Treatment.
In discussing the question of treatment we do not propose to deal with
general therapeutic measures which every physician in charge of nervous
or mental patients is hardly likely to neglect.[24] The importance of a
generous and easily digested dietary is generally recognised: as also
is the need for quiet and congenial surroundings, and for shielding
patients from disturbances, such as noises and the sight of wounded,
which are likely to evoke painful emotions and vivid memories of their
experiences at the front. It is also obviously important that the
physician should deal promptly and discreetly with any bodily ailments
from which the patient is suffering, being careful neither to minimise
their gravity and so give him any reason for the grievance that he
is not receiving proper attention, nor by exaggerating them to add
this anxiety to his other troubles.[25] These are questions which may
confidently be left to the discretion of the physician in charge.
_Firmness and Sympathy._
But there are certain other therapeutic measures commonly recommended
in text-books for application in the cases of patients suffering from
neurasthenic and hysterical troubles, which cannot be thus summarily
dismissed. As many of these patients are irritable and childishly
peevish, it is necessary that they should be treated with sympathetic
firmness, tact and insight. But, unfortunately, the words “firmness”
and “sympathy” are interpreted in a great variety of ways. While it is
important, for purely therapeutic reasons, that discipline should be
maintained, and that when the physician has decided what he considers
the proper treatment for the patient this should be rigorously carried
out, it is manifestly disturbing and injurious in many cases for the
officer to insist upon all the exacting details of military rules and
regulations. For the mentally healthy soldier, obedience to stern and
even harshly rigid regulations is often vitally important; but an
attempt by a medical officer to treat a ward of neurasthenic patients
in this way usually has disastrous results.
Quite apart, however, from the military aspects of the case, the
physician, without really investigating the history of a patient,
may label his trouble “hysteria” and forthwith adopt a course of
“firmness.” He may assume the attitude of doubting the genuineness
of symptoms which are very real to the sufferer. Under the plea of
helping to cure the patient the officer may assure him that there is
nothing much the matter with him and that if he tries he will soon be
all right. Such advice may be justifiable if based on a real insight
into the state of the individual sufferer, but this knowledge can be
gained only by a patient investigation of the cause of his trouble.
If the advice is given without this insight, it is a mere shot in the
dark. The fact that the device succeeds in a certain number of cases
is no excuse for its general adoption. And when it “misfires” no one
realises the fact more quickly than the patient himself. He realises
that the officer does not appreciate his condition and his confidence
is thereby destroyed.
It is useful, too, to consider for a moment the nature of treatment by
“sympathy.” When we used the phrase “sympathetic firmness” we intended
to indicate the insistence upon a strict observance of such methods of
treatment as a real insight into the patient’s condition may suggest.
The word “sympathy” was used in its literal sense of “feeling with”
the sufferer. But there is no class of patients upon whom sympathy
of the injudicious kind is more prone to work serious harm than the
psychoneurotic. The knowledge of this fact is often the excuse for the
adoption of the opposite attitude and the prescription of “firmness”
which, as we have seen, may be equally unintelligent and injudicious.
But sympathy of the injudicious kind is not _real_ sympathy. For unless
the sympathiser has a true appreciation of the patient’s condition,
and can look at things from his point of view, he cannot really feel
_with_ the sufferer. The latter may arouse in the would-be sympathiser
tender emotions and sympathetic “pain,” but unless the sympathiser
have insight, the pain, to put it crudely, is not likely to be “in
the same place” as that of the patient. Such misplaced emotion and
false sympathy, whether on the part of the doctor, the nurse, or the
patient’s relations, may do much harm.
In mild cases of mental trouble, however, where the patient still
retains a goodly portion of self-confidence and self-respect, this
“petting” variety of sympathy may sometimes be effective. Such a
patient may be cheered up by the presence of people sufficiently
interested in him to be sorry for his condition; and it may help him
to look on the brighter side of things and to forget his worries and
anxieties. But often it is apt, by suggestion, to aggravate his
troubles or even to discourage him from trying to recover.[26] Perhaps
it would be more accurate to say that such treatment gives him no
inducement to get better.
There are still not a few physicians who regard the group of functional
troubles commonly labelled “hysteria” as something closely akin to
malingering. If it would not be considered invidious we could quote
the opinions of well-known physicians published within the last five
years, suggesting that there is no real line of demarcation. (It is not
uncommon to meet the expression “_detecting_,” instead of _diagnosing_
hysteria.)
But even among those who regard these serious affections as something
more than mere simulation there is a tendency to look upon any form
of sympathy as a dangerous pandering to the patient’s lack of will
power.[27]
This attitude often finds expression in leaving the patient alone to
get better by his own efforts, or in suggesting to him that he is not
so ill as he thinks he is, and that all he needs is some work to occupy
his attention.
