WAR-SHOCK In the Press. STUDIES IN WORD -ASSOCIATION Edited by Dr. C. G. JUNG. Translated by Dr. M. D. EDER. ON DREAMS By Prof. Dr. SiGM. FREUD. Only authorized English Translation by Dr. M. D. EDER. With an Introduction by W. LESLIE MACKENZIE. M A., M.D. Crown 8v<>. 144 pp. Price 3J6 net. HYPNOTISM, OR SUGGESTION AND PSYCHOTHERAPY By Dr. AUGUST FOREL. Translated by H. W. ARMIT. M.R.C.S.. L.R.C.P. Large Crown 8vo. 382 pp. Price 7/6 net. LONDON : WILLIAM HEINEMANN WAR-SHOCK THE PSYCHO-NEUROSES IN WAR PSYCHOLOGY AND TREATMENT By M. D. EDER, B.Sc. LOND., M.R.C.S., L.R.C.P. LOND. Late Temporary Captain R.A.M.C., and Medical Officer in charge of PsychorNeurological Department, Malta feriuntque sumna* Fulgura monies. LONDON WILLIAM HEINEMANN London: William HeinL., they react normally. Contraction of left visual field. Loss of smell (tobacco) in left nostril, and of taste (salt, sugar) on left side of tongue. Hearing less on left side than on right. A complete left hemianalgesia. All the movements of the left upper limbs are feebler than right and associated with increase of tremor. There is pain over the cardiac region with palpita- tion and breathlessness. Tachycardia was noted with ANXIETY-HYSTERIA 87 a rapid irregular pulse ; occasional attacks of dyspnoea which are relieved by drawing a succession of deep breaths with a loud sigh in expiration. There is in- creased frequency of micturition, but the total amount of urine passed in the 24 hours is not excessive ; the urine is normal. The gait is normal. All the reflexes are brisk and equal. He surfers from intense pains over the back of the head, especially on the right side ; he sleeps badly, dozing for a few minutes and waking up with a start and in a profuse sweat. The nights are disturbed by nightmares and terrors. He complains of loss of memory and of inability to concentrate his attention either in conversation or in reading. A walk of a few yards or the reading of a few lines completely exhausts him. He is in great fear that he is " going mad." He is happily married and has three children. The amnesia is complete for the earlier years of his life, and selective for later periods. There is a complete loss of memory of everything up to the age of 11. He knows that he then left G. for a large town in the North of Ireland where he still lives. But he remembers nothing of G. ; whether he went to school there, the kind of house he lived in and so on. From that time up till the war the memory is good, yet with certain blanks as to dates, e.g., the year of his marriage. He could not at once say how many children he had nor their names. He had forgotten the name of his employer with whom he had been for some years. The patient was the manager of a cinema and was in daily association with his employer on the most friendly terms. These lapses of memory would obsess him, and he had various devices for overcoming the diffi- culty. Half a night he lay trying to think of this employer's name and then recollected he had a 88 WAR-SHOCK photograph with his autograph. The name was a very common Scotch name, and was also that of a physician who had seen him in Malta in August, 1915, and invalided him back to England. The physician's name was well known to the patient at the time of his illness. There were also defects of what Mercier l calls the practical memory, and to some extent one could say of this patient what Mercier writes of a case he quotes : " It is for future things that his memory is defective." An instance of this loss of practical memory, or apraxia, was his inability to strop a razor and although shown he would be immediately at a loss how to do it. (He was able to shave himself.) He did not know how to lace up his boots, and he would forget all appointments in regard to his work as an orderly, the hours of meals, etc.; the want of memory made him oblivious to the shoulder tic and the tremors. As he himself said, he forgot all about it till some one would ask him how his shoulder or face was. One could almost say that he forgot to see with the left eye, to hear with the left ear, to smell with the left nostril. On several occasions the content of consciousness had been abruptly broken and the patient possessed by a quite new stream of conscious ideas. Such a somnambulism occurred for instance on his return to duty in April, 1915. He had left D in Ireland overnight on his way to Aldershot ; in London he had several hours to wait. Walking about he suddenly found himself in V Street, D , with the Opera House in front of him. He crossed over to a fruit shop which he knew well, as it was at the corner of his own street (in D ) and was kept by a friend of his, Mr. (let us say) Leary. He went in and asked for Leary. The fruiterer knew nothing about Leary and a slight altercation arose ; he thought they were 1 " A Text Book of Insanity," 2nd edition, 1914, p. 106. ANXIETY-HYSTERIA 89 playing a stupid joke with him. He crossed back to look at the building and was dazed to find it was a blank wall. He asked some ladies passing him what had become of the Opera House and then his mind became quite blank till he awoke, quite himself, the next morning in the police station. The police had taken care of him overnight. He proceeded to Alder shot. He was told about the incidents of the previous night and understood objectively what had happened, but he had never yet been able to fit the events into the stream of his conscious life. It was no more to him than if he had read a similar curious story in the newspaper. He was not feeling well when he received orders to report for duty. He was in a condition when, as Mercier 2 puts it, "the states which should normally be subconscious are thus lifted into the light of full consciousness, and become subjects of attention without direct guidance from the will, which is otherwise engaged." It is easy here to read into the state thus lifted into full consciousness a wish- fulfilment. He wished to be at home in D ; he was at home in D ; a fruit shop became the fruit shop kept by his friend Leary at the corner of his own street ; the blank wall had become the Opera House of his own city. On another occasion, prior to his return to Malta in November, 1915, he had been three weeks in Aldershot, when one night, about ten o'clock, he dressed himself, put on his overcoat, haversack and water-bottle, and reported himself in the guard room as having just arrived. He gave his name correctly, drew his blankets, etc.; on leaving the room he was recognised and conducted back to his room. He awoke the next morning with complete amnesia of 2 C. Mercier. Discussion on " Imperative Ideas." Brain, 1895, p. 329. 90 WAR-SHOCK the incident of the previous night. " The next morning I was told about it and was frightened of myself." A few days later the same thing happened, when he was recognised by an orderly in the guard room. Here again we see the wish-fulfilment, the endea- vour to blot out the three weeks in Aldershot. After the shelling of the hospital in France (April, I 9 I 5) be had several hysterical fugues, wandering from the tents and hospital and "coming to himself" some distance away, ignoring how he arrived at the spot, the intervening period a complete blank. Minor instances of such lapses of memory were of frequent occurrence. In a word-association test 3 carried out with this patient, he, on one occasion, gave 68 per cent, of meaningless reactions and "faults," and a fortnight later 41 per cent. The percentage of meaningless reactions and faults among normal men of his own class is between 0.9 and 2.4.* By a meaningless reaction is understood a reaction which is either not a word at all or not an associa- tion. The non-associated words are frequently the name of some object in the room, as in this patient. A " fault " means the absence of a reaction altogether. Thus, a series of reactions with this patient ran : Stimulus-word. REACTION. Head Pin (one was on the table). green watch (one on my wrist). water button (on uniform). /'Pembroke (name printed p. , \ on a box in the " bunk" 1 where test was con- C ducted). 3 For the technique of this test, see "The Association Method " in Analytical Psychology. Opus cit., p. 94, et seq. 4 "The Associations of Normal Persons," by Jung and Riklin ; Chapter II. of "Studies in Word- Association." edited by Dr. C. G. Jung, translated by Dr. M. D. Eder. London : William Heinemann. (In the Press.) ANXIETY-HYSTERIA 91 Stimulus-word. REACTION. angel ship pick wool town sea. orderly. cigarette (I was smoking). This patient had made his own way in life; he had a rather forceful personality and a great love of independence. His father had been a school- master in Scotland, had then gone into a business in Ireland which had been a failure. Soon after the age of twelve the patient began to earn a living and at a very early age he was the main support of his parents. He was the youngest of the family, the other brothers and sisters had been better educated than himself and were all in far better circumstances. He was not on friendly terms with them. His father had died some years ago, but his mother, still alive, remained a member of the house- hold. Although he had been in many trades he succeeded best in work that was connected with the theatre, and for many years he had been engaged in some way with theatrical life. Super, actor, box- room attendant, pay-office, and finally manager of a cinema. Only in this way was he happy in his work. Sublimation. 5 The peculiar attraction the theatre had for him showed itself to be the sublimation of infantile exhibitionist tendencies. REGRESSION OF THE LIBIDO. To a man of this temperament the necessary army discipline was more than irksome. He was a "unit," his individuality felt swamped. There was no outlet 5 The replacement of infantile and childish impulses by corresponding adult outgrowths subserving more altruistic and ethical purposes is called sublimation, when this develop- ment takes place as normal growth from within, and not by compulsion, by authority or external pressure. There is no "repression " in successful sublimation. 92 WAR-SHOCK for the display of his personality, for the sublimation of his exhibitionist tendencies. His not to reason why, his but to do as he was told and told by others whom he regarded, whether rightly or wrongly, as inferior to himself in intellect and character. It must not be supposed that this represents the patient's conscious attitude or that he was in any sense fractious or insubordinate. Quite the contrary ; from independent witnesses (he had been an orderly in the hospital) I was able to gather that he was most faithful in the fulfilment of his duties a model orderly in every way until his health broke down; he had never voiced any complaint. The conflict raged within, and being debarred from reaching conscious- ness, owing perhaps to the patient's unusually high sense of duty, it found vent in phantasies. Jung 6 says, " If the individual consciously or unconsciously allows the libido (psychical energy) to turn away from a certain essential task the non-used up libido occa- sions symptoms of a painful nature, oppressing the individual at every turn." The wish to regain his feeling of lost individuality expressed itself in these attacks of somnambulism when he broke the chain of consciousness that bound him to the army by the temporary assumption of his former self. In the attack he was out of the army, he was b^ick again in his former life, he was the theatre manager or filled another of his favourite roles. A dream shows this desire for individual distinc- tion. "/ was in France at some hall or theatre, a hypnotist was on the stage with me. He asked for volunteers. I went . . . a lot of bugles. I was called to put out a fire." 6 "The Theory of Psychoanalysis," by C. G. Jung. New York : Nervous and Mental Disease Publishing Company. 1915. ANXIETY-HYSTERIA 93 The patient had once taken part in a rescue from a fire and his name had appeared in the local paper. The other associations showed that the fire stood for the display of individual energy, passion. (He knew that I used hypnotism in the treatment of some patients.) The dream is an unconscious demand from those in power to allow him to regain his individuality ; he wants to be called upon to display himself, to be a leader. THE CHOKING OF THE LIBIDO. Among the common symptoms in this choking of the libido is a return to infantile and childish phan- tasies, a regression to an earlier adaptation possibly long since abandoned, as in this case. A dream showed us in what infantile phantasies the libido was now engaged. " / was going to be hung. I was working at some hospital in France, with a German patient. I shot him with a revolver. I was put in a cellar and was brought out to be hung." The German patient turned out to be an older brother ; the rest of the dream was a typical one and will be understood by those acquainted with symbolic language. Its full explanation would re- quire a detailed exposition that would take us beyond the scope of the book. The last dream he brought me in analysis, just before he was transferred home, ran: " / was carried on a stretcher to the eye bunk and you were there, but you went out and left me. I tried to run after, but could not move any part oj me." (My work was carried out in the "eye bunk.") The analysis showed that this paralysis expressed his double -sided (ambivalent as Bleuler calls it) 9 WAR-SHOCK attitude towards leaving me. He wanted the treat- ment to continue, so that in the dream he is very ill and must be carried. (The patient was really up and dressed.) I leave him, it is my fault, as it were, that his treatment is to stop. He wants me. But he also wants to go home. Hence the paralysis a mental indecision. The shrugging shoulder (again left-sided) turned out to be a rather unusual form of symbolic conver- sion. It expressed disapproval of his own uncon- scious phantasies. The patient was under psycho-analytic treatment for four weeks ; this had resulted in improvement in his symptoms. The hysterical stigmata had left, the tic was much less frequent and violent. His burning headache had ceased and he was sleeping better (no hypnotic drugs had been given throughout). The somnambulistic attacks had gone and he was beginning to concentrate ; he could read a paper and write a letter; he brought me some verses he had written. But the analysis was incomplete, and the patient's unconsciousness had recognised, as his dream showed, that he was not cured and required further treatment. I feared he would relapse before very long. Such improvement is not infrequent in the early stages of analysis, and has too often deceived both patient and doctor. 