>He urges the desirability of the establishment of special +wards in connection with general hospitals, pointing out +that a mental case coming from such a ward would not +thereby be stigmatised as insane. He quotes from ‘an +American writer on psychiatry’:—“Fortunate would be +the community in which there was a fully equipped<span class="pagenum" id="Page_130">[Pg 130]</span> +and well-organised psychiatrical clinic under the control +of a university and dedicated to the solution of such +problems. The mere existence of such an institution +would indicate that people were as much interested in +endeavouring to increase the public sanity as they are in +the results of exploration in the uttermost parts of the +earth, or in the discovery of a new star.”<a id="FNanchor_91" href="#Footnote_91" class="fnanchor">[91]</a></p> + +<p>The Medico-Psychological Association’s report says:—</p> + +<div class="blockquot fs90"> + +<p>“The lunacy law does not permit of the establishment of +clinics on the lines which have been recommended, nor does +it provide for the admission of uncertified cases to the public +asylums. This, for the present at any rate, renders nugatory +the suggested schemes for affording treatment for incipient and +non-confirmed cases of mental disorder, and with that, to a +large extent, fail the opportunities for study on which stress +has been laid for adding to the knowledge and increasing the +efficiency of asylum medical officers.” (p. <a href="#Page_10">10</a>.)</p> +</div> + +<p>Such weighty opinions as these serve to emphasise a +further factor in the urgently needed reform—the necessity +for a thorough overhauling of the law of lunacy, so that, +while guarding the liberty of the subject, every obstacle +should be removed that obstructs patients threatened with +the dire calamity of insanity from securing preventive +treatment at the earliest possible moment.</p> + +<p>In the <cite>Lancet</cite> of August 5th, 1916, Dr. L. A. Weatherley +writes:—</p> + +<div class="blockquot fs90"> + +<p>“The great fact that must be continually brought forward +in all these discussions is that, according to the reports of the +Commissioners in Lunacy, the <em>recovery-rate of mental diseases +is to-day no higher than it was in the ‘seventies’ of last +century</em>. The ever-increasing difficulty in getting mental +cases with small means quickly under skilled care must, I feel +sure, account to a great extent for this lamentable fact.”</p> +</div> + +<p>“Marking time” since the seventies of the last century—how +does this condition compare with that of most of<span class="pagenum" id="Page_131">[Pg 131]</span> +the other branches of medical science? Heart disease, +diphtheria, tuberculosis, tetanus, sepsis of all kinds, all +these troubles and many others have shown unmistakable +signs of yielding to the incessant and many-sided assaults +of medical research. And, of insanity, all we have to +report in this country is “little or no progress for fifty +years.” Verily we have buried our talent deep in the +ground.</p> + +<p>Finally, we may quote from an article the opening +sentences of which might have been written yesterday, +yet it was published in 1849! It was the fourth report +of the visiting committee of Hanwell Asylum. The committee +say:—</p> + +<div class="blockquot fs90"> + +<p>“In the constitution of the Hanwell Asylum we are also +struck by the paucity of the medical officers attached to it. +There appear in round numbers to be about 500 patients on +the male and 500 on the female side, yet there is only one +resident medical officer attached to each department, and +one visiting physician for the whole establishment. The +inefficiency of so small a medical staff is obvious. If we look +across the Channel we find in Paris that the Salpêtrière, +with its thousand patients, has four times the number of +visiting physicians and ten times the number of resident +medical officers. The disproportion between the sane and the +insane is here so great that it is impossible under such a +system to bring any moral influence to bear upon the afflicted +multitude.”