The attempt is often made to justify such methods by the plea that
it is “bad for the patient to talk to him of his worries.” But how
a physician is to rid a patient of the very root of all his trouble
without first discovering and then discussing it with him is not
apparent. Nor, again, is it any more rational merely to tell a man who
is weighed down with some very real anxiety to “cheer up,” or to “work
in the garden,” or “take a walking tour.”
We are not maintaining that such methods do not often meet with
success in the case of many patients who are only mildly affected and
earnestly want to get better. But experience shows that such advice is
often fraught with danger, and, in severe cases of mental affection
is worse than useless. The experience of those physicians who have
been treating such patients with sympathetic insight during the last
two years affords a striking condemnation of the theory that it is
generally “bad to talk to them of their worries.” It has repeatedly
happened that as soon as the patient was asked about his troubles he
made a full statement of all that was troubling him and was obviously
relieved to confess his worries to someone who took an intelligent
interest in his welfare.
In many cases the mere unburdening of this weight of anxiety and the
removal by the physician of quite trivial misunderstandings which were
the original causes of it, were sufficient to cheer up the patient and
to start him on the way to complete recovery. Yet many of these men had
been inmates of a series of hospitals in which no attempt had been made
to discover what was the real source of all the trouble. Thus to their
other worries and anxieties was added the real additional grievance
that they were being neglected and were of no account. In many cases
this constituted a serious aggravation of the patient’s mental
disturbance and encouraged him to believe that his state was already
beyond help.
Those physicians who look upon such milder psychoses as varieties of
simulation should be reminded that the methods we have just mentioned
are not often likely to be effective in cases of real malingering.
In discussing the therapeutic use of “firmness” we have not thought it
necessary to mention those applications of this method which at times
are practised by combatant officers at the front. The use of military
authority to suppress the minor manifestations of nervousness, or the
resort to such expedients as unexpectedly firing off a gun alongside
a man afflicted with functional deafness, are merely examples of the
application of “suggestion.” They are akin to the use of “firmness”
by the physician who has not investigated the cause of the patient’s
trouble. The results of such expedients are as erratic in the one case
as in the other. But there is no need for us to discuss this practice
further, except to add that the knowledge that such “treatment by
military authority” has been tried before, still further diminishes the
justification for resorting to such measures when the patient reaches
the home hospital.
_Isolation._ Many physicians regard isolation as an appropriate
method of treatment for soldiers suffering from shock, and they urge
in justification of such a procedure the success which often attends
its use in civil cases. We do not deny the utility of isolation for
suitable cases, and success has attended its use when the patient’s
condition obviously required it. But the circumstances which were
responsible for causing the mental disturbance in the soldier may be of
a totally different nature from those which have upset the civilian;
and therapeutic measures which may be appropriate in eliminating the
civilian’s sources of irritation might be wholly unsuitable, if not
positively harmful, in the case of soldiers.
It cannot be too strongly emphasised in connection with this subject
that most of the theory and practice of treating hysteria by isolation
has been developed in civil life, and in very many cases with reference
to well-to-do women living in the lap of luxury. When such persons
develop hysterical symptoms, some sources of irritation in the home
or the social environment are often responsible. By isolation the
patient is removed from the noxious influence of both domestic worries
and mistaken sympathy; his or her whims and fancies are compulsorily
subordinated by self-discipline and consideration for others. At
home it is impossible satisfactorily to enforce such measures and
the attempt to do so will almost inevitably fail, because sympathy,
curiosity and anxiety on the part of various relatives hinder the
attainment of these objects. By isolation the patient is removed from
these unfavourable psychical influences. Through the freedom from
such disturbing stimuli, the abnormally intense reaction of the mind
is reduced. And in many patients of this class the desire to be cured
or to be active, which is produced by the boredom of isolation, works
favourably.[28]
But in most soldiers the circumstances are altogether different. In
the first place, the patient secures the change of surroundings by his
removal from the trenches to the hospital. Isolation, therefore, can
hardly be justified on that score. At the same time, the removal to a
military hospital at any rate should obviate all danger of his being
pestered by foolish relatives and friends with their mistaken sympathy
or excessive attention. And as regards the importance of discipline
and routine, the soldier is in a position very different from that of
the wealthy society lady, for he has already been subjected to such
training.
In some instances, however, just as in the civil cases, the boredom of
isolation may produce the good effects noted above. But there is the
corresponding disadvantage that if you isolate a man and put a special
nurse to look after him it is impossible to convince him that his case
is not serious. It may, indeed, help him to persuade himself that he
is really going insane. As a matter of experience, it is found that
very many men cannot stand isolation for long; they feel that they
must break out, even if they realise that punishment is certain for
doing so. The conversation of patients who are undergoing treatment
by isolation is often perfectly frank about it. They tell the medical
officer they will break out at the first opportunity; that the few
hours of freedom would more than compensate for the punishment which
would come afterwards. Again, it must be apparent that, when the
trouble is due in any considerable measure to the re-awakening of
emotions linked up with some painful earlier experience, isolation
is not likely to be effective in many cases, and may be definitely
harmful. Neither should it be forgotten that such measures fail to
isolate the patient from his worst enemy, himself.
