WAR-SHOCK
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HYPNOTISM, OR SUGGESTION
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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 Hein<mann, 19 7
PREFACE
As the material for this book I have taken the first
hundred consecutive cases of psycho-neurosis which
came under my care ; the psychoses have been ex-
cluded. A certain number of these hundred patients
were admitted into the general surgical and medical
wards of which I had charge in the earlier stages of
the Gallipoli campaign ; the larger number were
patients who were sent into the special department
which was formed later on and entrusted to me. By
limiting the detailed observations to a small number of
patients, who, however, present collectively the chief
varieties in the symptoms and psycho-pathology of war-
shock, a better basis is secured for the understanding
of this condition than could be obtained by a more
general account of larger numbers.
No claim is made for regarding the figures given in
this book as of universal validity. In medicine, perhaps
especially in psychological medicine, mere statistics
are, I believe, of little value, and are more prone to
occasion erroneous deductions than the detailed records
of a few cases.
The appendix (pp. 146-152) gives a summary of the
aetiology, symptoms and results of treatment of these
first hundred patients.
Through the friendly interest in the work taken by
my commanding officer, Lt.-Col. Scanlan, R.A.M.C.,and
the ever willing co-operation of the nursing staff, I was
Ti PREFACE
able to live with these patients for hours and days
together ; it was possible to make a fairly intensive study
of their difficulties and troubles.
To many of my one-time colleagues in the Malta
Command I am indebted for help in securing the well-
being of the patients : to them my thanks. More
especially to Surgeon-General Whitehead, A.M.S., who
sanctioned the creation of the special department, and
to Col. Purves Stewart, Consulting Physician to the
Malta Command. Col. Stewart saw most of the patients
before they came into the department ; he took the
liveliest interest in their progress, and was ever
generous in allowing me to have his earlier records of
the cases. My friend, Dr. H. Wingfield, I must thank
for his kindness in reading through the proof sheets.
This book does not pretend to deal exhaustively with
the ultimate concepts of the psycho-neuroses. I have
had in mind two considerations : to give so much of
the psychology as to make the symptoms intelligible,
and to show that soldiers suffering from war-shock
respond peculiarly well to psycho-therapeutic treatment.
It offends the scientifically trained mind to read, as I
did to-day : " A soldier, who became dumb two years
ago after an explosion, suddenly recovered his speech at
a cinematograph show."
It is not necessary that a soldier's cure should have
to depend upon the chance stimulation of his emotions
at some greater or lesser interval after his injury.
Medical science can to-day reduce this period of misery
and suffering to a few days in the vast majority of
soldiers afflicted by shell-shock.
The book was planned and mostly written whilst on
service, a condition which prevented any attempt at
a critical study of the literature. This cannot be made
till the war is ended. I have preferred to have this book
PREFACE vii
published during the war in the hope that my experi-
ences may be useful to others, may assuage, in howso-
ever small a degree, the sufferings* of that most splendid,
cheery and heroic figure, the British soldier, none other
than the common Briton the working man whose very
same virtues we too often fail to recognise without the
khaki.
M. D. EDER.
* Since this was written the following is one of several similar
cases that have come under my'notice : A clerk, aged 26, enlisted
at the beginning of the war. After several months in the
trenches he got shell-shock ; tried to carry on for some days,
but was then ordered to hospital. He remained in a hospital
and a camp for nearly ten months without any improvement.
He was then discharged from the Army with a gratuity of 20.
Believing himself now given up by the doctors as incurable, and
thinking that he would never support himself, he grew more
despondent than ever. When some weeks later he came under
my notice he was suffering from exhaustion, confusion of ideas.
causeless terrors, want of concentration, so that he could not
read or write a few lines or add a couple of figures. He was
being supported by his friends and relatives. A few weeks
treatment restored him to the normal and put him in a position
to earn a livelihood.
