_ CHAPTER XVIII. 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 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 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 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 hystérie which 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 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 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 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 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.
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 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 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. _