Even in those cases in which it is useful, isolation, if unduly
prolonged, may spoil its own good effects. It may so accustom the
patient to a solitary mode of existence that the presence of other
persons may make him irritable when at the end of his time of seclusion
he is compelled to associate with his fellows.
There is another fact which has to be taken into consideration—and
this applies especially in civil practice, where the patient or his
family have to pay for the treatment. We refer to the expensiveness
of treatment by isolation. Unless it can be shown that it is the
best or the only hopeful method to adopt, the physician must feel
some hesitancy in the majority of cases, in prescribing such costly
measures.[29]
Déjerine and Gauckler[30] have given an admirable account of the use
of isolation in the treatment of neurasthenia and hysteria. They are
careful to point out, however, that even in the case of civilian
patients, with whom of course their treatise is concerned, “isolation,
even accompanied by rest and overfeeding, is never enough.” It is
merely an adjunct, though, under certain circumstances, a necessary
one, of the treatment by persuasion. But “it would be irrational to
look upon the isolation of neuropaths as a therapeutic necessity from
which one might never depart. It only applies to particular cases.”
In proceeding to define the class of civilian patients for whom such
methods are appropriate they emphasise the value of isolation for
those whose troubles are due to, or aggravated by, “a bad family
environment.” In most cases the circumstances of the war-stricken
soldier do not come within the categories which they suggest as
justifying isolation. Moreover, most of the benefits which they
attribute to this therapeutic measure, _i.e._, removal from home
surroundings and from the particular worries and anxieties which have
caused the mischief, are attained (as we have already pointed out) when
the soldier is an inmate of a special—or, in fact, of any—hospital.
When Déjerine and Gauckler proceed to define the different degrees in
which the method of isolation may be practised; _viz._: (1) strict
isolation; (2) absolute isolation from one’s family circle and
environment, and (3) isolation from one’s family circle alone, or from
one’s usual environment alone—it becomes clear that the treatment of
every soldier who enters any hospital inevitably comes within the scope
of categories 2 and 3.
Even when writing of hysterical women these French physicians tell us
that—
“to show how slightly (their) experience has inclined (them) towards
any systematic treatment of the psychoneuroses by isolation,”
isolation has not seemed (to the doctors) to be necessary for “at
least a third of the neuropathic women who have been cared for at the
Salpêtrière. Again, it must be added that, of the patients admitted,
a certain number have been received at the hospital and naturally
submitted to the discipline which belongs to an isolation ward
much more for humanitarian and social reasons than because absolute
isolation seemed to be formally indicated.”[31]
From the completely different nature of the circumstances of the
nerve-stricken soldier and civilian respectively it is clear that
such total isolation can be considered necessary for soldiers only in
very few cases, even though the modified forms of isolation, to which
reference has been made, may be useful for most of such patients. The
important point that emerges from this discussion is the necessity
which is laid upon the physician of determining, in the case of each
individual patient, whether isolation of any kind is desirable, what
form it should take, and especially when it should be used, modified or
discontinued.
_Suggestion and Hypnosis._ We have already touched briefly on the
need for sympathetic firmness and for inspiring the patient with
confidence that he will recover. But such firmness can be useful only
when it is supported by respect for and confidence in the physician.
In most cases such respect can be gained only by acquiring a real
insight into the patient’s condition and by treating him tactfully and
reasonably. It is too often forgotten that the neurasthenic patient’s
continual and intense criticism of himself makes him especially quick
at intuitively becoming conscious of the physician’s failings. Under
such circumstances, if the doctor does not secure the patient’s respect
and convince him that he really understands his condition, the former’s
firmness and confident assurances will avail him nothing: he has
shown his hand; his failure will excite contempt; and the patient’s
intractable, _enlightened_ stubbornness will be fatal to any further
hope of influence on the part of that particular physician.
Ever since mankind first sought help from his fellows for his
afflictions of body or mind, confidence in the efficiency of the
adviser’s ability has been an essential factor in leech-craft. To be
able to convince a patient that he is going to recover and that medical
advice will help towards that end is certainly not the least of the
physician’s qualifications. But unless the assurances given him are
based upon real insight and understanding, the process of securing the
patient’s confidence is not very different from the charlatan’s blatant
boasting. In other words, it is analogous to the confidence trick.
The confidence which is inspired in the patient by his conviction of
the physician’s real understanding of his condition is an altogether
different matter. Such “suggestion” necessarily enters into all
successful treatment and this applies in a very special manner to the
cure of mental ailments.
But the question arises, is it useful or desirable to supplement these
measures of suggestion which are incidental to all human intercourse,
by more positive measures of induced “suggestion” or hypnotism? There
are wide discrepancies of opinion with regard to this matter. And, in
endeavouring to come to a conclusion concerning it, it is important
to eliminate as far as possible the emotional tone which the warm
discussion of this question has aroused in the past.