</p> + +<p>“... There ought to be a more numerous medical staff +<em>and a permanent clinic</em> attached to such an institution.... +The County Asylum of Hanwell, supported largely as it is +by county rates and parish assessments, is as much a hospital +as St. George’s or St. Bartholomew’s, and ought to have a +medical staff as numerous and efficient as those of any other +metropolitan hospitals. While charity might thus be administered +upon the highest principles of Christian benevolence, +something ought to be done to advance our knowledge of +science and thereby enable us to relieve the afflictions of +suffering humanity.”</p> +</div> + +<p>The dust lies thick upon this volume, published a short +time before the <em>Crimean</em>, not the present war. And<span class="pagenum" id="Page_132">[Pg 132]</span> +to-day, like this early Victorian committee, we still ask +for clinics, we still ask for scientific work to be carried out +by a more numerous and better equipped staff, we still +look across the Channel with admiration—in short, +approving the better, we follow the worse. We have +dawdled away half-a-century and more in comparative +idleness. Now the war has taught us our lesson. Are +we to forget it again?</p> + +<p>Excuses for inertia, brought forward before August, +1914, can be accepted no longer. The thousands of cases +of shell-shock which have been seen in our hospitals +since that time have proved, beyond any possibility of +doubt, that the early treatment of mental disorder is +successful from the humanitarian, medical and financial +standpoints. It is for us, not for our children, to act in +the light of this great lesson.</p> +<br> + +<div class="footnotes"><h3>FOOTNOTES:</h3> + +<div class="footnote"> + +<p><a id="Footnote_74" href="#FNanchor_74" class="label">[74]</a> p. 105.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_75" href="#FNanchor_75" class="label">[75]</a> It should not be forgotten, however, that resort is often +made to alcohol as an easy means of drowning the worry of an +incessant mental conflict. In other words, it is clear that in +treating alcoholism, as in treating insanity, we are not +absolved from the plain duty of seeking its mental cause or +causes. “Drink” then, in many cases, appears rather as a +secondary complication than as a primary factor.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_76" href="#FNanchor_76" class="label">[76]</a> <em>Cf.</em> W. Aldren Turner, <em>op. cit.</em></p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_77" href="#FNanchor_77" class="label">[77]</a> One of the most gratifying of these is the generous gift +of a clinic to London by Dr. Henry Maudsley. Up to the present +this institution has been rendering valuable service to the +country as part of the 4th London General Military Hospital.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_78" href="#FNanchor_78" class="label">[78]</a> <cite>Appendix to Medico-Psychological Association Report</cite>, +p. 18.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_79" href="#FNanchor_79" class="label">[79]</a> “One thing which impressed ... [us] ... when going +through ... the Giessen clinic with Professor Sommer, +was the frequency with which we heard him utter the word +‘recovering’ as we passed the patients.” <em>Ibid.