CONTENTS
CHAP. PAGE
PREFACE
I. INTRODUCTION ... ... ... ... i
II. CONVERSION- HYSTERIA ... ... ... 20
III. PSYCHOLOGICAL MECHANISMS IN CON-
VERSION HYSTERIA -.. ... ... 48
IV. ANXIETY- HYSTERIA ... .. ... 78
V. PSYCHASTHENIA ... ... 95
VI. DIAGNOSIS ... 118
VII. TREATMENT 128
VIII. SUMMARY OF CONCLUSIONS 144
APPENDIX, SUMMARY OF 100 CON-
SECUTIVE CASES ... ... ... 146
INDEX 153
CHAPTER I
INTRODUCTION
THE institutes of medicine remain unshaken by the
war. It has, however, raised many new medical
questions, thrown fresh light on old problems, and
demanded the application of the ancient principles
under novel conditions.
The war has apparently created some new diseases :
we read of trench-fever, trench-nephritis, and so on.
In the sphere of the psycho-neuroses no new diseases
are to be discovered. Oppenheim has, it is true,
written a book upon them, 1 but his new diseases
reflex paralysis, akinesia amnestica seem but due
to his ignorance of contemporary psycho-pathological
work. His German critics, Birnbaum, Lewandowsky,
and others, have sufficiently dealt with his claims.
(See the discussion at the Berliner Gesellschaft fur
Psychiatric, in the Zeitschrift fur die gesamte
Neurologic und Psychiatric. (Bd. 12, Heft. 4, 1916,
p. 427.))
But though no new diseases have been produced
by the war, we have learnt much that is new about
the old diseases, and obtained new evidence confirm-
ing earlier views. We have learnt that a psycho-
neurosis can be produced by stress of external condi-
tions, acting on a mind which is but a degree or so
more sensitive than the normal person's a sensitive-
1 ' ' Die Neurosen nach Kriegsverletzungen.
i
B
2 WAR-SHOCK
ness which should have involved no disability in
normal life, rather the contrary it might tend to
success in a man's particular vocation, or make an
artisan take a lead in the affairs of his own trade, or
parish affairs, or enter Parliament. This psycho-
neurosis is what I call War-shock.
It is to these conditions 'hat Grasset 2 refers as
presenting "la forme classique de 1'ancienne hemi-
plegie hysterique."
Though the form is the same, there is a difference
in kind ; in war-shock the external psychic factor is
overwhelmingly greater than the second factor the
predisposition.
This view is also maintained by Benon, 3 who
writes : " L' importance attachee pratiquement au jourd'-
hui a la predisposition ou mieux aux causes
predisposantes est tout a fait excessive."
We also find among soldiers suffering from the
same symptoms cases which correspond to the psycho-
neuroses more commonly seen in civil life. These I
call here non- war-shock cases.
The aim of this little book is essentially a practical
one ; it is hoped to give an understanding of the
mental processes at work in these affections, so as
to provide the sound basis for their adequate treat-
ment. Professor Elliot Smith in a valuable paper*
writes: "Everyone who has had any dealings
with the patients in the military hospitals scattered
throughout this country must admit that much more
might be done for patients suffering from some of the
protean manifestations of shock than is being attempted
at present. . . . Such patients may recover of them-
2 "Les psychonevroses de guerre": Presse Medicale, 191b,
p. 105.
3 "Les maladies mentales et nerveuses et la guerre."
R. Benon. Revue Neurologique, Fevrier 1916. No. 2, p. 215.
4 "Shock and the Soldier." The Lancet, April 15 and 22,
1916, p. 813.
INTRODUCTION 3
selves without any attention, but a large number of
them tend to get worse, and if they are left without
attention their symptoms are apt to become stereo-
typed into definite delusions and hallucinations."
There is no reason why this should be. The
symptoms respond to treatment quite as readily as
surgical or infectious affections ; nor, in the majority
of cases, need the active treatment be very pro-
longed.
