PSYCHO-NEUROSES
"Look, what I will not, that I cannot do."
_Measure for Measure_.
The psycho-neuroses, that is, the various perversions of nervous
energy and inability to supply and conduct nervous impulses properly,
consequent upon a mental persuasion which interferes with these
activities, have come to occupy an ever larger and larger place in the
field of medicine. The war has been illuminating in this matter. A
psycho-neurosis is, after all, a hysterical manifestation and it might
very well be expected that very few of these would be encountered in
armies which took only the _men_ of early adult life and from among
those, only persons who had been demonstrated to be physically and, as
far as could be determined, mentally normal. Neurologists would seem
scarcely to have a place in the war except for wounds of nerves {259}
and the cerebral location of missiles and lesions. Certainly none of
the army medical departments had the slightest premonition that
neurology would bulk larger in their war work than any other
department except surgery. That proved to be the case, however.
The surprise was to have, from very early in the war, literally
thousands of cases of psycho-neuroses, "shell shock" as unfortunately
they came to be called, which included hysterical symptoms of all
kinds, mutism, deafness, blindness, paralysis, and contractures.
France and England after some time actually had to maintain some fifty
thousand beds in their war hospitals mainly for functional nervous
diseases, the war neuroses of many kinds. During the first half of the
war, one seventh of all the discharges from the British army or
actually one third of all the discharges, if those from wounds were
not included, were for these war neuroses. They attacked particularly
the better educated among the men and were four times as prevalent
among officers as among the privates. In proportion to the whole
number of those exposed to shells and "war's alarms and dangers"
generally, these war neuroses were {260} more common among the men
than among the women. Nurses occasionally suffered from them, but not
so frequently as the men who shared their dangers in the hospitals and
stations for wounded not far from the firing line.
In the treatment of this immense number of cases, a very large amount
of the most valuable therapeutic experience for psychoneuroses was
accumulated. It was found that suggestion played a very large role in
making the cases worse. If these patients were placed in general
hospitals where there was much talk of wounds and injuries and the
severe trials of battle life they grew progressively worse. They
talked of their own experiences, constantly enlarging them; they
repeated what they had heard from others as if these represented their
own war incidents and auto-suggested themselves into ever worse and
worse symptomatic conditions. This was, after all, only the familiar
_pseudologia hysterica_ which occurs in connection with hysteria, and
which is so much better called by the straightforward name of
pathological self-deception or perhaps even just frankly hysterical
lying. If these patients were examined frequently by physicians, their
{261} symptoms became more and more varied and disabling and their
psycho-neurosis involved more external symptoms.
In a word, it was found that their minds were the source of extremely
unfavorable factors in their cases. The original shock or the severe
trials of war life had unbalanced their self-control and suggestions
of various kinds made them still worse. Much attention to their
condition from themselves and others simply proved to be constantly
disturbing. As was pointed out by Doctor Pearce Bailey, who had the
opportunity as United States Chief of the Division of Neurology and
Psychiatry attached to the Surgeon General's office to visit France
and England officially to make observations on the war neuroses, the
experience of the war has amply confirmed Babinski's position with
regard to hysteria. The distinguished French neurologist has shown
that the classic symptoms of hysteria are the results of suggestion
originating in medical examinations or from misapplied medical or
surgical treatment. He differs entirely from Charcot in the matter and
points out that it was unfortunate misdirected attention to hysterical
patients which led to the creation of the many cases of _grande
hysterie_ which {262} used to be seen so commonly in clinics in France
and have now practically disappeared. They were not genuine
pathological conditions in any sense of the word, but merely the
reflection of the exaggerated interest shown in them by those
interested in neurology, who came to see certain symptoms and were, of
course, gratified in this regard by the patients, always anxious to be
the center of attention and, above all, the focus of special interest.
The successful treatment of the war neuroses was all founded on the
will and not on the mind. Once a careful examination had determined
absolutely that no organic morbid condition was present, the patient
was given to understand that his case was of no special significance
but on the contrary was well understood and had nothing exceptional in
it. The unfortunate frequent demonstration of these patients at the
beginning of the war as subjects of special interest had been the
worst possible thing for them. After experience had cleared the way,
they were made to feel that just as soon as the attending physician
had the time to give them, he would be able to remove their symptoms
without delay. This was almost the only appeal to the mind {263} that
was made. It represented the suggestive element of the treatment.
The two other elements were reeducation and discipline. Once
suggestion had brought the patient to believe firmly that he would be
cured, he was made to understand that his cure would be permanent.
Then reeducation was instituted to overcome the bad habit of lack of
confidence that had been formed, while discipline broke down the
psychic resistance of the patient to the idea of recovery. In such
symptoms as mutism or deafness, the patient was told that electricity
would cure him and that as soon as he felt the current when the
electrode was applied, his power of speech or of hearing would be
restored, _pari passu_, with sensation. The same method was used for
blindness and other sensory symptoms. Paralyses were favorably
affected the same way, though tremors were harder to deal with. A cure
in a single treatment was the best method, for the patient readily
relapsed unless he was made to feel that he had recovered his powers
completely and that it would be his own fault if he permitted his
symptoms to recur.