7 7 I heard from this patient some time later. He was still in hospital having a rest cure ! Some of the symptoms, as I feared, had returned. CHAPTER V PSYCHASTHENIA THE name given by Janet calls attention to one of the most prominent clinical symptoms in these cases, the intense exhaustion, as Freud's term, obsessional neurosis, rivets attention upon another of the main clinical features. I have retained Janet's designation because it is the better known, and had I adopted an unfamiliar name for this group of diseases I should have fashioned one that fastens upon a deeper psycho- logical aspect. But, for reasons already given, the psycho-analysis of none of my patients was complete and the results given in this chapter are too meagre to add much strength to any far-reaching psychologi- cal conclusions. Still, some of the analyses do, I think, offer evidence in support of Jung's 1 intro- version theory as well as to a further conception which I will leave unnamed. COLLECTING MANIA FEAR PSYCHIC AMBISEXUALITY. No. 95 was living in a north-eastern town that was bombarded in December, 1914. A shell came through the roof of a house where he was staying with his wife, child and father. No one was hurt, but for the next three weeks he was quite " broken down." He could not undress nor go to bed at night, but slept 1 Analytical Psychology, op. cit., p. 847. 95 96 WAR-SHOCK fitfully in a chair. He was " all of a tremble" and started at the least noise, breaking into a fit of crying at the slightest provocation or at none. His wife used to comfort him. He gradually got better "in himself " but still felt very nervous and trembling ; he was afterwards afraid to drive a motor bicycle or a horse and cart, both used in his business. Never- theless he felt he must "do his bit" and enlisted in August, 1915, in the A.S.C. motor transport but broke down right away. He was to be retained for home service, but implored his C.O. to give him a chance of serving abroad. He was sent to Salonica. It was found that he was too nervous to drive and he was given work in the stores until, owing to in- attention, he made some mistakes and was kept for odd jobs, such as clearing the rubbish away round the tent, removing stones. He had a fit and was sent into hospital. When he came under observation in February, 1916, he was suffering from sleeplessness, inability to fix his attention, terror so extreme that if a motor went by the hospital grounds he would scuttle under the bed. With difficulty could he be persuaded to take off his clothes at night ; he had a " collecting mania," having gathered several bags of cigarette pictures for his little girl and bags of stones from the shore. The fear of Zeppelins was obsessional. The Sister coming in with a lantern was sufficient to send him under the bed ; another obsession was that he would be accused of stealing, e.g. his own uniform and boots, since he had done no fighting. There was analgesia of both legs to the knees and of the left arm to the shoulder. There was no history of previous nerve trouble ; he was happily married, in a decent position, a total abstainer ; he had often taken part in boxing competitions and cycle racing. (His " legs used to get excited before a fight.") PSYCHASTHENIA 97 This patient showed his grit by enlisting voluntarily, against the wishes of his wife, family and friends, and by getting abroad ; a strange contrast with his con- dition of fear and terror. The following two dreams throw light on this contrast. Dream. He was at home dressed as a High- lander and saw his little girl who did laugh so did he, Dream two days later. He was a Chinaman in native dress, with a long pigtail; beautifully long hair right to the floor, No analysis of the dreams was made (nor, of course, any interpretation given to the patient). These are typical dreams of being or desiring to be female. The Highlander's kilt is a disguise under which the endopsychic censor permits such unconscious wishes to appear in consciousness without betrayal. A Chinaman is perhaps more tell-tale ; Europeans pro- verbially find it difficult to distinguish a Chinese man from a woman, on account of the flowing robes, the lack of hair on the face, etc.; in this dream the pigtail, as if the latent meaning was trying to get expression, was beautiful and long, reaching to the ground. - It is important to note that the " dream- work " aims primarily at disguising the meaning of the dream, or its latent content, from the dreamer himself ; the censor is much less concerned with concealing its significance from third persons. The symbolism here used, though plain enough to myself, was quite effectual so far as the dreamer was concerned. It is probable that if the first of these two dreams had been analysed in the usual way and the dreamer had 2 It must not be assumed that a Chinaman invariably stands for "woman.'' There might be, of course, some specific memory. I am only dealing with it when it is a universal, not a particular, symbol. H 98 WAR-SHOCK realised its significance, the second dream would not have occurred, or very different symbols would have been used. The reading of this dream shows, as I have said, a concealed wish to be a woman ; he is psychically a woman. This gives the clue to the patient's exces- sive emotivity, his exaggerated fears, his " woman's " heart that burst out crying if he saw a child in the street. The primitive unconscious is wont to exaggerate any part, especially to overact its popular attributes. If a woman may be regarded, without prejudice, as the lawyers say, as a more timorous creature than the male, then the unconscious repressed female in a male exhibits fear greater than was ever shown by any woman ; if a woman is popularly taken or typically regarded as having motherly feelings towards any child, then the female suppressed in the male weeps bitterly over every passing child. It is a case of ambisexuality, the male side being shown by the desire to share in the fighting. The origin of this exaggerated psychic ambisexuality was not discovered, for no deep analysis was made, though the anamnesis and some other dreams threw some light on the problem. The " collecting mania " was connected with a money-complex. His father, beginning life very humbly, had amassed quite a respectable sum of money. This patient felt a desire to amass money like his father, to have his father's money so that there was an under feeling of bitterness and rivalry towards his father. This found conscious compensa- tion in the most exaggerated praise of his father and of the patient's wonderful goodness as a boy and man towards his father, of extreme punctiliousness in money matters ; see, for instance, his doubt whether he should not return his pay to the State since he had done no soldiering, which co-existed with singularly PSYCHASTHENIA 99 naive reckonings as to how much he would be able to draw by the time he reached England. The result of treatment by hypnotic suggestion is very interesting; he was easily hypnotised and responded readily enough to suggestion under hypnosis but post - hypnotic influence was for a time altogether absent. His fears remained, his excessive emotivity, sleeplessness, and so on. We continued our psychological investigations (diagnostic psycho-analysis as it may be called) and he brought me the material briefly summarised here together with the dreams. I then used the know- ledge, deduced from the psychological examination, under hypnosis, telling him that he was no longer to act the timid female, that his womanly side would quite go, that he was a vigorous male, that he had no exaggerated female characteristics, that he did not want to bear children (another dream showed this phantasy), but to be the father of children and so on. He re-acted post-hypnotically to these suggestions ; from that time (the sessions were repeated) the fears began to diminish and finally disappeared. The next day he proudly told me that he had brushed his boots the first time since leaving England, nearly two months ago. He no longer scuttled under the bed if he heard a motor-horn ; the analgesia disappeared. This case shows the advantage of knowing what suggestion to give in difficult cases ; in easy cases, of course, the stereotyped suggestion answers well enough. To obtain the information required for accurate suggestion we can apply the results of psycho-analytic knowledge to our patients' symptoms history and dreams. In the waking state this patient was not aware of the suggestions that had been made to him during hypnosis, upon which he subsequently acted. He knows nothing to this day about the possession of a money-complex, of his unconscious 100 WAR-SHOCK attitude to his father, or of his strongly marked female side. FEAR CONTENDING WITH DESIRE The following is but a fragmentary history; I have included it because, incomplete though it is, it presents a not uncommon psychological attitude. No. 100 was admitted for physical and mental exhaustion and insomnia. There were no physical signs. All he wanted to do, as he put it, was to lie coiled up in bed; it was an effort to think, it was an effort to eat, it was an effort to turn round in bed ; he did not want to become aware that he had legs or hands. It was not the condition of apathy as seen in melancholia. He wanted to lie coiled up in bed, but he could not; he could not prevent himself being stirred into some kind of activity by his surroundings; conversation would trick him, as it were, into a discussion; then he would think this activity was injurious and would fall into silence. " I'm tired out, and though I spend most of my days in bed, it is without rest or sleep." " I feel I have to go through the whole weary business again." " What's your name, age, service what's the matter with you ? Why can't you sleep ? I'm simply too tired to bother with it all," was his feeling on admis- sion to our department. The patient was 28 ; he had been married subsequent to joining the army. He had joined the service in the autumn of 1914, his health not being good enough to join at the beginning of the war, and had risen rapidly to high N.C.O. rank. He had seen service in France and the East. He was much worried about the relationship between himself and his commanding officer a recent appoint- ment whom my patient believed was trying to get him reduced in rank. That the patient had risen from merit alone was clear ; he had no Army friends. PSYCHASTHENIA 101 He had been educated at a public school and had afterwards had good appointments in the Colonies, having returned to England two years before the war for family reasons. The work abroad was rather responsible, of a nature calling for much individuality and management of subordinates. It was doubtless to this training, combined with great natural gifts, that he owed his rise. There had been three similar attacks of illness before the war, in fact he was convalescing when the war broke out. The family history was medically not good. His had been a solitary life ; he had had but one friend at school and later in life found it difficult to get into touch with men and women. Like so many in similar case life never seemed wholly real to him ; he had drifted along. With many abilities, he had not hitherto found his niche in the world ; " people did not understand him." The home life had not been a happy one; between himself and his father there had always been opposition ; he was out of touch with his mother and sisters. He had become in- terested in ideas and social reforms, especially in sexual problems. Frankness between the sexes he was wont to regard as the first desideratum and he claimed that he had been able to establish this with the one or two women he had known at all inti- mately ; " a platonic relationship" on this basis had been his ideal. He had kept himself pure and had never indulged in the mildest flirtation. He had a horror of sex and he complained