The positive usefulness of hypnosis in relieving many of the acute
symptoms in recent cases of shell-shock has been fully demonstrated by
the important series of articles by C. S. Myers, in the _Lancet_.[32]
When it is possible by such means to restore to the patient his lost
memory or speech or banish his despondency it often proves that the
only hindrance to the complete restoration of his normal personality
has been removed.
“It may be argued,” to quote Myers’s own account, “that mutism,
rhythmical spasms, anæsthesia, and similar purely functional
disturbances disappear after a time without specific treatment. But no
one who has witnessed the unfeigned delight with which these patients,
on waking from hypnosis, hail their recovery from such disorders can
have any hesitation as to the impetus thus given towards a final cure.
More especially is this the case in regard to the restoration of lost
memories. Enough has already been said here about the striking changes
in temperament, thought, and behaviour which follow on recovery from
the amnesia... The restoration to the normal self of the memories of
scenes at one time dominant, now inhibited, and later tending to find
occasional relief in abnormal states of consciousness or in disguised
modes of expression—such restoration of past emotional scenes
constitutes a first step towards obtaining that volitional control
over them which the individual must finally acquire if he is to be
healed.
Thus the minimal value that can be claimed for hypnosis in the
treatment of shock cases consists in the preparation and facilitation
of the path towards a complete recovery.”[33]
Even if we admit that other measures, such as the administration of
chloroform for the cure of hysterical mutism, may in some cases effect
similar improvements, this should not blind us to the incontrovertible
fact that hypnotism has been proved to be a valuable therapeutic agent
in the early stages of shell-shock.
As a cure for certain patients who have passed the acute stages of
shell-shock or other forms of war-strain, its use requires great
discrimination in the selection of suitable cases and extreme care in
its practice. It is very probable, too, that hypnotic suggestion by
itself should never be regarded as sufficient treatment for these
cases, though undoubtedly it may be of great use as a part of such
treatment.
A view endorsed by some well-known physicians is that all psychotherapy
should be addressed to the functions of consciousness, and that
hypnosis, which is addressed to the functions of automatism, is
therefore undesirable. As a general statement this is undoubtedly true
of a great number of cases, but there occur instances in which it seems
that this sensible rule may be wisely and judiciously broken. In some
cases hypnosis helps in more quickly breaking down resistances, which
occur in patients too beset by their own auto-suggestion and false
beliefs to be able easily to grasp the arguments and persuasions which
the physician may have spent days and weeks in vainly endeavouring
to get accepted. Thus assistance may be sought without in any way
interfering with subsequent treatment of the patient by psychological
analysis and re-education.
The following instance illustrates the use of hypnotic suggestion in
the manner described above.
The case was one of violent spasmodic tremor in the right arm of a
soldier. When in a state of convalescence from a wound and shell-shock
he suddenly encountered his company officer, to whom he was greatly
attached. This officer had lost his right arm since he was last seen
in France by the patient. The shock of suddenly meeting the officer
in this condition set up the man’s tremor. The case came under
psychotherapeutic treatment some weeks later, when the patient, who was
an extremely emotional individual, had lost all hope of recovery. Any
attempt at purposive movements of the right hand and arm threw all the
muscles of the right side of the body into a violent state of jerky
tremor.
Long continued treatment by persuasion failed to effect any improvement
whatsoever. The medical officer in charge of the case therefore decided
to try hypnotic suggestion. This was easily carried out; the hypnotic
state being moderately deep, though the patient was still in touch with
his environment. Hope, courage and assurance of recovery _following
his own effort_, together with determination to make every endeavour,
were suggested to him. The patient was assured at each sitting that
his nerves and muscles would every day respond more and more to his
efforts at self-control. After a very few short sittings the man’s
hopeless attitude became changed to one of hope, effort and attention
in the waking stage, and there was a slight but decided improvement
in his voluntary power. Hypnotic suggestion was then given up, and
the treatment was continued by means of encouragement, exercises and
explanation of his trouble, with the result that two months later he
was fit for discharge from the hospital.
It may reasonably be doubted whether methods of persuasion alone would
have cured this man. In any case, it is clear that it would have taken
a very long time. It is also probable that hypnotic suggestion alone,
if continued, would very quickly have removed the symptoms. It may
be doubted, however, whether it would have effected a permanent cure
in a person so open to auto-suggestion. It seems, therefore, that a
judicious combination of methods was advisable.
We are of the opinion that hypnotic treatment, when used with skill,
discretion, and discrimination, has its place in the treatment of
shell-shock and similar conditions, both in the acute and chronic
stages.