My earlier nerve cases had to be picked out from
the heterogeneous diseases, mostly surgical, admitted
to my wards : e.g., in the very first batch of patients
admitted to my wards the day our hospital was
opened, June 10th, 1915, was a hysterical deaf-mute.
I am thus enabled to confirm from personal experience
the statements of others that functional diseases are
rare among the wounded. I cannot go so far as
Wiltshire, who claims that "Shell-shock is not to be
seen in surgical wards," i.e. "as exemplified by
monoplegias, paraplegias, mutism, somnambulism,
fits, hysterical fits, and neurasthenia" 5 : out of 150
cases only 14 had been wounded.
Horstmann 6 has seen no functional diseases
among the wounded, whilst Nonne 7 says they are
very rare. Rothmann 8 and Oppenheim, 9 on the
other hand, say that functional diseases are very
frequently associated with organic lesions.
The following table shows in 100 consecutive cases
(the psychoses have been excluded) the relationship
between surgical injury, shell-shock and functional
disease.
5 Harold Wiltshire. "A Contribution to the Etiology
of Shell-Shock." Lancet, June 17, 1916. p. 1207.
6 Quoted Zeitschrift fur die gesamte Neurologic u. Psy-
chiatric, April, 1915, Bd. 11, Hf. 5, p. 344.
7 Ibid, p. 344.
8 Ibid. p. 345.
9 " Zur Kriegsneurologie." Berliner klinische Wochen-
schrift, 1914. No. 48.
4 WAR-SHOCK
Without previous injury, shell-shock, etc. . . . 53
Following shell-shock 19
Associated with injury such as wound, fall,
etc. (frost-bite in two cases) ... ... 28
100
\
Shell-shock has been given prominence on account
of its prevalence and the various hysterical symptoms
that have followed the high explosions. Exactly the
same symptoms have occurred, however, after shrap-
nel wounds, falls, and without previous injury at all.
We take note of shell-shock in the aetiology, but to
make it into an independent disease (apart from
practical convenience) is about as valuable as it would
be to regard enteric fever arising from drinking
polluted water as a different disease from enteric
fever arising from drinking polluted milk.
The view that mere chemical poisoning is the
causative agent in shell-shock has nothing to recom-
mend it. Suggestion in any form, whether the
patient is awake or under hypnosis, could not remove
the poison, but it may immediately relieve the
symptoms. In what way shell-shock or poison, as
auto-mimicry, is a contributing factor is pointed out
later on (p. 48). And from that point of view the
shell-shock may be said to be the causal agent : that
is to say, had there been no shell there would be no
concussion and no subsequent hysterical mimicry of
that concussion ; but equally of course, if we trace
the sequence further back, we should say if there had
been no war, etc., or if the Kaiser .... and so on
ad infmitum.
We agree with Grasset 1 that it is "la presence
et la predominance de Pelement psychique" upon
which the emphasis should be laid in these affections ;
1 Loc. cit. p. 105.
INTRODUCTION 5
hence the term psycho-neurosis. Wiltshire 2 con-
cludes that "any psychic shock or strain may cause
a functional neurosis, provided it be of sufficient
intensity relative to the nerve resistance of the indi- '
vidual. Such shock or strain need not have any
connection with "sex complexes."
The term functional disease is a very good one
if it be understood that we have primarily an inter-
ference with function, which may or may not produce
secondarily a structural change. This is in sharp
contrast with the organic diseases where the primary
lesion is structural, the interference with function
being secondary. A fracture of the femur inter-
feres with the function of the leg, a wound of the
musculo-spiral nerve interferes with the function of
the hand, but the interference with function is
consequent on the structural changes. In a
hysterical paralysis of the leg, in hysterical wrist-
drop, no primary organic lesion, macroscopic, micro-
scopic, muscular, or bio-chemical, need be postu-
lated. We can account for these conditions by
psychological laws. In doing so we must exclude
altogether physical terms, brain-cells, movements
of dendrites and the like. This is not the place
to examine, as I hope to do in another book, the
relationship between mind and body placed by
recent psychological work upon a more scientific
footing ; it must be sufficient to say that against the
very current dogma that disease is inconceivable
without some underlying physical basis, the dogma
in this little book is that some diseases are con-
ceivable without any underlying physical basis ;
mens peccat, non corpus. The evidence for this
statement will be found in the psycho-pathology
of the diseases which are treated (Chapters III, IV
and V). To prevent misunderstanding the corollary
2 Loc. cit. p. 1, 212.
6 WAR-SHOCK
may be added that some diseases are inconceivable
without an organic basis.