that the language of the barrack-room and the camp was filthy. He found that women and sex were the only topics of conversation and it was the one theme he wanted to shun unless it could be discussed in an entirely rational and scientific spirit, as he complained it never was. He had, during his stay in parts of the 102 WAR-SHOCK world notorious for their license, kept himself un- spotted chiefly, he believed, for a girl whom he had known in England the first woman outside the home circle he had known ; she had been the main factor in bringing him away from the cramped and rather sordid home atmosphere. She (and her brother) had inspired him with ideals of life, had awakened a certain literary instinct and had urged him towards a higher life. There was no question of marriage with this lady, who was some years older, and with her he had never discussed the sexual problem in any way. On the surface there was this pure and rational attitude towards sex; but beneath there was a raging torrent of desire which had never found any outlet, of course a not very uncommon position. " More than I, if truth were told, Have stood and sweated hot and cold, And through their veins in ice and fire, Fear contended with desire." It was in compensation for this ill-regulated sexual life in the unconscious that he became so horrified at the common attitude towards sex. He found the talk of the barrack -room and the camp filled with nothing but woman and sex because it was the only talk which at once attracted his attention he was unconsciously on the quivivefor every allusion to sex. Those acquainted with the life among soldiers will know that sex-talk is no more rampant among them than among any other body of men. From an experience gained in three different campaigns with soldiers, British and non-British, in very different countries and under very different conditions, I have found the interests of the soldier as wide as life itself at all events on active service where only I have been intimately associated with them and this most intimately, for a long sojourn in a besieged up-river PSYCHASTHENIA 103 post produces the closest associations with one's fellow-sufferers. To one who has lived with men when they were doing the real fighting it is in- teresting to contrast the poetry written by warlike poets with that written by poet warriors. 3 In our patient it was then this fear of sex that led him to try and put it on a rational basis. It was his own sexual problem that he must solve ; as is so frequently the case, his individual need became identified with the general need. As type of his early adolescent phantasies the following may be given. He would imagine that his two schoolmistresses (much older than himself) were naked and he was driving them along whipping them, or he was bathing with them naked and striking them. Similar phantasies occurred with others, e.g., with a little girl of his own age and with a typist engaged in an office with him. (Never had he phantasies with the ideal Miss X.) His frank discussions with women had never led him to the disclosure of these and similar phantasies that had haunted him for years. A dream will show the nature of some of these phantasies. On a boat running out of A Harbour, going down the River B . * We went through a narrow passage which came gradually to a point, and got stuck in the mud. Ship did not stop. Looking out of the port hole window I saw a Zeppelin in the dis- tance. It was attacked by a fleet of balloons. One burst and all the bits came dropping through the air. 3 Compare Kipling's "Barrack Room Ballads" with the gallant Grenf ell's -'Into Battle " or the writings of journalists safe at home like Bottomley and Blatchford with the works of actual fighters like Boyd Cable and the author of "A Student in Arms." 4 I omit the names of these places to prevent identification of the patient. 104 WAR-SHOCK One end of the Zeppelin was dropping but it rose and woke me up with a start. The patient was totally unacquainted with psycho- analytic literature ; he did not even know that he was being analysed ; and, of course, no sugges- tion was made to him as to what might be the meaning of the dream. He was, however, well read in the Bible and other literature, so that with symbolic language he was at home. His associations to the incidents as described in the dream soon brought him to an appreciation of the symbols he had used. He discovered that the narrow passage stood for the vagina and that the mud was the anal region ; that the boat coming down the passage (the vagina) was himself (cf. , the birth of Moses, of Ra, and other legendary heroes discovered in infancy floating in barks on water). When by association he had identified the balloon as the womb and the Zeppelin as the phallus, and further associations showed that it was his mother's womb and his own phallus, the dream got a meaning for him. Birth is per anum or at least closely con- nected with that region of " filth." The sexual act is filthy like the act of defalcation ; as another patient once put it to me, coitus was just the same as going to the w.c., to be performed on the same hygienic ground. His phallus (Zeppelin) is the prey of women (balloon) which will destroy his male power. The further motive of the dream was then brought home to him. For him sexuality is a sin derived from the woman; "Through the woman came sin. The woman tempted me and I did eat." The mean- ing being that he would ascribe the blame for his difficulty in overcoming the adaptation to a normal life to the mother this is the CEdipus motiv. Jung writes : 5 " The neurotic who cannot leave 5 " Psychology of the Unconscious." Op. cit., p. 304. PSYCHASTHENIA 105 the mother has good reasons ; the fear of death holds him. It seems as if no idea and no word were strong enough to express the meaning of this. Entire religions were constructed in order to give words to the immensity of this conflict. The struggle for expression which continued down through the cen- turies certainly cannot have its source in the restricted realm of the vulgar conception of incest. Rather one must understand the law which is ultimately expressed as incest prohibition, as coercion to domestication, and consider the religious systems as institutions which first receive, then organise and gradually sublimate, the motor forces of the animal nature not immediately available for cultural purposes." With this dream we may take a later one. " With my mother in house in B. (town where he was born). We went for a walk and coming back I saw the house was on fire. Mother said, ' We've saved our wedding presents! I asked if my books were saved, but they had all been burnt}* This dream requires some explanation. The patient in the anamesis had at first dilated upon the joy he had found in the marriage state: for the first time there had been complete harmony in his life. Analysis had shown that in reality the patient had been bitterly disappointed ; marriage was wholly distasteful and abhorrent. He had tried to overcome this repugnance and to make love become the rapture depicted by poets and novelists. He had thought that it was treachery to his bride to acknowledge even to himself his misgivings and vainly hoped with time the union would bring him, if not real happiness, at least contentment or that perhaps death in battle would solve the riddle. What had rushed him into marriage did not become quite clear, but it is to be remembered that the army life gave him for a time certain satisfac- 106 WAR-SHOCK tions (compare his phantasies), that at first he was able to forget himself and to become more normal. It was shortly after joining that he had his first amorous adventure; he took a young lady, whom he accidentally met, to some entertainment and went so far as to put his arm round her waist. There was a revulsion of feeling the next day but it was not long afterwards that he became engaged (not to this girl) and was married. He was perhaps carried away in this almost adolescent state by what Mr. H. G. Wells would call the enterprising female. Now the patient understood that he was imper- fectly developed, despite the rather wandering life he had led and the Army experiences ; he knew himself to be quite immature and, like Peter Pan, he did not want to grow up. Knowing that I could only treat the patient for a very short time, I did rather hurry him, but he was very intelligent and his unconscious in a receptive mood. He understood that relationship between his wife and himself would not be satisfactory until he swept away all dishonesties from himself, that the first step towards a real life in common was to do away with his pretended raptures and literary make- beliefs. Courage to face himself was the primary need. There followed 48 hours of acute misery and then the dream his books were destroyed the mannerisms which were only plumes borrowed from others, were ended. Having divested himself of what was so merely external he must meet the world with his own resources. The dream suggests that there is in the unconscious no clear distinction between his wife and his mother; the house, his early home, like the city, is "a maternal symbol, a woman who fosters the inhabitants as children." 6 6 Jung, op. cit., p. 224. PSYCHASTHENIA 107 Fire is a well-known symbol of passion, of the libido. 7 The patient has gone a little way on the path to reality ; he has discovered that his libido is still attached to his mother and that he must free himself therefrom before he can overcome his fear of sex. That fear overcome, he will be ready for the next stage in his development sex will no longer fill the overwhelming role that it at present does in this masked fashion. The process of self-deception must end if any harmony is to be established. We can understand that with this tremendous conflict of emotion raging within him the patient should be exhausted. There is inertia because the fight for reality loomed so terribly in front of him. There was no time to make a complete analysis, of course, nor to help the synthesis. It remains, as I said, a fragment, but the history suggests that sex must be on a satisfactory footing before the individual aim can be discovered or have any value. In some cases the understanding of the sexual life will be sufficient in itself to bring about a normal if somewhat restricted life. IDIO-KINESIS. No. 99. The patient is a married man, aged 29, a private of some months' service, who, after three months in France, was sent to Salonica, where he was invalided for severe and persistent backache, insomnia, and occasional enuresis. On Feb. 5th, 1916, he presented a widespread analgesia, with odd normal patches, and a zone of hyperaesthesia in the lumbar region. It is his mental condition, however, that will be here dealt with. There were sleeplessness, general restlessness, inability to fix his attention on anything for more than a few minutes. 1 Jung, op. cit., p. 162, et seq, io8 WAR-SHOCK In conversation with his mates he would, for instance, be suddenly quite oblivious of what they had been talking about and feel uncertain whether he had spoken or not. He read for a few lines and would throw down the paper. In writing home he once told me that he had begun twenty letters, destroying each, and then finished a few lines. He was so " shy " that he could only with difficulty walk along the hospital grounds, feeling then that everybody was looking at him. He had found it impossible to number off in the ranks, and had he to address his commanding officer he would become speechless. He was morbidly anxious about his family; though he had no reason to suspect illness, he would carry a letter from his wife two or three days in his pocket before venturing to open it, lest there should be bad news. There were numerous obsessions or eccentricities. In walking he must mark each flagstone and touch each post. He had the impulse to count and to arrange things in patterns, counting on his fingers or the panes of windows in the rooms and arranging them in sets of twos, threes, etc. An obsession that came to light was an impossibility to go into a shop or restaurant alone. By dint of great effort he could thrust himself into a hosier's or tailor's shop alone, after a careful survey to ascertain that no other cus- tomers were present. This peculiarity was the cause of numerous embarrassments. His wife, to whom he was ashamed to confide the trouble, would ask him to buy something when he was going out. He would assent, realising at the same time the impossibility of the task, and already inventing some lame excuse to be presented on his return. Often had he gone without a meal when motoring alone because he could not face going into a restaurant. At times a cloud seemed to come over him and he PSYCHASTHENIA 109 did not seem in the world at all, but was without, a spectator watching and but dimly interested in the movements of men and women, himself included. He was a Public School man, with a well-developed and subtle intellect ; he was well oriented in space and time. He realised quite well the absurdity of his obsessions, and, as he said to me, "I know I'm a damned fool and it's rot, but there it is, I cannot help myself." We learn from his history: That he had never done any work since he left school at 18 until he joined the