In the majority of cases of some considerable duration, however, and
in practically all those in which the trouble is due to some ante-war
worry or emotion, it may be regarded as provable that hypnosis _alone_
will be of relatively slight use and in many cases may be positively
harmful, for under such circumstances, even with the most favourable
conditions, it would result merely in the removal of symptoms; and the
removal of one may be followed by the appearance of another, which may
even be induced by the process of hypnosis. Moreover, in cases where
there is a tendency to the development of a double personality hypnosis
may have the effect of increasing the risk. Further, if the patient has
sufficient of his own will-power to enable the process of re-education
to be carried out, it is clearly undesirable, both on psychological and
ethical grounds, for the doctor to impress his influence from without.
In considering the possibility of the usefulness of hypnotic suggestion
it is important to bear in mind that various factors may come into play
in impressing an event upon the patient’s memory, or in determining
the effect of the shock from which he is suffering when he arrives
in hospital. In the first place there is the vividness or intensity
of the stimulus; in the second, the degree of recency; in the third,
the frequency of the stimulus; and in the fourth its relevancy. By
the latter is meant the extent to which a given event appeals to
the individual’s past experience, and becomes integrated into his
personality.
A patient who has recently received a severe shock, the effects of
which alone represent the real trouble, without the disturbance of
any antecedent experience, might quite well be relieved by hypnotic
suggestion from sleeplessness, pain, or amnesia; and in some cases
this removal of the acute symptoms which determine the persistence
of the shock effects may lead to complete recovery. A single and
sudden wholly irrelevant experience, such as the bursting of a shell,
which has no relationship whatever to the patient’s past experience,
and produces effects by its vividness and its recency, might quite
well be neutralised by another kind of wholly irrelevant intrusion,
such as hypnotic suggestion. This argument may perhaps be made more
intelligible by a homely analogy. A temperate man walking along the
street might be thrown temporarily into a condition of faintness or
collapse by seeing some ghastly accident, but by taking a “brandy and
soda,” which to such a man would be a wholly irrelevant experience,
the physiological expressions of his emotions might be controlled and
he might be able to proceed on his way, and to overcome completely
the effects of the transitory occurrence. But in the case of a man
who, for example, had been greatly worried by monetary troubles for
a number of years, the “brandy and soda” would not produce anything
more than a temporary alleviation of his troubles. The latter
illustration represents the chronic psychosis which, as Déjerine has
so admirably explained, is quite unsuitable for hypnotic treatment.
But the distinguished French neurologist’s statements do not seem to
apply to the former type of case, due to a vivid recent shock, in the
symptomatology of which troubles before the shock play no part. In
such cases the results of hypnotic suggestion are often brilliant, if
erratic, as is the “brandy and soda cure” for the man who is overcome
by a sudden terrible experience in the street.
There are, however, patients who have not sufficient will-power or
intelligence to be properly re-educated, to whom a certain amount of
suggestion may be of some use.
Those who have used hypnosis in civil practice are aware that in
certain individual cases of long-standing trouble, such, for example,
as chronic alcoholism, hypnotic treatment is of unquestionable value.
Among soldiers suffering from the long-standing effects of shell-shock,
hypnosis may be able in some cases to help in the restoration of health
with an effectiveness that no other method can rival.
Both the danger and the possible usefulness of hypnotism may be
illustrated by an actual case. It is that of a man all of whose
companions were destroyed by the bursting of a shell, and who suffered
for months afterwards from complete loss of memory. A medical man
hypnotised him, and perhaps with undue tactlessness, brought back
the memory of the critical incident at the front, stripped of all
the episodes which led up to or followed it. This excited in him
the most violent emotions, and he became sick with terror; for the
revived incident seemed perfectly real to him, or, as he described
it afterwards, “it jumped up against him,” and for weeks he was so
utterly terrified that he would not go near the doctor. Even though
he could not retain the memory of any other recent events the horror
of that experience seemed to have made him remember his dread of a
particular medical man. But by making use of the information gained
during that revival under hypnosis of an incident unknown to anyone
but the patient, which his amnesia up till then had kept sealed up, it
became possible for another medical officer to bridge the gap between
his memory of previous events and the experiences which the patient was
known to have had in the military hospitals.
In speaking of the results of hypnotic treatment as being brilliant
but erratic, it is important to remember that the same observations
apply to suggestion without hypnosis. For instance, the application of
electricity to the vocal cords in cases of hysterical aphonia affords
an admirable illustration of the treatment by suggestion, even if the
method savours of charlatanism. An excellent demonstration of the part
which psychical factors play in such cases is afforded by the story
of a sailor on the German battle-cruiser _Derfflinger_, recorded by
Blässig.[34]
“A seaman from the _Derfflinger_ was brought into a naval hospital
with loss of voice on Dec. 22nd, 1914, and could speak only in
a whisper. He said that he had always had good health, with the
exception that as a child he had diphtheria, but recovered without
tracheotomy or any complication. His voice had always been clear and
well under control. At the beginning of December he had a slight
cold, which he attributed to sentry duty on deck in very stormy and
wet weather. While in the ammunition chamber of the big guns he was
greatly upset during the firing and suddenly lost his voice. After
fourteen days he recovered his speech. On Feb. 12th, 1915, he returned
to hospital with complete loss of voice, immediately after the
naval engagement in the North Sea. On Feb. 15th he was treated with
electricity, directly applied to the vocal cords, and on March 20th he
was discharged with complete recovery of his speech. But on returning
to duty, as soon as he went on board his ship his voice was suddenly
lost for the third time, and he remained aphonic.”