The dogma at the back of this book does not stand
upon the fashionable doctrine (less fashionable to-day)
of a psycho-physical parallelism. The use of
terms such as region of the mind, passing into the
unconscious, and so on, which would imply that the
mind is extended, are to be regarded as figurative; I
could not omit these terms without troublesome
paraphrases and a full explanation of the doctrine
that the mind has relationship to time, whilst matter
(here as brain and nervous system) is related to
space.
Though the influence of mental processes upon the
body will be the chief study, the action of physical
processes upon the mind will receive notice. Every
physician is, of course, acquainted with and makes
use of these reciprocal actions in a general way.
We all know that cheerful surroundings and sympa-
thetic understanding can occasionally convert physi-
cal illness "from a consuming fire into a gentle
licking flame, and make it thus expire."
We must also recognise that physical means have
sometimes a no less valuable effect upon mental states;
Lord Byron was not singular in finding a dose of
salts to be the most exhilarating stimulant in moods
of depression.
The diseases here considered are hysteria and
psychasthenia. I have excluded the term neuras-
thenia altogether, because I am unable to find, at any
rate in the troubles produced in the war, any clinical
entity that corresponds to this term. Beard, who
baptised this disease, defined neurasthenia as a
"chronic, functional disease of the nervous system,
the basis of which is impoverishment of nervous
force, waste of nerve tissue in excess of repair ; hence
the lack of inhibitory or contributory power physi-
INTRODUCTION 7
cal and mental the feebleness and instability of
nerve action and the excessive sensitiveness and
irritability local and general, direct and reflex." 3
It is not any stickling for etymological rectitude that
gives rise to an objection to the term. It is the
impossibility of apprehending the disease. Beard
already included in his book a mass of symptoms,
obsessions, phobias, hysterical manifestations, to
which later writers have added. Neurasthenia is
now frequently an euphemism for insanity in a patient
where for some reason or other the word insanity
must not be or is not mentioned ; it is not without its
danger when thus used. In colloquial usage, much as
the laity speak of a nervous breakdown, or of rheu-
matism, or a touch of the gout, or a chill on the liver,
the word no doubt will continue to find useful
employment.
Freud 4 has dealt with the difficulty by giving
the name neurasthenia to the following syndrome :
exhaustion, mental and physical ; depression, pressure
on the head, spinal irritation, and dyspepsia. "Accord-
ing to Freud's views this clinical picture corresponds to
the specific cause of excessive masturbation or frequent
pollutions, or better expressed, neurasthenia [as thus
limited] may in every case be traced back to a con-
dition of the nervous system which has been acquired
through excessive masturbation or arisen spontane-
ously from frequent pollutions." 5
I have not found this simple syndrome among
soldiers; not, of course, that masturbation does not
3 "A Practical Treatise on Nervous Exhaustion (Neuras-
thenia)," by G. M. Beard, A.M., M.D. New York; Second
Edition, 1880, p. 115. His first paper with the term neuras-
thenia was published in 1869, in the Boston Medical and
Surgical Journal.
4 " Neurosenlehre. Sammlung kleiner Schriften," Vol. I.
1893-1906. Leipzig and Vienna : Deuticke.
5 " Freud's Theories of the Neuroses," by Dr. E. Hitsch-
mann, translated by Dr. C. R. Payne. New York, 1913, p. 15.