Army as a private. He had substantial private means. He had been married three and a half years and had a son and was devotedly (morbidly?) attached to wife and child. His time had been engaged in travelling about the world, in various sports; he was an excellent shot and was selected for sniping in France, where his "bags " brought him great credit. He was the son of a well-to-do ship- builder and from the earliest days was passionately interested in ships and engineering. His school holidays were chiefly spent in his father's or the adjoining yards, where he was always planning, and later on designing, new kinds of ships and engines never to be used. During his boyhood's holidays he would accompany his father on business journeys and would sit in the customers' office whilst business transactions were carried on always, in his own words, " gloating with joy at his father's cleverness and talk." From about six, or perhaps earlier, up till the age of eleven, he slept with his father in the same bed. He had a proper affection for his mother, but it was a pale reflection of the worship of his father. He passed creditably through school, did quite well at games, and it was understood that he would enter his father's business . On leaving school his father no WAR-SHOCK said : No need to hurry about business, take a couple of years and see the world. After two years he returned ready and anxious to enter business. But the father suddenly had a "nervous breakdown," and the son was compelled to remain in the closest attendance upon his father for the next year. The sick man would have no one else near him and would not listen to the youth's approaching the business. The father better, the son felt the real need of a change and went away for six months; he returned, and again there was the talk of his entering the business. His father had a second attack, and again for a whole year the son was chained to his father. He then again took some months rest, and on his return the father had withdrawn from the business; there was no longer talk of the son's doing any- thing. Indeed, any approach to the subject seemed so to agitate his father that his son, fearing another attack, avoided the subject. This brief sketch will suffice to demonstrate the dominant part played by the father the patient was assuredly the father's thing, no independent being. An incident will show this dependence. My patient was at a seaport when he was about 21, awaiting a ship to go abroad, when a friend of the family met him and invited him to stop there. He could give no reply, was extremely embarrassed, and wired to his father to come and help him. The father travelled the four hours' journey, and my patient only felt completely at ease when he met his father. Now it is easy to see something unnatural in this relationship, to interpret it, following Freud, as a repressed homo-sexual father-complex, whilst the phobias could be explained as substitutes or deriva- tives of early repressed sexual curiosities ; but this interpretation would be quite insufficient. We learn that the boy passed through a normal PSYCH ASTHENIA ill schooling, that no symptoms developed until the father's breakdown, that this breakdown was the frustration of the patient's whole ambition to build ships and engines, to invent new kinds. That was his special work in life. He knew every important ship and most of the unimportant ones that were afloat. He could recognise a ship immediately ; we often tested his knowledge, which never failed. He would recognise boats by their whistle and would at once say the particular ship's name, when she was built, her tonnage, etc. A fine ship passing the coast would fire him and rouse him from his lethargy. He experienced a sense of mystery and wonder in ships, something that Wordsworth must have felt when he wrote those sonnets : ' ' This ship was nought to me nor I to her, Yet I pursued her with a lover's look." "... and something dark Of the old sea, some reverential fear, Is with me at thy farewell, joyous bark." He was in love with ships. Love of father, mother, to be a husband, etc., these he shared with humanity in common but ships that was the individual thing which absorbed such energies as were not to be devoted to the common duties of life. His father stood to him for power and ships and engines through the father he could climb to his own pinnacle. And then comes failure. The patient, inhibited from following his purpose, regresses, turns back and seeks in his phantasies the consolations and the position which belong quite legitimately to childhood but do not fill up the adult outlook. If we have hitherto written of the unconscious as something archaic and crude, we must now correct that by adding that the unconscious is also creative and constructive. A cross-section, so to say, of any mind at any given moment would reveal not only the 112 WAR-SHOCK past but the germs of the future the potentialities to become realities with time. The psyche never is, but is always becoming changing ; there is ever an onward thrust. Biologically the great functions of life are : I. Those directed to the individual comprising (a) Self-conservation and (b) Growth. II. Those directed to the species comprising (a) Preservation of the race and (b) Racial development (variations). But we discover in human beings a spiritual life apart from and independent of the biological prin- ciple. This has also two relationships. It is related to the universal spirit as part of the world-conscious- ness and it is related to the self, forming the individual spiritual life. This desire for an increasing individual life of the spirit is a strong dynamic force which we may call idio-kinesis. This idio-kinesis does not, among ordinary normal persons (I must exclude cer- tain individuals, e.g., the true saints), demand full expression until the biological energy of the individual has received or is receiving its due satisfaction. Conflict ensues a neurosis when the ordinary individual endeavours to satisfy his spiritual life without having satisfied his biological functions ; again, neurosis may arise from a thwarting of the spiritual life by conflict between the energy directed towards the world-consciousness and the idio-kinesis. Again, since this latter is ever undergoing change, we have here a constant source of conflict within the self. Idio-kinesis finds its expression in the most diverse ways. In this patient it was seeking expression in ships; conflict had produced stagnation. The energy which should have found individual expression [this idio-kinesis] was stayed. Hence his suffering. He could marry and fulfil some common biological objec- tives of life. The difficulties were enormous PSYCHASTHENIA 113 granted, but life is relentless. Difficulties must be surmounted. And the patient was gradually learning this. Two of his latest dreams illustrate this new adapta- tion. "/ was in a cargo boat in the river; we were steering straight into the ferry and harbour. The pilot rang down full speed astern. I pushed him out of the way and rang down full speed ahead, two points to starboard. We went straight past ferry and harbour without an accident." A few days later : " In a motor car : came to some rocks which sprang up in front of me. The machine broke down. I abandoned it and walked, clambering over the rocks. It was tough work. My object was a ship. I got to the ship ; took hold of the wrench and signalled to let go." We found by analysis that the pilot in the first dream and the motor in the second stood for the father. The meaning became clear. He must first sacrifice (knock down, abandon) the father element in himself, then his life's purpose (ship), will be directed ahead and in the right way (starboard). There are difficulties (rocks) ahead, but he will climb over them. When the unconscious of our patient has reached this, when he has thoroughly learnt that he must surrender that which is infantile and immature in himself the clinging to the father that he must be master of himself, we have reached a new view-point. All his will-power will be still required to make good the lesson but he need no longer be the victim of unknown impulses. He is not cured, but he has begun to see in what direction the world might again live for him when his energy began to be directed in these new channels ; the phobias and obsessions, even those unanalysed, began to diminish in strength. 114 WAR-SHOCK But until these had been fully analysed he would be wanting in the knowledge required to secure the full- ness of a new attitude towards life there would be continual backslidings regressions. The time at our disposal was too short to do more than get him to catch a glimpse of the promised land. He has yet to climb his Mount Pisgah to obtain a full vision. It will be seen that in these cases of psychasthenia no cures were effected ; the patients could not remain long enough under treatment for this ; a cure in these bad cases requires months. We had to be satisfied when the acute psychical symptoms abated. These were all cases of pre-war neurosis on a psychopathic basis the cases that remain more or less invalids with ever recurrent breakdowns, ending perhaps finally in an asylum. If such illnesses are taken seriously as soon as the symptoms show themselves, psycho- analysis offers them good hope, I believe the only hope, of fulfilling themselves, of averting the other- wise almost certain uselessness of their lives and the too frequent miserable termination. But these considerations do not properly belong to a book on war-shock. DREAMS. Dreams play so large a part in the diagnosis of the psycho-neuroses that I must add a few words on the subject, though it is one too large to treat in this little book; fortunately there is now an available literature. 8 8 "The Interpretation of Dreams," by Prof . Sigm. Freud. Translated by Dr. A. A. Brill. London : Allen &Unwin. 1913. "On Dreams," by S. Freud. Translated by Dr. M. D. Eder. London : William Heinemann. 1913. Freud's "Theory of Dreams," by Dr. Ernest Jones, op. cit. " Analytical Psychology," byC. J. Jung, op. cit. PSYCH ASTHENIA 115 Naturally a good deal of fun has been made of dream-analysis, which is likened to the dream inter- pretation of the ancients. With this it has as much resemblance as has modern urinary analysis to the water casting of the Middle Ages. The water casters felt that such an excretion as the urine must be of some use in the diagnosis of disease and they made guesses, sometimes true guesses, at discovering what the changes in the urine, changes in colour and so on, could possibly signify. It was left for a later age to invent a technique for the examination of the urine and thereby to interpret its changes in various diseases. Similarly with dreams, our predecessors felt that dreams must have some message, and they made guesses, sometimes correct, at what the message could be; but it was left to Sigmund Freud to dis- cover a scientific technique whereby to read the riddle of the dream. Of course many acute minds had before Freud dimly felt that in some way the dream might be significant. Bagehot'' has a rather remark- able passage which is worth quoting. Writing in 1 87 1 , he says : " That belief is not a purely intellectual matter is evident from dreams, when we are always believing, but scarcely ever arguing ; and from certain forms of insanity, when fixed delusions seize upon the mind and generate a firmer belief than any sane person is capable of. These are, of course, ' unortho- dox ' states of mind, but a good psychology must explain them, nevertheless, and perhaps it would have progressed faster if it had been more ready to compare them with the waking states of sane people." As an introduction to the understanding of dreams, we may recall the varieties of symbolic conver- sion in Chapter III. In the functional paralysis 9 "On the Emotion of Conviction," by Walter Bagehot. Vol. III., p. 192, of his collected Literary Studies. 