</em>, p. <a href="#Page_17">17</a>.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_80" href="#FNanchor_80" class="label">[80]</a> <em>Op. cit.</em>, p. 2.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_81" href="#FNanchor_81" class="label">[81]</a> <em>Op. cit.</em>, pp. 15-16.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_82" href="#FNanchor_82" class="label">[82]</a> <i lang="la" xml:lang="la">Vide infra.</i></p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_83" href="#FNanchor_83" class="label">[83]</a> p. 202.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_84" href="#FNanchor_84" class="label">[84]</a> “... at present we have few facilities for teaching the +subject, and the subject is not taught.” (<cite>Medico-Psychological +Association’s Report</cite>, p. 20.)</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_85" href="#FNanchor_85" class="label">[85]</a> Concerning this sentence the <cite>British Medical Journal</cite> wrote, +on Nov. 29th, 1914, “A more severe indictment of the existing +system than is contained in this report it would be difficult to +frame.... We can add nothing to this strongly worded condemnation +except an expression of agreement with the opinion +that the statement of the facts submitted demands the earnest +attention of public authorities and all interested in the welfare +of the insane.”</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_86" href="#FNanchor_86" class="label">[86]</a> Irrelevant because such books give an account of the +morbid anatomy of the nervous system only as it presents itself +after disease of very long duration.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_87" href="#FNanchor_87" class="label">[87]</a> pp. 82 <em>et seq.</em></p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_88" href="#FNanchor_88" class="label">[88]</a> “The Development of Psychiatric Science as a Branch of +Public Health,” <cite>Journal of Mental Science</cite>, January, 1912.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_89" href="#FNanchor_89" class="label">[89]</a> The gratifying establishment of the Maudsley clinic and +the provision of facilities for out-patient treatment at a few +hospitals in England and Scotland are signs that matters are +at last improving. But we are sure that the physicians in +charge of such out-patient departments would be the first to +admit their inadequacy and to urge the desirability of the +psychiatrical clinic of the kind described in this book.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_90" href="#FNanchor_90" class="label">[90]</a> <cite>Archives of Neurology</cite>, 1903, Vol. II, p. 1.</p> + +</div> + +<div class="footnote"> + +<p><a id="Footnote_91" href="#FNanchor_91" class="label">[91]</a> <cite>Archives of Neurology</cite>, 1907, Vol. III, p. 28.</p> + +</div> +</div> + + +<hr class="chap x-ebookmaker-drop"> + +<div class="chapter"> + +<p><span class="pagenum" id="Page_133">[Pg 133]</span></p> +<h2 class="nobreak" id="Index">Index.</h2> +</div> + + +<ul class="index"> +<li class="ifrst fs80"><span style="padding-left: 5em"> <em>Page</em></span></li> + +<li class="indx">Agoraphobia, <a href="#Page_92">92</a></li> + +<li class="indx">Alcohol and insanity, <a href="#Page_106">106</a></li> + +<li class="indx">Allbutt, Sir Clifford, <a href="#Page_27">27</a>, <a href="#Page_34">34</a></li> + +<li class="indx">Amendment of Lunacy Law, need for, <a href="#Page_130">130</a></li> + +<li class="indx">Appointments in asylums, <a href="#Page_116">116</a></li> + +<li class="indx">Asylums, lunatic, <a href="#Page_105">105</a> <em>et seq.