This is clear evidence of the fact that his trauma was psychical. His
previous history perhaps contains the clue explaining why, in his case,
it was his voice which was affected. The application of the faradic
current was suggestion pure and simple.
In emphasising the limited usefulness and possible danger of suggestive
therapeutics in many cases that are not quite recent, we have not been
referring to that method of suggestion which is involved to a greater
or less degree in all successful treatment of disease—the process of
gaining the patient’s confidence and impressing him with the idea that
he is going to recover.
“The conversational attitude, the familiar manner of talking things
over, the heart-to-heart discussion, where the physician must
exert his good sense and feeling, and the patient be willing to be
confidential” is the method which Déjerine calls ‘psychotherapy
by _persuasion_.’ “It consists in explaining to the patient the
true reasons for his condition, and [for] the different functional
manifestations which he presents, and above all, in establishing
the patient’s confidence in himself and awakening the different
elements of his personality, so as to make them capable of becoming
the starting-point of the effort which will enable him to regain
his self-control. The exact comprehension of the phenomena which
he presents must be gained by the patient by means of his own
reasoning.... The part that the physician plays is simply to recall,
awaken, and direct....”[35]
No one who has not had the experience of guiding mental patients in the
way so lucidly expounded by the French physicians can form any adequate
conception of the remarkable efficacy of these common-sense methods
in restoring to those who are afflicted a normal attitude of mind. It
is certainly saving considerable numbers of soldiers from the fate of
insanity. These methods are not novel, even if the fuller comprehension
of their mode of operation is only dawning upon us now. This point has
been admirably expounded by Déjerine and Gauckler, from whose book we
must quote once more:—
“May we be permitted to quote a few lines in which Bernardin de St.
Pierre has defined, more exactly and better perhaps than we could do,
and with a sort of prescience of what is needed, the very rôle that we
would like to [see our physicians adopt towards their patients].
I wish that there might be formed in large cities an establishment,
somewhat resembling those which charitable physicians and wise jurists
have formed in Paris, to remedy the evils both of the body and of
one’s fortunes; I mean councils for consolation, where an unfortunate,
sure of his secret being kept and even of his incognito, might bring
up the subject of his troubles. We have, it is true, confessors and
preachers to whom the sublime function of offering consolation to the
unfortunate seems to be reserved. But the confessors are not always
at the disposition of their penitents. As for the preachers, their
sermons serve more as nourishment for souls than as a remedy, for
they do not preach against boredom, or unhappiness, or scruples, or
melancholy, or vexation, or ever so many other evils which affect the
soul. It is not easy to find in a timid and depressed personality the
exact point about which he is grieving, and to pour balm into his
wounds with the hand of the Samaritan. It is an art known only to
sensitive and sympathetic souls.
Oh! if only men who knew the science of grief could give unfortunate
people the benefit of their experience and sympathy, many miserable
souls would come to seek from them the consolation which they cannot
get from preachers or all the books of philosophy in the world. Often,
to comfort the troubles of men, all that is necessary is to find out
from what they are suffering (_Etude de la Nature_, 1784).”
Déjerine and Gauckler add:—
“One could not express any better, or any more directly, what we never
cease to maintain, however lacking in science it may seem at the
first—namely, the real therapeutic action of kindness.
Liberated morally, and having regained consciousness of self,
and freed in addition from his functional manifestations by the
appropriate processes ... the patient is cured. He is cured from
his actual attack. But his mental foundation, his psychological
constitution, still remains in the same condition which permitted
him under emotional influences to become a neurasthenic. The rôle of
the physician is, therefore, not ended. He must still build up his
patient’s life, still practise prophylaxis, and get the patient into a
condition where his character will be established.”[36]
_Rational Treatment._ So far in this chapter we have been discussing
what may be described as general methods of treatment, which do not
_necessarily_ involve any attempt to probe into distinctive individual
symptoms and to discover the real fundamental cause or causes of the
trouble. The measures so far considered are empirical rather than
rational. But they are the only methods of treatment discussed in most
of the text-books.
It is an axiom in medicine that correct diagnosis is the indispensable
preliminary to the rational and intelligent treatment of disease. This
fundamental principle is universally recognised in dealing with bodily
affections; but it is the primary object of this book to insist that
_it is equally necessary to observe the same principle in the case of
mental illness_.