8 WAR-SHOCK
occur among them; many of them are at the adoles-
cent age when masturbation is common enough, and
I have had, of course, soldiers addicted to masturba-
tion or complaining of frequent pollutions. But it
has not in them given rise to neurasthenia as thus
defined. Case 100 (see p. 100) would at first sight
seem to be an instance of this, since the only symptom
for which he was sent into hospital was exquisite
fatigue ; but psycho-analysis revealed a very different
picture from that given by Freud. I do not, of
course, suggest that Freud's neurasthenia does not
exist, only that I have not come across it among
soldiers. Freud split off from Beard's neurasthenia
another group of symptoms, the anxiety-neurosis.
This again I have not found in its pure state among
soldiers, whilst his other clinical picture of anxiety-
hysteria is common.
I have followed Freud in dividing hysteria into
two groups.
A. Conversion-hysteria, which includes the affec-
tions of the senses and locomotion, fits, and so on.
Here the mental affection is converted into its physi-
cal equivalent.
B. Anxiety-hysteria, where the condition of dread,
anxiety, fear, is the prominent symptom and is due
to some repressed unconscious mental complex.
The association of this condition with vaso-motor and
other symptoms is dealt with in Chapter IV.
Psychasthenia, which to some extent corresponds
to Freud's obsessional neurosis (Zwangsneurose),
is the other psycho-neurosis which is found among
soldiers ; clinically the cases correspond very well to
Janet's 6 description: "Les psychastheniques . . .
preseatent un abaissement de la conscience dans sa
totalite . . . Cet abaissement general qui n'est pas com-
6 Pierre Janet. "Les Obsessions et la Psychasthenie."
Vol. I., p. 675. Alcan: Paris. 1903.
INTRODUCTION 9
pense par un retrecissement du champ de la conscience
leur donne des sentiments d'incompletude bien plus
accentues qu'ils ne sont d'ordinaire dans 1'hysterie."
Obsessions, imperious acts, phobias and various phy-
sical stigmata characterise the psychasthenic.
On the above classification my 100 cases show:
Conversion-Hysteria ... 77
Anxiety-Hysteria ... ... 17
Psychasthenia ... ... 6
100
Most of the cases in the group of anxiety-hysteria
correspond to cases included by Janet among his
psychasthenics.
This book does not treat of the psychoses as found
among soldiers. Having had charge of a mental
ward in connection with the psycho-neurological de-
partment, some investigations were able to be made
into the psychology of their insanities, although the
patients were with me for too short a time to obtain
any complete knowledge ; the treatment was neces-
sarily unsatisfactory because our hospital was not
fitted out for mental patients, and the patients were
transferred to England at the earliest opportunity.
Despite these limitations, I feel justified in saying
that a considerable number of the psychoses occurring
in the war, first attacks with a good psychological
history, bid fair to become entirely well under proper
treatment.
I have not seen any statistics as to the number of
psychoses in our armies ; it may be of interest to
mention that Alt 7 estimates them at 1/1000 in the
German Army. Hoche, 8 on the basis of previous
1 Zeitschrift f. die, g.Ncur. und Psychatrie, Bd. 12, Heft. 1,
p. 6.
8 Ibid. Bd. 11, Heft. 5. p. 330.
10 WAR-SHOCK
experiences in German wars, places the insane to be
about 2/1000, and thus in an army of <H millions he
says there would be about 8-10,000 insane.
Jung has divided the psycho- neuroses into (a)
diseases of extraversion (hysteria) and () diseases
of introversion. I have been tempted to follow him,
but my analysis of many of the cases was not funda-
mental enough to venture here on this difficult path.
A broad psychological distinction between hysteria
and psychasthenia can, however, be made; if with
Freud we may say that the hysteric suffers from his
past, the psychasthenic suffers from his future.