</em></li> + +<li class="indx">Attitude of medical profession to psychology, <a href="#Page_102">102</a>, <a href="#Page_106">106</a>, <a href="#Page_111">111</a></li> + +<li class="indx">Attitude of public towards insanity, <a href="#Page_78">78</a></li> + +<li class="indx">Analysis, comparison of chemical and psychological, <a href="#Page_54">54</a></li> + + +<li class="ifrst">Bacon, Francis, <a href="#Page_9">9</a></li> + +<li class="indx">Baltimore Psychiatric Clinic, <a href="#Page_110">110</a></li> + +<li class="indx">Bernardin de St. Pierre, <a href="#Page_45">45</a></li> + +<li class="indx">Blässig’s case of loss of speech, <a href="#Page_43">43</a></li> + +<li class="indx">Boston Psychopathic Hospital, <a href="#Page_82">82</a></li> + +<li class="indx">British attitude towards insanity, <a href="#Page_79">79</a>, <a href="#Page_120">120</a></li> + +<li class="indx">British medical training, <a href="#Page_114">114</a></li> + +<li class="indx"><em>British Medical Journal</em>, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_18">18</a>, <a href="#Page_106">106</a>, <a href="#Page_116">116</a>, + <a href="#Page_129">129</a></li> + +<li class="indx">Burt, C., <a href="#Page_3">3</a>, <a href="#Page_17">17</a></li> + +<li class="indx">Butler’s, Samuel, <em>Erewhon</em>, <a href="#Page_103">103</a></li> + + +<li class="ifrst">Cannon on bodily effects of emotion, <a href="#Page_8">8</a></li> + +<li class="indx">Carnegie Foundation’s report, <a href="#Page_112">112</a></li> + +<li class="indx">La Charité Hospital, <a href="#Page_83">83</a></li> + +<li class="indx">Chloroform, use of in cases of loss of speech, <a href="#Page_12">12</a></li> + +<li class="indx">Clinics for treating mental disorders, <a href="#Page_84">84</a>, <a href="#Page_107">107</a>, <a href="#Page_121">121</a></li> + +<li class="indx">Clinics, cost of, <a href="#Page_125">125</a></li> + +<li class="indx"> ” functions of, <a href="#Page_83">83</a>, <a href="#Page_121">121</a></li> + +<li class="indx"> ” efficacy of, <a href="#Page_82">82-85</a>, <a href="#Page_123">123</a></li> + +<li class="indx">Common sense not infallible, <a href="#Page_58">58</a></li> + +<li class="indx">Conflict, mental and moral, <a href="#Page_98">98</a></li> + + +<li class="ifrst">Déjerine and Gauckler, <a href="#Page_6">6</a>, <a href="#Page_34">34</a>, <a href="#Page_35">35</a>, <a href="#Page_42">42</a>, <a href="#Page_44">44</a>, <a href="#Page_45">45</a>, + <a href="#Page_46">46</a>, <a href="#Page_90">90</a>, <a href="#Page_120">120</a></li> + +<li class="indx">Defects of British methods, <a href="#Page_120">120</a></li> + +<li class="indx"><em>Derfflinger</em>, sailor from German battle-cruiser, <a href="#Page_43">43</a></li> + +<li class="indx">Diagnosis, importance of exact, <a href="#Page_47">47</a> <em>et seq.</em></li> + +<li class="indx">Dreams, <a href="#Page_22">22</a>, <a href="#Page_61">61-63</a></li> + + +<li class="ifrst">Emotion of fear, <a href="#Page_92">92</a></li> + +<li class="indx">Emotions, <a href="#Page_3">3</a>, <a href="#Page_9">9</a></li> + +<li class="indx"><span class="pagenum" id="Page_134">[Pg 134]</span>Emotional factor as cause of mental disturbance, <a href="#Page_71">71</a></li> + +<li class="indx">Evils resulting from delay in treatment, <a href="#Page_81">81</a></li> + + +<li class="ifrst">Fear, <a href="#Page_92">92</a>, <a href="#Page_95">95</a></li> + +<li class="indx">Financial aspect of reform, <a href="#Page_125">125</a> <em>et seq.