116 WAR-SHOCK of the hysteric one finds ideas, wishes and mental processes in general represented by their physical counterparts. So it is in dreams. The pictures in the dreams stand for, are symbols of, mental processes. We find an instance of a horse being the symbol of the man himself (p. 81), of fire symbolising passion, inability to move standing for indecision of the mind, and so on. It must be remembered that in dream-analysis the symbols to be interpreted are individual, not only to the person, but may even be to the dream itself. Thus, fire may not symbolize the same idea to another person as it did to No. I oo. In the dream of No. 78, and at subsequent stages of the analysis of the same person, it might be found that fire had another symbolic value. The discussion of typical symbols would take us too far, and would lead into the regions of folk-lore, comparative religion and mythology. Those inter- ested should read Jung's ' ' Psychology of the Uncon- scious " J where, taking the published phantasies of a modern young lady he has sought to unravel them by a comparison with the symbolisms of mythology and religion. The value of the dream is that it gives us, in dis- guised form, something direct from the unconscious. One word of warning is necessary ; the meaning of the dream is only to be apprehended from its latent content that is to say, when all the " free associa- tions " to the component parts of the dream have been given. From the dream, as dreamt and related, the manifest content, no meaning is to be deduced. It is to be remembered that there are two motives for the symbolisation and the endopsychic censure is different in the two cases. Firstly, to conceal the 1 "The Psychology of the Unconscious." Translated by Dr. B. M. Hinkle. New York : Moffat, Yard & Co. 1916. PSYCHASTHENIA 117 dream thoughts from the dreamer's conscious self, the censor prevents ideas out of harmony with the dreamer's conscious self, a more highly developed self, from entering into consciousness. Secondly, to prevent the apprehension of an idea which is beyond the dreamer's experience. In the first case the meaning of the symbols used may be apparent to the outsider though not to the dreamer, since the main object is a self-concealment, whilst the attempt to prevent others knowing the dream thought is only secondary. In the second case only the dreamer himself can really furnish the clues to his symbols ; though it has an apparent rendering in universal terms it has a quite particular application. The dream here deals with the future and present, using the past experiences because they are the only means of comparison which the dreamer has. The motor-car dream (p. 113) is such a dream, showing what Jung calls the prospective tendency of the un- conscious. CHAPTER VI DIAGNOSIS THE soldier is not immune from the nervous diseases of the civilian ; syphilis of the central nervous system is found among men in the fighting line, as are tumours of that system, disseminated sclerosis, epilepsy and so on. The diagnosis among soldiers of these diseases from the psycho-neuroses does not present any new features. The differential diagnosis of epileptic from hys- terical fits is of medico-military importance and at times difficult ; we may not see the soldier in a fit and may have to rely upon the description of the attack given by himself or his comrades. There is hardly any feature in the epileptic attack which may not occur in a hysterical attack ; biting the tongue, the empty- ing of the bladder or of the rectum may be present in hysteria. In the chronic epileptic, an unlikely person to be found at the front, the well-known stigmata of the epileptic character, such as limitation of the field of presentation, retardation of all response to stimuli, stereotypy and poverty of speech, moodi- ness, egocentricity, exuberant emotion, irritability, suffice to make the diagnosis easy. The question of epileptic or hysterical fits may be sometimes settled by a psycho-analytic diagnosis. The word-association test, which Ernest Jones l has l Op. dt., p. 210. 118 DIAGNOSIS 119 likened to the differential blood count, may be often useful in this examination. Reliance is not to be placed so much upon critical words as upon the interpretation of the results. The experiment is very easily carried out, but this interpretation, like that of every other psychological test, requires judgment and experience. Jung 2 gives the following reactions as characteristic of epileptics : (a) Explanations of an extremely awkward and detached character are given by way of confirmation and completion of the re- actions. The stimulus-word is frequently repeated in the reaction. (V) The outer form of the reaction is neither stereotyped nor limited except in regard to its egocentric formation, which occurs with peculiar frequency (31 per cent.). (c) The emotional references are frequent, they are almost undisguised (religion, moralising, etc). (cf) The reaction-times show their most extreme variations only after the critical reactions. The abnormally delayed times are not found at peculiarly difficult words but at places which are determined by the preservation of an emotional tone. In the following case the diagnosis of hysteria was made on the result of a word-test (200 words), which disclosed nothing characteristic of epilepsy, and by the fortunate chance that two recent dreams were remembered and at our disposal. No. 75, a garrison soldier, aged 21, felt giddy whilst sitting on a wheelbarrow, screamed out and fell to the ground in a fit. He felt sick afterwards but did not vomit. Two days later he passed his 2 "Studies in Word- Association.'' Op. cit. Chapter III. " Analysis of the Associations of an Epileptic," by C. G-. Jung. 120 WAR-SHOCK water whilst sleeping on his bed in the afternoon ; he awoke with a violent headache, Later that evening whilst standing he had another "fit" and fell. He did not pass water but awoke with a burning head. He was carried to his bed by some of his companions. He had not hurt himself in the fall. There was no injury to the tongue. A witness who had inserted a wedge into the patient's mouth, but whose evidence of the attack was confused and unreliable, said there was blood-stained froth at the mouth. The patient stated that he had had " fainting fits " between the ages of 9 and 1 5 ; in one fit he is said to have bitten his tongue; he had been excused school-attendance on account of these fits. He remembered wetting the bed sometimes up to his eighth or ninth year. The patient was admitted to hospital, and I saw him the day after the second attack when he still com- plained of headache. He was a driver engaged in garrison duty ; the day after the first fit he was afraid to take out the horses ; he had a vision : " the horses falling on the hill and the waggon running into them." He had not previously suffered from fears of any kind. He took the horses out but with great qualms ; there was no accident. The night before the first fit he had a dream : " Our stables had been turned into a big hospital where I was." The night before the second fit (i.e., after having taken out the horses) he dreamt : " That the stable was built differently ; that it was now the ward of a hospital ; we had 18 men there : I saw all the beds in the sfables, and I was lying in one of the beds with clean sheets." Analysis : There are only four men now in the detachment, which means that each man has to be on guard every other night in addition to the day duties. (Guard from 6 p.m. to midnight, or midnight to 6 a.m.) DIAGNOSIS 121 He has felt the want of sleep through the many guards he has to do. One of his chums has had appendix trouble and has been sent home ; another is in hospital with enteric fever. Just before the fit he had been boasting that he was the only one who had never been ill. He had been in M 15 months ; he liked it at first, but the routine work has become very dull, and he has nothing to do in his spare time. He would like to get to the front, but there was no chance ; thought he deserved a change and to be sent home. He was engaged before he left, but he heard recently that the young lady had broken off the engagement. Both dreams express the same unconscious wish- fulfilment. He will never get away from M unless he is ill ; the stables are thus conveniently turned into a hospital ward and he is in hospital. One chum has already gone home and the other is going (all enterics being ultimately sent to England). Boasting about something is a not uncommon form of an unconscious wish for the opposite. The fear about an accident with the horses is a (repressed) wish not to have the horses to take out. Meantime he conscientiously carries on his work. The conflict between the conscious and unconscious trends ends in the hysterical attack with fulfilment of the uncon- scious wish for he is ill and sent into hospital. The analysis was not pursued further, so that the meaning of the childhood's fainting attacks cannot be given. It is significant that he was a " bed wetter" till rather late in childhood; the emptying of the bladder after the first fit is probably connected with the renewal of certain childhood's conflicts. The results of the analysis of the dreams undertaken entirely for diagnosis, not for therapeutic purposes, were of course not communicated to the patient. In the diagnosis of functional disease, even where 122 WAR-SHOCK it seems self-evident, complete and systematic exami- nation is of course to be made. The presence of organic affections, in addition to the functional one, may be revealed, or some further stigmata may be discovered. An interesting observation of the former condition is described by Purves Stewart 3 in a soldier with wrist-drop of the left hand due to a shrapnel bullet, whose track had crossed the musculo-spiral groove. There was, however, complete anaesthesia of the left upper limb from the acromion downwards ; an anaesthesia, therefore, not corresponding with the distribution of the injured nerve. In mutism and deafness the symptoms seem obvious, but without systematic examination malingering is not excluded and the analgesia sometimes co-existing with mutism and deafness, such as described on p. 37, would be missed. In mutism the patient should be examined to see whether he can whistle, laugh, cough, sigh ; mutism is sometimes complete ; a good test for the cough is to strip him as for examination of a hernia, asking the patient to cough ; this routine examination, which all soldiers have gone through, may take him off his guard. The patients can express themselves well in writing, unlike ordinary aphasics. The laryngoscope may show adductor paralysis. The faradic current should not be used in hysterical mutism of soldiers, useful though it is in the common functional aphonia of girls and others. In functional deafness and ambly- opia the services of the specialist, if available, should be requisitioned to make a report upon the state of the special senses not necessarily a diagnosis of the patient's condition. 4 An older generation of clinicians 3 Op. tit. (4th Edition), p. 61. 4 In Malta I was fortunate enough to have the opinion of Col. Purves Stewart, A. M.S., for most of the general cases, and of Capt. A. D. Griffith. R. A.M.C., aa well for the eye cases. DIAGNOSIS 123 called these amblyopias anaesthesia of the retina; it is not a bad term as a clinical description, although the stimuli are really conveyed to the brain, just as they are in anaesthesia of the skin. The ophthalmoscopic examination is negative ; the patient is not betrayed by any of the tests which reveal the malingerer. Convergence may be absent and the examination of the visual fields may show the characteristic stigmata of hysteria. There is a concentric contraction of the visual field (see pp. 34, 35) with alterations in the colour fields. The examination of hysterical paralysis shows : (1) The anaesthesia corresponds to no anatomical nerve-distribution. It is regional, not anatomical, in its distribution. As we have seen in Chapter II, a complete hemianalgesia is common, and this, unless there be special cause to the contrary, is on the left side in right-handed people and vice versa. Sometimes the patient, though he says he is unable to feel a pin-prick, can locate it on or near to the place pricked with the normal hand. The joint sense may be impaired and astereognosis be present with this anaesthesia; the yes-no test is sometimes positive. That is, the patient answers "no" when pricked in the anaesthetic area without noticing the contradiction, when asked to say "yes" when he feels the prick, " no " when he does not feel it. (2) As recovery sets in the anaesthesia fades away gradually towards the periphery ; 5 one can sometimes, mark its progress from day to day, or sometimes under suggestion, it disappears with absolute sudden- ness. Thus, to a soldier with a complete left hemianal- gesia of unknown duration it was suggested under hypnosis that he could now feel the prick of the pin on his arm, and he did. It was then said: "You can feel everything all over the body." Sensation 5 See the illustrations in Pnrves Stewart, op. cit., p. 394-5. 124 WAR-SHOCK became at once normal and so remained after he was awake. (3) There may be impairment of joint sense and astereognosis due to the anaesthesia. (4) The gait is often typical in hysterical para- plegics; thepatient shuffling along, sometimes sup- porting himself and falling rather softly if all support is taken away. (5) The reflexes may be sometimes exaggerated in functional as they often are in organic diseases, but they are never absent permanently in functional disease. (6) The paralysis, like the anaesthesia, follows, as a rule, no anatomical rule ; movements as a whole are affected. (7) The muscles respond to faradism in hysterical palsies ; reaction of degeneration is absent. The use of finger prints has been suggested in the diagnosis of functional from organic diseases of the upper limbs. It is said that when the finger prints of the two hands are compared there will be found an alteration in the finger prints of the injured side in injuries, more especially, of the median and ulnar nerves, whilst no changes are found, or but rarely, in functional disease. 