The most interesting phase of the successful treatment of these war
neuroses for us was {264} the fact that the ultimate dependence was
placed by the French on a system of management which was called
_torpillage_. _Torpillage_ consists in the brusque application of
faradic currents strong enough to be extremely painful in hysterical
conditions, and the continuance of the procedure to the point at which
the deaf hear, the dumb speak, or those who believe themselves
incapable of moving certain groups of muscles come to move them
freely. The method has proved highly effective and requires but little
time and practically no personnel except the medical officer who
applies the treatment and the non-commissioned officer who takes the
patient at the end of the treatment and continues the exercise of the
afflicted parts. One treatment suffices. The apparatus is of the
simplest, the only accessory to the electric supply and the electrodes
consisting of an overhead trolley which carries the long connecting
wires the whole length of the room, thus making it impossible for the
patient to get away from the current which is destined to cure him.
In a word, the man who would insist on maintaining a false attitude of
mind towards himself, though that attitude of mind was not {265}
deliberate, and least of all not malingering, was simply made to give
it up. Sufficient pain was inflicted on him so that he was willing to
accept instead of his own false opinion the opinion of his physician
that he could accomplish certain functions. _Torpillage_ was, in other
words, simply "a method of treatment which gave authority to a medical
officer to inflict pain on a patient up to the point at which the
patient yields up his neurosis." As a rule, the infliction of very
little suffering is needed, for once the demonstration is made that he
will have to suffer or give in, it does not take him very long to give
in. There is no doubt at all that the method is eminently effective,
particularly in those cases which were entirely refractory to other
modes of treatment.
It would remind us of some old modes of treatment which were in
popular use long ago, but which had gone out entirely in our milder
generation because we thought their use almost unjustified. It was not
an unusual thing three or four generations ago to rouse a young woman
out of an hysterical tantrum, once it was perfectly clear from
previous experiences that it _was_ really an hysterical tantrum, by
dashing a pitcher of cold water {266} over her. Sir Thomas More
relates that he saw a number of people suffering from various forms of
possession--and any neurologist will confess that some hysterics must
have a devil--who were cured by being roundly whipped. Certain men
and women who complained that they were unable to walk or to work and
thus became a care for relatives or for the community, were cured by
this, as it seemed to later generations, heartless mode of treatment.
Now, we have turned to curing the war hysterias by punishment, that
is, by the infliction of severe pain, in just the same way. A great
many of these patients who suffer from neuroses and psycho-neuroses,
and especially from hysterical inhibitions so that they cannot hear or
cannot walk or cannot talk, represent inabilities similar to many
which are seen in civil life. Patients complain that they cannot do
things; their friends say that they will not do them; and the
physician sees that the root of the trouble is that they cannot
_will_. Now, however, that war has permitted the use of such remedies,
physicians have found that they can, to advantage, force the patients
to will and that once the will has been recalled into action, its
energy can be maintained.
{267}
Of course the compulsory mode of treatment was not represented as a
punishment, but on the contrary it was always presented as a form of
treatment which was extremely painful but necessary for the condition.
Presented as punishment, it would have been resented, and the patient
would probably have set about sympathizing with himself and perhaps
seek the sympathy of others, and this would prevent the effectiveness
of the treatment. It is very evident that as the result of compulsory
methods of treatment, and of the recognition of the fact that major
hysterical conditions are largely the result of suggestion and must be
cured by enabling the patient to secure control over himself again,
the outlook for the treatment of the psychoneuroses will be very
different as a consequence of the experience that has been gained.
Above all, the place of the will will be recognized, and there will no
longer be that coddling of patients and that analysis of their minds
for long distant psychic insults of various kinds which will explain
their condition, that has done so much harm in a great many ways in
recent years.
Another feature of the French treatment was that the neurotic patients
should be {268} isolated. This isolation was complete. It had been
found that association with other patients, the opportunity to tell
their troubles and be sympathized with, did them harm invariably and
inevitably, so that those whose neurotic symptoms continued were taken
absolutely away from all association with others. Not only this, but
all other modes of diversion of mind were denied them. They were
placed in rooms without reading or writing materials and even without
tobacco. This solitary confinement would remind one of the enforced
privacy of the old-fashioned rest cure in which the patient was
absolutely secluded from all association with relatives or others who
might in any way sympathize with them. The soldier patients were kept
in this complete isolation until such time as they showed themselves
amenable to treatment. This was usually not very long.
As a matter of fact, the isolation rooms had to be used very little
but were found necessary and especially effective in the management of
relapsed cases. Just as soon as soldier patients learned that such
isolating rooms were available, they became much more ready to give up
their neuroses, and as a consequence, in most places, the isolating
department did {269} not have to be used, and in some places they
could even be given over to the lodgment of attendants. It was quite
sufficient, however, that they had fulfilled their purpose of changing
patients' attitude of mind towards themselves and giving their will
control over them.
As Colonel Pearce Bailey, M.C., says, in most of these patients,
persuasive measures and contrary suggestion were quite sufficient, but
when they failed, disciplinary measures proved effective. How are we
going to be able to make such disciplinary measures available in civil
life is another question, but at least the war has made clear that
neurotic patients who claim that they cannot do something and actually
will not do it, _must be made to do it_, for this will prove the
beginning of their cure. It seems probable, as Doctor Bailey adds,
that the reason why the treatment of officers was more difficult--and
it must not be forgotten that in proportion to their numbers, four
times as many officers suffered from so-called shell shock as
privates--was exactly because these modes of discipline, amounting
practically to compulsion, were not used with them.
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