</em></li> + +<li class="indx">Firmness, <a href="#Page_28">28</a>, <a href="#Page_31">31</a></li> + +<li class="indx">Flexner’s report on medical education, <a href="#Page_110">110-113</a></li> + +<li class="indx">Forgetfulness, <a href="#Page_49">49</a></li> + +<li class="indx">Forsyth, D., <a href="#Page_4">4</a>, <a href="#Page_8">8</a></li> + +<li class="indx">Freud, S., <a href="#Page_63">63</a>, <a href="#Page_73">73</a></li> + + +<li class="ifrst">Gaupp on hysteria, <a href="#Page_22">22</a>, <a href="#Page_23">23</a></li> + +<li class="indx">German attitude towards mental disorder, <a href="#Page_84">84</a></li> + +<li class="indx">Giessen clinic, <a href="#Page_84">84</a>, <a href="#Page_122">122</a></li> + + +<li class="ifrst">Hanwell asylum, <a href="#Page_131">131</a></li> + +<li class="indx">Hart, Bernard, <a href="#Page_57">57</a>, <a href="#Page_119">119</a></li> + +<li class="indx">Heredity, the influence of, <a href="#Page_78">78</a>, <a href="#Page_86">86</a>, <a href="#Page_88">88</a>, <a href="#Page_89">89</a></li> + +<li class="indx">Hesse, experience in, <a href="#Page_82">82</a></li> + +<li class="indx">Hypnotism, <a href="#Page_36">36</a> <em>et seq.</em></li> + +<li class="indx"> ” usefulness in recent cases, <a href="#Page_38">38</a></li> + +<li class="indx">Hypnotism, objections to use of, <a href="#Page_39">39-44</a></li> + +<li class="indx">Hysteria, <a href="#Page_22">22</a>, <a href="#Page_30">30</a>, <a href="#Page_94">94</a></li> + + +<li class="ifrst">Instincts, <a href="#Page_3">3</a>, <a href="#Page_91">91</a></li> + +<li class="indx">International Congress of Medicine, <a href="#Page_110">110</a></li> + +<li class="indx">Isolation, treatment by, <a href="#Page_32">32</a> <em>et seq.</em></li> + +<li class="indx">Isolation, limits to usefulness of, <a href="#Page_34">34</a>, <a href="#Page_35">35</a></li> + + +<li class="ifrst">Jung, C. G., <a href="#Page_71">71</a>, <a href="#Page_74">74</a>, <a href="#Page_86">86</a></li> + + +<li class="ifrst">Kindness, therapeutic value of, <a href="#Page_45">45</a></li> + +<li class="indx">Kraepelin, E., <a href="#Page_91">91</a></li> + + +<li class="ifrst"><em>Lancet</em>, <a href="#Page_4">4</a>, <a href="#Page_5">5</a>, <a href="#Page_14">14</a>, <a href="#Page_37">37</a>, <a href="#Page_130">130</a></li> + +<li class="indx">Law relating to Lunacy, need for amendment, <a href="#Page_130">130</a></li> + +<li class="indx">Loss of memory, <a href="#Page_43">43</a></li> + +<li class="indx"> ” sight, <a href="#Page_11">11</a></li> + +<li class="indx"> ” sleep, <a href="#Page_7">7</a></li> + +<li class="indx"> ” speech, <a href="#Page_11">11</a>, <a href="#Page_43">43</a></li> + +<li class="indx">Lunacy, need for amendment of law relating to, <a href="#Page_130">130</a></li> + +<li class="indx">Lunatic Asylums, <a href="#Page_78">78</a></li> + + +<li class="ifrst">Maghull Military Hospitals, <a href="#Page_108">108</a></li> + +<li class="indx"><em>Manchester Guardian</em>, <a href="#Page_24">24</a></li> + +<li class="indx">Maudsley Clinic, <a href="#Page_125">125</a></li> + +<li class="indx">Medical education, inadequate teaching in psychology, <a href="#Page_100">100</a></li> + +<li class="indx">Medico Psychological Society’s report, <a href="#Page_80">80</a>, <a href="#Page_105">105</a>, <a href="#Page_108">108</a>, <a href="#Page_112">112</a>, + <a href="#Page_118">118</a></li> + +<li class="indx">Mott, F. W., on clinics, <a href="#Page_129">129</a></li> + +<li class="indx">Möhr, on theory of isolation, <a href="#Page_32">32</a></li> + +<li class="indx">Munich clinic, work of, <a href="#Page_122">122</a> <em>et seq.