6 The diagnosis of the psycho-neuroses must not be allowed to rest upon negative evidence ; it does not suffice to diagnose a hysterical paralysis by a process of exclusion. Positive evidence must be obtained by a psychological examination which should, at the same time, discover the mechanism and pathology of the symptoms. MALINGERING. To confuse functional disease, war-shock, with malingering is no more excusable than would be the mistaking of an innocent tumour for a malignant 6 Cestan, Descornps and Euziere. La Presse Medicate, 1916, June 8, p. 261. DIAGNOSIS 125 tumour. We are all, physicians and surgeons, liable to error, but though the sufferers may pardon our mistakes and we may excuse them in others, we must never condone our own mistakes in diagnosis. The differentiation between a psycho-neurosis and malingering is, in principle, psychological. In malin- gering the motive is conscious, the patient consciously pretends to suffer from some symptom ; in functional disease the motive is unconscious ; the symptom develops in obedience to motives, desires, causes, of which the patient's consciousness knows nothing. Simple cases of malingering are recognised by simple psychological observation ; one infers at once from the patient's general demeanour, from his story and so on, that he is shamming. More refined malingering, especially where there has been some original trauma, requires more complete physical and psychical examination. In this, as in every other branch of medicine, reliance should not be made upon some "infallible" test, say the electric battery applied to the seat of pain, but upon a balancing of many signs and symptoms and the observer should try to keep himself as unbiassed as possible. A good beginning is for the observer to remember that he is biassed in one direction or other, and to try and discover, if possible, his particular bias. My own experience in the army has been almost entirely amid the sick and wounded ; among these patients I can confirm the statements of Myers 7 and others that malingering is most rare. The regimental M.O. may, of course, have a different story to tell. A complete physical examination of every patient, even when malingering is strongly suspected, is the first important step in diagnosis. (This remark does not apply so rigidly to the regimental doctor to whom the idiosyn- crasies of the men will be known.) Disturbances of 7 Loc. cit., p. 608. 126 WAR-SHOCK sensation, the peculiarity of gait, are important ; the malingerer's gait, however skilful, does not corre- spond to the peculiar shuffle of the hysteric. All text-books on eye-diseases give tests for pretended blindness. In hysterical deafness the patient has often the "woolly " appearance of the organically deaf, which the shammer does not show. The beginning of a reply to a question by movements of the larynx, lips and mouth will be often noticed in the shammer, who will, on cross-examination, indignantly deny having made them ; the hysterical patient's attitude is very different, to him it is not an accusation. Dundas Grant 8 points out that patients with psychical deafness sometimes acquire lip - reading with great rapidity, which he regards as "unquestion- able evidence of a high degree of deafness." Grant suggests the following test : " It is the dilatation of the pupil which follows the sudden blowing of a whistle without the patient being aware of it ; in several cases of labyrinthine deafness this was absent, but in others which seemed to be of psychical origin the reflex was present, although the deafness was absolute or nearly so. In the dullness of hearing due to exhaustion, which shows the tuning- fork indications of nerve-deafness, there is usually preservation of hearing for the highest pitched tones. Labyrinthine and psychical deafness may be combined, but the labyrinthine factor is generally unilateral." " Exaggeration" of symptoms or undue sensibility to pain is not malingering ; one man with a functional paraplegia will be cheerful and try his utmost to get about; another with the same affection will be de- pressed, complain that he is done for life, cannot 8 Discussion on Shell-shock. Proceedings of Royal Society Medicine, loc. cit., p. xxxviii. DIAGNOSIS 127 walk a step. These are temperamental differences which we all allow for in organic diseases and must be prepared to find in functional diseases likewise. A patient's desire to make the most of a symptom neither excludes functional nor organic disease. Functional disease may exist along with malinger- ing, just as we have seen that organic and functional disease are not mutually exclusive. In all serious cases a psychological examination should be made. The discovery of the unconscious motive for the symptom, its psychological expla- nation, diagnoses the condition. Though psycho- therapy is not admissible as a therapeutic test, the cure of the symptom by psychotherapeutic measures will confirm the diagnosis arrived at before treatment. The differential diagnosis of the psycho-neuroses from one another is based upon the psychological principles set forth in the earlier chapters. CHAPTER VII TREATMENT THE results of psychotherapy in cases of war-shock establish its claim to be the chief method of treat- ment. The following table summarises the results in the first hundred unselected cases treated: Method of Treatment. Cured. Improved. No change. Total. Suggestion under hypnotism ... 70 ... 7 ... 2 ... 79 Suggestion with- out hypnotism 3 ... 2 ... ... 5 Suggestion under anaesthetic ... 6 ... ... ... 6 Psycho-analysis... 1 ... 4 ... ... 5 Other methods ... ... 1 ... 1 ... 2 Diagnosis -with- out treatment ... ... [3] ... 3 80~ 14 6 [3] 10? By a cure we mean complete cessation of all the symptoms ; a certain number of these patients when cured were sent into the convalescent camps at Malta and were then drafted back to the Front. The majority went back to England at varying intervals after their recovery, the intervals varying with the military-medical requirements. I often tried to ascertain the subsequent fortunes of these patients, but have only succeeded in a few instances. By improvement is meant relief of some symptoms only ; thus, the paraplegic, No. 9, was able to walk 128 TREATMENT 129 normally, the analgesia had gone, but as the rigidity of the back remained when he left us we had not reckoned it a cure. (A wider claim for this parti- cular case is made by Purves Stewart, 1 who writes, " under treatment by suggestion the weakness of the legs rapidly disappeared, the 'stocking' anaesthesia cleared up and the patient became able to walk normally.") In the cases where the prominent symptoms are psychical we have reckoned it an improvement when sleep returned, the patient could control himself and concentrate his attention. The cure in the great majority of cases took place very rapidly ; e.g., mutism recovered in the course of a few minutes ; many cases of palsy or complete paralysis (hemiplegia) recovered in less than 24 hours. Cases frequently called neurasthenia, but which I have here included among the anxiety -neuroses, were the slowest in recovering, but in many of these cases the main symptoms, such as the exhaustion, insomnia, dread, headache, tremors, disappeared in a week. No case was under treatment for more than four weeks ; very few remained under treatment for more than two weeks. Of secondary importance is treatment by what Dr. Stansfield calls "rational lines," 2 "absolute rest and quietness, with all the sleep possible, pre- ferably with agreeable surroundings in the country ; a nourishing, easily assimilated food, and the like," or by what Major Mott 3 denotes as "only common sense and interest in the welfare and amusement of these neurotic patients." Hydrotherapy, electrotherapy, massage are, in 1 Loc. cit., p. 516. 2 Proceedings of Royal Society. Discussion on Shell-shock Loc. cit., p. 32. 3 The Lancet, March llth, 1916., p. 553. 130 WAR-SHOCK my opinion, of tertiary importance ; I agree with Dr. Leonard Guthrie,* who says, ' ' I believe that all forms of treatment involve the employment of either suggestion and persuasion or of some novel and unexpected emotional or physical shock," with the exception of treatment by psycho-analysis, which does not involve anything of this kind. We, of course, want the best surroundings we can get for our patients, just as the surgeon would desire them in the case of a fractured bone but, just as he employs something specific to the bone injury, so we should employ something specific to the mental injury. "Rational lines of treatment," "common-sense," demand the treatment which most rapidly relieves the patient and sends him back to the army most quickly. Suggestion under hypnotism, especially when the suggestions are based on the knowledge of the particular psychological mechanism which has pro- duced the symptom, is, from this rational point of view, the method of election for cases of war-shock in the soldier. The soldier is peculiarly susceptible to suggestion ; the whole training and discipline make him respond to the authority of the Medical Officer. It is because war-shock differs in the respects already pointed out from the psycho-neuroses such as we see in civilian practice, and of which the war also furnishes instances I have discussed several cases in this book that the results of suggestion are so much more favourable than are usually obtained, at any rate in my own knowledge, in civil practice. Babinski 5 distinguishes functional cases that dis- appear rapidly under psychotherapy from those in 4 Proceedings, Royal Society, loc. cit., p. 41. 5 Revue Neurologique, 1916. Nos. 45, p. 52. TREATMENT 131 whom this method seems to have no effect, His view is endorsed by Grasset, Claude, and others. A better division is into the following group : A. War-shock ; cases of psycho-neurosis without previous history, family or personal. B. Non war-shock ; psycho-neurosis with a previous history. There were, as already stated, in the one hundred cases, 70 of Group A. and 30 of Group B, The following table shows the comparative results of the treatment of the two groups ; both total cases and in percentages : RESULT OF TREATMENT OF IOO CASES. War-shock. Non War-shock. 62 per cent. Cured 62 . Improved ... 6 . No change ... No treatment, diagnosis only 2 .. ,. 91*5 per cent. .. 8-5 ... 18 ... 8 ... 3 ... 1 ... 62 ... 27' ... 10 70 100 30 100 Of the war-shock cases 68 were treated, and of the non war-shock, 29. As might be expected the former give better results, 91 "5 per cent : 62 per cent. In no case of the former was the condition un- changed, all three total failures (10*4 per cent.) being among the non war-shock cases. No results of any value are obtained by a comparison of the results obtained by the different methods of psychotherapy that were employed. For instance, all the cases treated by suggestion under an anaesthetic were cured, but this method was selected for the deaf and dumb cases in whom there were obvious difficulties in the way of hypnotising. It can be done by writing, but it is a tedious process unless one has an excep- tionally clear and imposing script. Again, only one case out of five was cured by 132 WAR-SHOCK psycho-analysis but this method was only applied in non war-shock cases of great severity with a strong neuropathic history (family and personal). The particular psychotherapeutic method employed was selected as the most appropriate after the pre- liminary psychological and clinical examination. The objection raised to treatment by suggestion under hypnosis, e.g., by Dejerine and Gauckler, 6 that one weakens instead of strengthening the patient's critical powers, applies, as I pointed out in my Malta Address (loc. cit., p. 668), and as Professor Elliot Smith also observes" to suggestion in all forms, whether it takes the form of suggestion in the waking state, common-sense talks, rest, distraction, electro- therapy, or spontaneous recovery. The objection has no validity in cases of war-shock, though it has point in cases of profound hysteria or psychasthenia which come under notice in civil life. Minor advantages of psychotherapy are that it requires no elaborate apparatus, no prolonged sojourn in hospital, and has no savour of charlatanism like the more popular and less efficient methods such as electrotherapy, massage, Weir-Mitchell treatment. By none of these methods, not even in spontaneous recovery, does the patient learn, although he may obtain intellectual apprehension, the real significance of his illness, nor can this be brought home by any arguments addressed to the conscious self (such as Dubois' persuasion method). Psycho-analysis, which was employed in six cases of the 100 (in one case for diagnosis only) is the only method that enables the patient to deal with the underlying mental state, and not merely with the symptom ; in psycho-analysis the patient learns for 6 " Les maladies fonctionelles des Psychonevroses." Paris : Masson & Co., 1911. 