It may seem ironical to stress this elementary consideration, but it
is notorious that accurate diagnosis is too often ignored in cases
of incipient mental disturbance. It is idle to pretend that such a
procedure is unnecessary, or to urge in extenuation of the failure to
search for causes that many patients recover under the influence of
nothing more than rest, quiet, and ample diet.
Many mild cases of illness, whether bodily or mental, may and do
recover even if undiagnosed or untreated. But on the other hand many
mild cases get worse; and it is the primary duty of the physician
correctly to diagnose the nature of the trouble and to give a
prognosis—to decide whether the illness is mild or severe. Some of the
most serious cases of incipient mental trouble are those of patients
who do not seem to be really ill, and are easily overlooked by a
visiting physician. They are quiet and inoffensive and display no
obvious signs of the insidious processes that are at work in them. But
all the time they may be, and often are, brooding over some grievance
or moral conflict, worrying about their feelings, misinterpreting them
and gradually systematising these misunderstandings until they become
set as definite delusions or hallucinations. If, acting on the belief
that it is bad to talk about a patient’s worries, the physician leaves
such a man alone, he is clearly neglecting his obvious duty. For the
whole trouble may be due to some trivial misunderstanding which he
could easily correct.
In the severer forms of mental disease, precise diagnosis is even more
intimately related to treatment than in the case of bodily illness.
For when a patient’s illness is recognised as some bodily affliction,
such as pneumonia or appendicitis, certain general lines of treatment
are laid down as soon as the appropriate label has been found for
the complaint, though, in the case of the latter illness, there is
added the further problem of whether or not surgical interference is
indicated.
In cases of mental disturbance, however, the general lines of treatment
cannot thus arbitrarily be determined merely by finding an appropriate
label. It is true that as in the treatment of bodily disease, certain
general principles must be observed, such as the provision of
abundant and suitable food, and the protection of the patient from
all disturbing influences. But the essence of the mentally afflicted
patient’s trouble is some particular form of anxiety or worry which
is _individual and personal_. The aim of the diagnosis, therefore,
should be not merely to determine the appropriate generic label for
the affliction, but rather to discover the particular circumstances
which have given rise to the present state. The special object of the
physician should be to remove or nullify the exciting cause of the
disturbance; and in order to do this it is essential that he should
discover the precise nature of the trouble. The diagnosis, therefore,
must be of a different nature from that demanded in case of physical
illness, where the condition may be adequately defined by some such
generic term as “lobar pneumonia” or “acute appendicitis,” and its
gravity estimated by the general condition and physique of the patient.
In the case of mental trouble, the physician has to make an individual
diagnosis, based not only upon an insight into the personality but also
into the particular anxieties of each patient.
But even when it is recognised that exact diagnosis of the particular
circumstances of each individual patient is essential, if the trouble
is to be treated rationally and with insight, there still remain many
difficult problems as to procedure.
Amongst those whom experience has convinced of the efficacy of
psychological treatment for this class of case, there are indications
of a divergence of opinion in the matter of procedure. Some believe
that it is sufficient if the medical man has discovered the real cause
of the trouble and explained it to the patient. Other workers look upon
a preliminary psychical examination merely as a means of diagnosis,
the unveiling of the hidden cause of the trouble; and consider that
the treatment should be the laborious and often lengthy process of
re-educating the patient, and so restoring to him the proper control of
himself. It is of the utmost importance to emphasise the undoubted fact
that those who maintain either of these views to the exclusion of the
other are committing a grievous and dangerous error, for there is no
sharp line of demarcation between the two procedures.
A sensible and intelligent man, once the cause of his trouble has
been made clear to him, may be competent to continue to cure himself,
or, in other words, to re-educate himself, and completely to conquer
the cause of his undoing. But the duller and stupider man may need a
daily demonstration and renewal of confidence before he begins to make
any progress. It is precisely analogous to the experience of every
teacher of a class of students; the brilliant man will seize hold of a
principle at once and learn to apply it without further help, whereas
the dull man needs repeated and concrete demonstrations before it sinks
into his understanding.
In dealing with soldiers, and this applies with especial force to the
regular army, the conditions in many of the cases differ considerably
from those of the civilians. Trifling forgetfulness in the civilian
would perhaps not be a serious cause of worry, but in the soldier,
inured by years of training to strict discipline, forgetfulness of
even trivial instructions, or any difficulty in understanding complex
orders, is likely to bring down upon his head condign punishment. Such
lapses are regarded by the soldier as extremely serious offences,
because years of training and discipline have inculcated this idea.
When as the result of shock such soldiers are afflicted by even slight
forgetfulness, they become worried by it much more than would the
civilian and exaggerate its importance until it becomes a real terror
to them. As the result of their training they may regard such phenomena
as altogether abnormal; and by a process of rationalising what to them
is a novel experience, they are apt to imagine that they are going mad.