</em></li> + +<li class="indx">Myers, C. S., on hypnotism, <a href="#Page_5">5</a>, <a href="#Page_30">30</a>, <a href="#Page_37">37</a>, <a href="#Page_38">38</a></li> + + +<li class="ifrst">Neurotic parents, influence of, <a href="#Page_89">89</a></li> + + +<li class="ifrst">Pear, T. H., on effects of loss of sleep, <a href="#Page_7">7</a></li> + +<li class="indx">Persuasion, psychotherapy by, <a href="#Page_44">44</a></li> + +<li class="indx">Physical basis of disease, <a href="#Page_96">96</a>, <a href="#Page_99">99</a></li> + +<li class="indx"><span class="pagenum" id="Page_135">[Pg 135]</span>Pierce, Bedford, on need for reform, <a href="#Page_18">18</a>, <a href="#Page_79">79</a>, <a href="#Page_83">83</a>, + <a href="#Page_129">129</a></li> + +<li class="indx">Proportion of cases cured in asylums, <a href="#Page_82">82</a>, <a href="#Page_109">109</a></li> + +<li class="indx">Proportion of cases not needing asylum treatment, <a href="#Page_82">82</a></li> + +<li class="indx">Psychoanalysis, <a href="#Page_73">73-75</a></li> + +<li class="indx">Psychological analysis, <a href="#Page_53">53</a> <em>et seq.</em></li> + + +<li class="ifrst">Rational treatment, <a href="#Page_46">46</a></li> + +<li class="indx">Re-education, <a href="#Page_53">53</a>, <a href="#Page_72">72</a></li> + +<li class="indx">Régis, on significance of word “neuropathic”, <a href="#Page_94">94</a></li> + +<li class="indx">Reform of methods for dealing with mental disturbance, <a href="#Page_128">128</a></li> + +<li class="indx">Research, the importance of, <a href="#Page_117">117</a></li> + +<li class="indx">Rows, R. G., <a href="#Page_82">82</a>, <a href="#Page_108">108</a>, <a href="#Page_122">122</a>, <a href="#Page_126">126</a></li> + + +<li class="ifrst">Savage, Sir George, <a href="#Page_27">27</a>, <a href="#Page_129">129</a></li> + +<li class="indx">Shaw, G. Bernard, <a href="#Page_93">93</a></li> + +<li class="indx"><em>Sherlock Holmes</em>, <a href="#Page_63">63</a></li> + +<li class="indx">Smith, May, on effects of loss of sleep, <a href="#Page_7">7</a></li> + +<li class="indx">Sommer, R., <a href="#Page_109">109</a></li> + +<li class="indx">Stewart, Purves, <a href="#Page_95">95</a></li> + +<li class="indx">Subjective disturbances, <a href="#Page_12">12</a></li> + +<li class="indx">Suggestion, <a href="#Page_36">36</a></li> + +<li class="indx">Suppression of emotions, <a href="#Page_9">9</a></li> + +<li class="indx">Syphilis, <a href="#Page_106">106</a></li> + +<li class="indx">Sympathy, <a href="#Page_28">28</a>, <a href="#Page_29">29</a></li> + +<li class="indx">Stigma of insanity, <a href="#Page_84">84</a></li> + + +<li class="ifrst">Text-books on psychological medicine, inadequacy of, <a href="#Page_118">118</a></li> + +<li class="indx">Treatment, <a href="#Page_27">27</a></li> + +<li class="indx">Tuberculosis, comparisons with, <a href="#Page_77">77</a>, <a href="#Page_85">85</a>, <a href="#Page_114">114</a></li> + +<li class="indx">Turner’s, W. Aldren, report, <a href="#Page_14">14</a>, <a href="#Page_108">108</a></li> + + +<li class="ifrst">Unconscious factors, influence of, <a href="#Page_57">57</a> <em>et seq.</em></li> + +<li class="indx">Understaffing, medical, of asylums for the insane, <a href="#Page_81">81</a></li> + + +<li class="ifrst">Weatherley, L. A., <a href="#Page_130">130</a></li> + +<li class="indx">Wiltshire, H., <a href="#Page_10">10</a></li> + +<li class="indx">Work, therapeutic value of, <a href="#Page_50">50</a></li> + +<li class="indx">Worry, relief of, <a href="#Page_67">67</a>, <a href="#Page_68">68</a></li> + + +<li class="ifrst">Ziehen, T., <a href="#Page_83">83</a></li> + +<li class="indx">Zürich University Psychiatric Clinic, <a href="#Page_86">86</a></li> +</ul> +<br> +<br> + +<div style='text-align:center'>*** END OF THE PROJECT GUTENBERG EBOOK 75421 ***</div> +</body> +</html> + diff --git a/75421-h/images/cover.jpg b/75421-h/images/cover.jpg Binary files differnew file mode 100644 index 0000000..7c71beb --- /dev/null +++ b/75421-h/images/cover.jpg |