7 Loc. cit., p. 27. TREATMENT 133 himself the real significance of his disease, a privilege only acquired by a bitter self-realisation. Whilst it is, in my opinion, the only method for the radical treatment of the psycho-neuroses, it is inapplicable and unnecessary for the treatment of cases of war-shock, and for many of the psycho- neuroses occurring among soldiers. To use it here is to employ a Nasmyth hammer to crack a nut. The shock of battle is not an every-day affair especially such warfare as this. It is this unusual experience, so utterly foreign to the normal routine of life, that has bowled the man out. He requires temporary reinforcement of his own will-power, and this is just what hypnotic suggestion supplies. The practical objection, apart from the philo- sophical objection, in the ordinary civilian type of psycho-neurosis that one symptom is cured to be replaced by some other symptom, does not hold in war-shock cases, the symptoms when cured are not, in my experience, replaced by other symptoms. The results obtained in Malta may claim to be due purely to psychotherapy. The patients were two thousand miles from Britain and did not know whether they would be sent home or back to the Front on recovery. No bribe was offered in the shape of a promise to get the patient sent to England on recovery ; many cases, indeed, owing to the military-medical situation, had to be sent to the Convalescent Camps and so back to the Front on recovery, and this sooner than was altogether advisable. Babinski s and other French authorities have recog- nised the value of psychotherapy in the treatment of the war psycho-neuroses. Nonne 9 also speaks 8 Loc. tit. 9 Nonne. ZurtherapeutischenVerwendtmg der Hypnose bei Fallen von Kriegshysterie. Med. Klinik, 1915, p. 51/52. 134 WAR-SHOCK of the exceptionally good effect of systematic and exclusive hypnosis in these cases. Out of 63 of his cases 51 were cured, 46 by suggestion under hypnosis, 5 by suggestion in the waking state ; of the 12 cases uncured 10 were refractory to hypnotism. (A very large number which leads me to believe that these were not cases of war-shock as denned in this book.) GENERAL PROCEDURE, It may be well to state exactly what the procedure !..". a was. The patients were transferred to the psycho- neurological department, after having been seen by one of the consulting physicians to the Malta Com- mand and recommended for treatment. A few cases from neighbouring hospitals were treated as out- patients, of course with the sanction of the C.O. These patients when admitted were scattered in the various wards, so as to avoid a conglomeration of persons suffering from nerves with, it was feared, disastrous intercommunication. But this is not necessary or desirable. The patients could not be prevented meeting and talking with one another in the grounds or wards, etc. ; in- deed, it was not a case of evil communications cor- rupting good manners, the contrary was the case. The new patients were able to note the rapid pro- gress towards recovery of the older ones. The patient underwent a physical examination in the ward after admission. He then came to a " bunk " placed at my disposal by the O.C. (Lt.- Col. Scanlon). This was a bare, whitewashed room furnished with an armchair, " officer's table " and wooden chair. The psychological investigation was conducted in private. No one was allowed into the room. The patient was comfortably seated in the chair and put as much at ease as possible. An ex- TREATMENT 135 planation was given to him as to the nature of the proposed enquiry and treatment, and he was encour- aged to talk about himself and his illness, his life in the army , and so on ; any dreams were taken , but nothing more was done the first day. The next day, after a short conversation, when the procedure of hypnotism was explained, hypnotism was induced, and suggestions given based when possible on the results of the psychological observation. In most cases Liebault's method of inducing hypnotism by direct suggestion readily produced drowsiness. Sometimes Braid's method was adopted at the first attempt, an ophthalmoscopic mirror being held before the patient's eyes for a few minutes. As a rule the stage of drowsiness was quite suffi- cient for our purposes ; but when further insight was desired on the pathological aspects of the disease, and sometimes for treatment, deep sleep and somnam- bulism were produced. In producing hypnosis there was no necessity to exclude the presence of strangers and the sitting was used as a means of demonstrating the production and phenomena of hypnotism to one's colleagues . Collective suggestion under hypnotism was found also of practical value. We could have four or five patients on ordinary chairs (the room not holding more comfortably), and hypnotise them all (either singly or collectively), passing from one to another with the individual suggestions. This saved time and allowed more time for the individual examinations. As a rule a patient was not kept under hypnosis longer than fifteen or twenty minutes. After being awakened, he was required to carry out consciously what he had accomplished under hypnosis and was then directed to return to his ward and rest for half an hour. 136 WAR-SHOCK A too long prolonged hypnotism is exhausting to most persons and retards recovery. The patients were seen every day alone ; naturally with 20 to 30 patients one could not give an hour to each daily ; for some, 10 minutes had to suffice when one perhaps gathered some fresh information or obtained a dream. Hypnotism is easily induced among soldiers ; in only three cases of them did it altogether fail at the first attempt. The selection of cases unsuitable for this procedure was made after the psychological examination. If, after a few days treatment, no improvement was noticed, hypnotism was given up and suggestion in the waking state was tried. HYPNOTISM UNDER ANESTHETIC. On June 10th, 1915, a deaf mute, No. 35, was admitted into my ward from Gallipoli, the only medical case in a batch of wounded soldiers. The work was very heavy, the hospital having been opened on the 8th of June, and I wrote to the patient I would attend to him in a day or two, and he would get well. It was not till three days later that we could take him in hand ; enquiries were made in writing ; this was found a tedious business (my hand- writing, I regret to say, is none too good), and hyp- nosis under such conditions did not promise to be very satisfactory, so recourse was had to the well- known method of inducing hypnotism under an anaesthetic. This method of inducing hypnotism under an anaesthetic should be reserved for cases where hypnosis is very difficult ; personally I should restrict it to functional deaf mutism, mutism, or deafness. TREATMENT 137 Milligan l advocates this method not only in those cases but also in hysterical loss of memory, palsies, deformi- ties. Hypnosis is so readily induced among soldiers that there is no reason at all for submitting these patients to the extra risk of an anaesthetic. Sugges- tion under ordinary hypnosis works quite as rapidly as when under an anaesthetic. Chloroform was given till light anaesthesia was obtained ; the patient was then told he would be able to hear and speak when he woke up. A mouth-gag and the tongue-forceps were used. The suggestion was repeated continuously until the patient awoke. The patient spoke whilst under the anaesthetic. A gramophone happened to be playing in the adjoining ward ; this was the first sound he heard on awaking ; the goat-bells outside were next heard. He spoke a little later. This method was used in all cases of deaf mutism with entire success. It failed in one case under the care of Lt. Fothergill, R.A.M.C. This patient had been previously hypnotised by Lt. Fothergill but the suggestion had not been successful. In another case of mutism, No. 42, hypnotism was induced, but the suggestion was unsuccessful. The chloroform method was not used because the patient, on the advice of a doctor, did not wish it. This patient had been rather harshly treated. It would seem that a surgeon who saw him was inclined to regard it as a case of malingering, and applied the electric battery to the larynx, which made him feel worse ; the battery was used a second time ; perhaps, rather naturally, the surgeon somewhat resented the failure of the patient to improve under a mode of treatment which had been often successful in hysterical aphonia among girls. The patient came under me some ten 1 "A Method of Treatment of Shell-shock," by E. T. C. Milligan. M.D., B.S. The British Medical Journal, July 15th, 1916. p. 73. 138 WAR-SHOCK weeks after he had been on the island ; suggestion under hypnosis failed, but I began in the conscious state the re-education of his speech. One by one, I got him to pronounce the letters of the alphabet, by showing him the position for each letter ; he was getting successful with simple consonants and words when he had to be transferred to England. PHYSIOLOGICAL RE-EDUCATION. This process (physiological re-education) is, of course, slow, but in cases of long standing when other therapy fails it deserves consideration. Re-education is a method to fall back upon in cases of paralysis when psychotherapeutic methods fail. Each part of the limb must be separately educated to fulfil its function, and finally co-ordina- tion of the limbs and body must be taught. This method of physiological re-education is also recommended by Briand and Philippe 2 in obstinate cases, who cite a case of deaf mutism of some dura- tion successfully treated by exercises in respiration, blowing, whistling and phonation. SUGGESTION WITHOUT HYPNOSIS. Treatment by suggestion without hypnosis is of course familiar to every practitioner ; the patient is encouraged by being assured that there is no physical injury, that he will get better, that it depends on his own good will. But it is not everybody who can be thus helped to make an effort; it is desirable to adapt the language to the patient. There are some persons who resent talk of this nature and on whom it would have the contrary effect. A certain tact is required to discover this and to fit the exhortation 2 " L'audi-mutite rebelle d'origine emotionelle." Le Progrce Medicale: September 5th. 1916, p. 147. TREATMENT 139 to the patient. Just as we must adapt the splint to the individual fractured limb, so we must adapt our suggestion to the individual paralysed mind ; stock suggestions are no better than stock splints for injured soldiers. PERSUASION RE-EDUCATION. These are terms given by various writers to suggestion without hypnosis. De jerine and Gauckler 3 say that " it consists in explaining to the patient the true reasons for his condition. The part that the physician plays is to recall, awaken and direct." To the patient this comes merely as suggestion; cure comes about, although the writers have failed to recognise it, exactly in the same way as by suggestion under hypnosis, that is, by "trans- ference " to the physician. We shall deceive ourselves less as to the method of a cure if we keep to the original term " sugges- tion" for all methods which depend upon the physician's directing and governing the patient. Cases where the treatment is exactly that described by these writers as persuasion have been described (see No. lo, p. 71). In what class of war-shock cases suggestion with- out hypnosis yields quicker results than with hypnosis is a difficult question to decide. When no post- hypnotic influence occurs after the second or third session, I prefer to use suggestion (persuasion, re- education, etc.). Psycho-analysis is the method for the exploration of the unconscious mind whereby the energy hitherto wasted in internal conflict is made available for the purposes of life. Whereas any medical man can easily master the technique of hypnotism and suggestion in simple 3 Op. cit. 140 WAR-SHOCK cases, psycho-analysis requires a long apprentice- ship; it cannot be acquired from books alone. It will not be described here ; no one is qualified to undertake psycho-analysis who has not submitted himself to the discipline of psycho-analysis by another. Like every practical art it must be learnt in the workroom. The study of the literature, important as it is, cannot replace the laboratory. SUGGESTION AND PSYCHO-ANALYSIS. This is the most fruitful method of treatment in war-shock. The general results of psycho-analytic knowledge are applied to the results obtained from the psychological examination of the individual patient. We aim at discovering the psycho-patho- logy of his symptoms (not necessarily of the whole mental state). This knowledge is used as the suggestion whilst the patient is under hypnosis (or not hypnotised). Many cases cited give evidence of the value of this method (see No. 95, p. 95). The difficulty in suggestion is to know what to suggest. When you have discovered the patient's complex this difficulty is overcome. The procedure is, of course, not new ; I have practised it with a col- league in London for some time before the war, he sending me the patients for psycho-analytic examina- tion. The discovery of what lay at the roots of the symptom was imparted to my colleague who used the information in suggestion under hypnosis. Distraction. Sufficient has been said on this subject in the section on the soldiers' heart. Rest. In a few cases, but in very few cases, rest, feeding, Weir-Mitchell treatment may be necessary. The type of case requiring this is a soldier who has had several mental breakdowns before the war, who is suffering from psycho-neurotic symptoms with acute psychical symptoms, such as incoherence, insomnia TREATMENT 141 want of concentration, with accompanying wasting and anaemia. I have cited a case where the psycho- neurosis only developed after enforced rest in hos- pital and this should serve as a hint how dangerous this treatment may be. It is most unsuitable for cases of war-shock among soldiers it prolongs their illness and may sow the seeds of a more