Such patients often dream about incidents in their army life when they
had been forgetful and got into trouble; they become obsessed with the
haunting fear that they are likely to get into perpetual difficulties,
are worried by the thought that they are incompetent for the duties to
which they have been accustomed, and may imagine themselves debarred
from all useful work. However, they are easily reassured when the
medical attendant explains to them that in ordinary life civilians
are frequently subject to such experiences, and that it is only the
special circumstances of army life which make such trivial lapses seem
serious to them. Not only is the soldier much more scared by such
things than the civilian, but it is also a very remarkable phenomenon,
and certainly one which came as a surprise, that the neurasthenia of a
soldier is apt to be very much more serious than that of the civilian.
For when a really brave man is stricken by fear he is more seriously
affected by the terror of an experience which to him not only has a
larger element of novelty than in the case of the civilian, but also
wounds him more deeply by convincing him that he is lacking in that
very quality which is most essential for his professional work.
_The Therapeutic Value of Work._
It should be unnecessary to emphasise the desirability of preventing
the neurasthenic from dwelling upon his subjective troubles by
occupying his mind with other things. This end may often be achieved
by the provision of suitable occupation, and where possible, for
many obvious reasons, this occupation should take the form of useful
work. The worker then feels that he is not a mere burden upon the
hospital which is treating him: the institution in its turn benefits
materially. But it is necessary to sound a note of warning against
the indiscriminate prescription of work as a panacea. First of all it
should be certain that the work is of such a kind as really to interest
the patient and to occupy his mind. There are many varieties of work,
especially of manual labour, which can be performed mechanically, and
do not succeed in distracting the attention from worries and anxieties.
But more important even than this is the consideration that there are
some mental troubles from which no form of work will distract the
patient. Especially is this the case in many of the psychoneuroses
caused by the war. The sufferer is often haunted day and night by
memories which torture him not merely by their horror but also by
another aspect which is even worse: the ever-increasing moral remorse
which they induce. A patient may be troubled not only by the terrible
nature of the memory but by the recurring thought, “If I had not
done” this or that, “it might never have happened.” The reader will
easily see how such a thought may arise in the mind, especially of a
nerve-stricken officer or “N.C.O.” after weeks of brooding in private
upon the memory of a disaster. Now, such self-reproaches are frequently
based upon entirely insufficient evidence, and if the medical officer
is given the opportunity of calmly discussing their foundations with
the patient, the result is often to reassure him and to enable him to
view his past in an entirely new light. It is then, and not before
then, that he will be able cheerfully to enter upon useful occupation
and to benefit by it. To suppose that the mere physical fatigue
induced by a day’s hard work will banish all forms of insomnia betrays
an ignorance of one of the most important causes of this malady;
_viz._, mental conflict. It is well known that bodily fatigue in the
case of a mentally excited patient may merely increase his unrest at
night. Again, anyone who has had a few months’ experience of receiving
the confidence of these nerve-stricken soldiers will know that some of
their troubles are so poignant that the attractions of the (apparently)
most interesting kinds of occupation leave them cold.
To sum up, the physician may confidently prescribe work when, by
investigating the history of any particular case, he has satisfied
himself that such occupation will be likely successfully and profitably
to distract the patient’s mind from his worries. But the prescription
of work for the patient must be regarded as a sequel to, not as a
substitute for, the performance of work by the doctor.
FOOTNOTES:
[24] Such, for example, as those set forth in the series of articles in
Vol. VIII, of Sir Clifford Allbutt’s _System of Medicine_, 1899, pp.
88-233.
[25] The part played by bodily disease in the causation of mental
disturbance has been concisely summarised by Sir G. H. Savage in the
introductory chapter on Mental Disease in Vol. VIII, of Allbutt’s
_System of Medicine_, pp. 191-195.
[26] Or in some mild cases, to encourage him to wish to remain an
invalid under such pleasant conditions.
[27] In his careful studies of these conditions, C. S. Myers has
called attention to the mistaken notion of regarding these troubles as
“fundamentally due to disordered volition,” _Lancet_, Sept. 9th, 1916,
p. 467.
[28] This explanation of the reasons for the use of isolation is taken
from Mohr’s article in Lewandowsky’s _Handbuch der Neurologie_.
[29] As Sir Clifford Allbutt has pointed out (_op. cit._, p. 158).
[30] _The Psychoneuroses and their Treatment by Psychotherapy_,
translated from the French by Jelliffe, 2nd Edition, 1913, p. 311.
[31] _Op. cit._, p. 315.
[32] Feb. 13th, 1915 (p. 316); Jan. 8th, 1916 (p. 65); Mar. 18th, 1916
(p. 608); and Sept. 9th, 1916 (p. 461).
[33] _Op. cit._, p. 69.
[34] _Münchener Medizinische Wochenschrift_, June 15th, 1915, p. 335.
[35] Déjerine and Gauckler, _op. cit._, p. 283.
[36] _Op. cit._, pp. 302-3.