permanent psycho-neurosis. War-shock requires vigorous treat- ment and return to active life as soon as possible. The reckless way in which a rest cure and over-feeding are ordered indiscriminately for all persons suffering from any form of psycho-neurosis reveals lamentable ignorance. It is the very reverse of rational treat- ment. It is as if one were to prescribe digitalis off hand for every patient who complains of a pain in the left side of the chest, or opium for everyone who has abdominal symptoms. A rest cure is not merely negative or even symptomatic treatment. To a not inconsiderable number of these patients it is some- thing positive and positively dangerous. In some obsessional cases a rest cure delivers the unfortunate victim over to an unceasing conflict with his fears without the chance of any distraction. A rest cure is a sad misreading of Hilton's advocacy of physio- logical rest. To many hysterics a rest cure affords the ideal conditions for retirement from life's duties and strengthens their motives for remaining ill. Drugs are used, of course, in the treatment of different physical ills in the same way as the patient's wounds receive attention. Stimulants are valueless and as the soldiers had not to buy their own drugs any value that Sanatogen or its British counterparts might have are discounted. This expensive form of quackery is useless in the Army. The only hypnotic, used very occasionally, was one of the bromide salts. Occasionally hypnotism was 142 WAR-SHOCK used to put patients to sleep ; for wounded patients in a restless, excited condition it was often useful. Hypnotism had also a useful field in the first and second dressings of very painful wounds. AFTER TREATMENT. Cases with a pre-war history of psycho-neurosis are, in general, useless for the fighting ranks ; they can find plenty of other useful occupations in the Army or civilian life. The war-shock case is as suitable for return to the field as the soldier who has recovered from severe wounds. After cure of the symptoms the patient should not be sent forthwith to the Front. Six weeks to three months after-cure is required, the first part of which time I cannot but think might be spent on furlough with his family ; the latter part in one of the con- valescent camps where the soldier will be gradually retrained. Gaupp 4 found that in his hysteric patients "the symptoms returned and became intensified as soon as the words ' fit for duty ' are said." It is not my experience ; I imagine that Gaupp's cases had not been cured in the sense in which the word is used in this book. As I have already said, many of my patients went to the Convalescent Camp in Malta with the knowledge that this meant returning to the Front (which they did). Ten days at the least always elapsed from the time they were marked up fit for the Convalescent Camp till the time they went. In no case was there a relapse; on the contrary, the knowledge that their medical officer seemed to think them cured served to put them in better spirits. 5 In 4 I quote from Prof. Elliot Smith's summary of Gaupp's paper; loc. cit., p. 17, 18. 5 These men, of course, expressed no wish to go back to the Front and all would have preferred to be sent home. TREATMENT 143 one case (No. 1) after a relapse in the sense that irritability had come on, the patient begged me to send him to the Camp as soon as he got better, which I did with the happiest results. Another patient (No. 32) also got moody by being unavoidably detained in hospital after he was well. The Uncured. If properly treated the number of uncured cases will be small ; my figures give 3 per cent., but this number could be reduced. It includes No. 62, a case of enuresis which had existed from childhood, and was not in itself a disease totally disabling the patient either from service in the Army or civil occupation. (He had always earned a living before the war.) The other case of mutism will certainly recover his speech probably he recovered it on reaching England. The third case (No. 84) is probably a case who will get well with a year's change and rest. No patient should be discharged from the Army till cured. It is cruel to send these men back into civil life, unless they have a good post, or a small pension. The hopeless cases, who are not likely to recover whilst in the Service, may perhaps be bribed into improvement by an understanding that as soon as they are better they will be discharged. Suitable employment should be found for them before they leave the Service. From every point of view an early and adequate treatment of these cases is imperative ; many of the patients, if discharged uncured, will sink into chronic invalidism. The artisan who feels himself unable to continue his job, even though he have a small pension, is, with the necessary limitation of his interests, a misery to himself and to his family. CHAPTER VIII SUMMARY OF CONCLUSIONS (1) WAR-SHOCK is hysteria occurring in a person free from hereditary or personal psycho-neurotic antecedents, but with a mind more responsive to psychical stimulus than the normal. (2) The wrenching from the customary calling and life, the new discipline, the peculiar and terrible mental strain of modern war-conditions acting upon this sensitive mind determine the disease among soldiers. (3) In 100 consecutive cases of psycho-neurosis 70 per cent, correspond to this description; 30 per cent, have neuropathic antecedents, hereditary or personal ; the latter correspond more closely with the psycho-neuroses seen in civil life. (4) Shell-shock, gas-poisoning, or other physical injuries do not cause the disease. The symptoms are protean palsies, analgesia, amblyopia, mutism, deafness, affections of the vegetative system such as the soldier's heart, vomiting, diarrhoea, insomnia, loss of memory, somnambulism, phobias and obses- sions of all kinds. (5) These symptoms are the result of mental conflicts or other mental phenomena ; all the symp- toms can be understood in terms of the mind without any reference to physio-pathology. (6) The psycho-pathology of war-shock is that of 144 SUMMARY OF CONCLUSIONS 145 the psycho-neuroses, and the mechanisms those dis- covered by Freud in hysteria. (7) War-shock is not a new disease ; it is a variety of hysteria where the one factor (the psychic trauma) is overwhelmingly large in relation to the second factor (predisposition) ; it is separated from non war-shock cases in degree, not in essence. (8) The treatment par excellence is hypnotic suggestion. The suggestion by preference being directed to the complex as determined from the psychological examination and general psycho- analytic conclusions. (9) 91 '5 per cent, of cases of war-shock were cured by this method and 8' 5 per cent, improved. Of soldiers with previous neuropathic antecedents, who form only a third of the total number, 62 per cent, were cured ; 27'6 per cent, improve ; and 10'4 per cent, are unaffected. Cure is very rapidly effected ; most cases are well in less than two weeks ; some in a few minutes or hours. (10) The usual objections to hypnotic suggestion do not apply to war-shock by reason of the absence of neuropathic antecedents. (11) All methods of treatment, other than psycho- analysis, are based on suggestion ; including " spon- taneous recovery," persuasion, reasoning,symptomatic treatment, electrotherapy, etc. The objection to these indirect forms of suggestion is that they are less effective (more uncertain and less rapid) than sugges- tion under hypnosis. (12) The earlier the patients are treated by this method the better. (13) The majority of war-shock patients so cured can return to the Front in three to six months. (14) Cases of "functional" disease should not be discharged from the Army until cured. 146 ^Q GQ QQ ^ X ^> II Q ^> 1*H IB 5 S Z ^ ~ >> s a O z Z .n * r PN K. 3> a ** 5 1*1 o ^ PH ^ <1 2 | 1; *! JW 5 =?- s-o II II PI + 1 B 1 . . . "g . ... j> r C3 *O o I O M S & ~ :: '- S rv S DCS o o O s?O O O O i i | B B 0) -3 a x o E -u r-i *. fl ' * " * " ~ i 00 Chief Symptoms. Left hemianalgesia, atrophy of subcutaneous tissue. Left hemianalgesia, anaes- thesia headache, myopic astigmatism. Hyperaesthesia of scar, anal- gesia elsewhere. Hyperaesthesia of scar. Hyperaesthesia of back, anal- gesia lower limbs, right above knee, left below knee. Pain along left sciatic nerve, " slipper " anaesthesia. Pleurodynia, pain in back, insomnia. Pain in breast following re- moval of adenoma. o ^^ c 3 "> c3 c^ f3 ^ 5 c S " * fe S-.2 w .P-3 'S-2 s - Si o cS 1 1 i i S. c'~ ' g*j-g '-*> "3 "3. rs * ** F-I ^ t-l & x o'g" QQ m r-* *ir t ( i-M 8-fJ f3 d? S O fe Eq O (0 9g e d 5 S fS 1 1 III 08& 10 _0 a o 1 s 32^ a S3 C Cl C5 CO SO C- CO Q o? 3 2 || B-^ <-' C ' 3^ h| ^* - C ' r-4 t ii^- T" ^^ ^J CD ^J d} O CD "S T3 o> 10 H ^c i- fc. t- U t-i E E E 1 I a 3 o S O ff a 00 2 ass 'i ^ ^ U O a ^^ CO B Paraplegia, analgesia-anaes- thesia legs, pain and rigid back. Took part in Boer War. Paraplegia, "stocking" anal- gesia. Paraplegia, analgesia legs, pain in back. Paraplegia, analgesia lower limbs. Paraplegia. Paraplegia, analgesia lower limbs to mid third of thigh. 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' 9 - -*J " MAS o 5 5 i 3 9 fl 02 M.2 ? .2 13 o ,a o - O 00 $3 - tfl CJ3 be eg a! .a O >> a o >> a ks, al analg rtigo. mnia. ach go, . il - ' .; *o ser twilight nambulism, hesia, tic, H s > -^ 5 vi _ II 1 O =5 FH Cj J3 ft EC O . S >-.=4-i a; O co O g-g Head Hea Vert Fits. Gan Som ana K e> P s "o >> -=*-< ||||lji|jlflf &g -Potn^aJoxiX^.S^- ^"^ a a ^ a a a a a CO ^> C5-lOOCOrH i-lOO r-i CO ^ &l C? CO d rH t- ?* 3D QO CO CD * W CO 3D CO go J> co 8 152 o *C T3 0> C 00 SI 1 ^gg I-H 1 1 0> 8 O "3 S >> C O 33 8 a fl * a S "S "5 hSS op a, S >. CQ r g S oo *'S O O ? 6C >> cs 2 *w * - tf 9 M ISa&iljll . "isc Following shell- explosion, wound, tc., or no previou injury or disease. ? 1 a 32 i i f i 1 a 02 (0 10 "S 5 aS3& 1W1 a ^ a s TJ, CO a >. I C* ^ a a CO CM xi t- * cc +++++++ 30 o oi o os os a OCC5Q INDEX. ADRENIN, increased under emotion, 84 After-treatment, 142 Ambisexuality, psychic, 98 Amblyopia, functional, 68 1 ) 123 Amblyopia, persistent, 32 Amnesia, 87 Antecedents of patients. 8 Anxiety-hysteria, 13, 78 Anzacs and psychoneuro- sis, 17 Aphonia, 30 Astasia-abasia, 27 Auto-mimicry, 48 Babinski, 130, 133 Bagehot, on dreams, 115 Beard, 6 Benon, 2 Binswanger, 20 Biological functions, 112 Blinking, 39, 57 Boasting, 121 Briand et Philippe, 138 Campbell, Dr. Harry, 14 Cannon, W. B., 84 Choking of libido, 93 Claw-hand, 25 Collecting mania, 98 Compensation, psychologi- cal, 67 Conflict, 17, 112 Contracture of knee, 26 Conversion-hysteria, 8, 48 Deafness, 37, 126 Degeneration and hvsteria. 16 Dejerine et Gauckler. 132 Diagnostic psycho-analysis, 99 Dreams, 92, 97, 103, 113-117 Drop-wrist, 25 Endopsychic censure, 116 Enuresis, 42 Epilepsy, word associations, 119 Epileptic fits and hysterical fits, 120 Fear and desire, 102 ,, repression of, 79 Forsyth, D., 13 Frazer, Sir J. G., 65 Freud, 7, 8, 44, 56, 58, 67 73 95, 114 Fugues, 88 Functional anaesthesia, why left-sided, 61 Functional disease and wounds, 4 Ganser twilight state, 40 Gatti, Lodovici, 48 Gaupp, 142 Gesture, symbolic, 63 Grant Dundas, 120 Grasset, 4, 15 Guthrie, Leonard, 130 Heart, the soldier's, 42 Hemeralopia, 36 Hemianalgesia, psychology, of, 59 Hemiplegia and mutism, 24 Herz, M., 45 Heteromimicry, 54 Homosexuality, 110 Horse, identification with 54, 81 Horse symbolic, 82 Horstmann, 3 Hyperaeethesia, 21 153 154 INDEX Hyperthyroidism, blood in, 80 Hysteria, its two forms, 8 Identification, 54 Idio-Mnesis, 112 Incest-motif, 11 Janet, Pierre, 8 Jones, Ernest, 78, 118 Jung, 10, 90, 92, 94, 116, 119 Laudenheimer, 13 Lewandowsky, 62 Leyton, O., 45 Libido, 91, 93 MacKenzie, Sir J., 43 Malingering, 125 Masturbation, 64 Memory, loss of, 73 ,, practical, 89 Mercier, C.A., 88, 89 Milligan, T. C., 137 Money-complex, 98 Mott, F. W., 14, 28, 129 Mutism, psychology of, 54 69, 70 Mutism, shell-shock, 28 without shell-shock 29 Myers, C. S., 22 Neurasthenia, Beard's, 6 ,, Freud's, 7 Nonne, 3, 15, 133 Obsessions, 108 CEdipus-myth, 73 Oppeuheimer, 1 . 3. 62 Paraplegia, 71 Predisposition, 2 Prospective tendency, 117 Psychasthenia, 8, 95 Psycho-analysis, 11, 132, 139 ,, and suggestion, 140, 141 Psychoneuroses, two types, 17 Psychoses excluded, 9 , , German statistics, 9 Rationalization, 75 Re-education, 138, 139 Regression, 91 Rest-cure, evils of, 141 Rothmann, 3 Self-deception, 106 Sensory symptoms, 20 Sex, rational, 102 Shell-shock, 4 Ships, love of, 111 Smell, disorders of, 37 Smith, Elliot, 2, 14 Soldiers' interests, 103 suggestible, 130 Somnambulism, 86 Speech-complex, 66 Speech disorders, 27 Spirit, life of the, 112 Stammering, 30 Stekel, 62 Stewart, Purves, 61, 123 Stoney, Florence, 85 Sublimation, 91 Suggestion and anaesthetic, 136 Suggestion, collective, 135 , hypnotic, 134 , without hypnosis, 138 Taste, disorders of, 38 Tics, 39 Transference, 56 Treatment, procedure, 134 results, 128 Unconscious, archaic, 64 ,, creative. 111 Uncured, 143 Vaso-motor symptoms, 79 Vomiting, hysterical, 41 War-shock, 2 Wiltshire, 3 Word-association, 90 Words, materialisation of, 64 WOODS & SONS, Ltd., Printers, 338-9, Upper Street, N. University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hilgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. REC'D LD-URL APR 151MI APR 24 A 000557337 3