Each forward step, babyhood to childhood, child-
hood to puberty, puberty to adolescence, is fraught
with difficulties for the psychasthenic ; he cannot fit
himself into the real world which his unconscious self
has already foreshadowed. However clear and
urgent is the need for adapting himself to the situa-
tion which his mental and physical growth demand,
when it comes to execution his mind becomes inert.
To avoid the difficulties which loom so tremendous,
his mind busies itself in the creation of phantasies
centering round the past. If we have on the one
hand the creative impulse in man which transcends
his experiences, we have on the other hand what we
may call creation (libido) in opposition, i.e., content-
ment with the present, basking in the sun, sloth the
deadliest of the seven deadly sins. This mind will
form a thousand difficulties and obstacles to its on-
ward path, difficulties and obstacles which will never
be ascribed to this inertia, but will be invariably put
down to the doings of other persons or to troubles
arising from the real world. It is discovered that
"Shades of the prison house begin to close
About the growing boy."
This prison house becomes the incest motif, the
INTRODUCTION II
"terrible mother," 9 the temptress, the serpent; the
fear of the father. The child has gradually to wean
itself from the warm family life, once a necessity for
its very existence, to acquire spiritual autonomy, just
as it has had to gain physical independence.
This book does not deal with the more fundamental
problems of the psycho-neuroses and the relationship
of these affections to more normal lives. In only six
cases was psycho-analysis, the only method with
which I am acquainted that lays bare the innermost
secrets, carried out for therapeutic purposes. That
is to say, in only six cases did the patient learn to
make the diagnosis of his condition, to realise him-
self in any measure, to arrive at an understanding of
his unconscious complexes and conflicts. Nor was
the treatment complete in any of these six; the
necessities of military medicine did not permit me to
keep the patients long enough under my care in
Malta for this. For professional, not scientific,
reasons some of these cases are not published.
In the other cases I have been content to find the
psychological explanation of the mechanism of the
symptoms. 1 This could be done by a close per-
sonal relationship with the patients, allowing them
to talk at their ease, asking few questions, but
gathering their life-history, earlier characteristics,
their dreams past and present, the details of their
symptoms, and their mental and physical condition,
both at the time when the disease occurred and
subsequently. The interpretation of the knowledge
thus acquired has been made by the results of that
9 See "The dual mother role" in Jung's " Psychology of
the Unconscious," translated by Dr. B. M. Hinkle. New
York: Moffat, Yard & Co., 1916.
1 This explains the omission of the full history of No 81, who
had a fairly complete treatment by psycho-analysis with excel-
lent result. I was able to keep this patient under observation
several months after the end of his treatment.
12 WAR-SHOCK
psycho-analytic work which we owe to the genius of
Freud.
So far as these 100 cases of psycho-neuroses in
war are concerned, it will be seen that sex is not
the only factor. Sex is often, to use one of Freud's
terms, a " Deck-E-rinnerung," a " cover-memory "
to conceal something more momentous. See the
analysis of cases Nos. 99 and 100, pp. 100-114 But
in some cases sex, in the form of the typical QEdipus
myth, is very clearly brought out (No. 26, p. 74),
whilst in other cases it was highly probable that
adequate psycho-analysis would have laid bare a
sexual complex which again would have shown
to be itself symbolic of the individual's mal-
adaptation. The method of interpretation upon
which I had to rely cannot bring these deeper
complexes and ultimate aims to light. The deeper
layers of conflicts do not emerge into the conscious
until the more superficial complexes have been dealt
with by consciousness.
Nor is it just funk, as one neurologist calls
it, that gives rise to functional diseases; the part
that suppressed fear may play in the produc-
tion of hysteria will be considered later, but this
is quite another thing. Among the many mutes I
have seen it is rare to find one who was struck
speechless by terror. But terror is not funk, or
fear.
A few instances of sex perversions have been
encountered, but none happens to be included in the
first 100 cases. I have no evidence to confirm a
statement made by Teuton 2 that war exercises
an important influence upon the sexual life in its
various phases, both inhibiting and stimulating it;
2 Geschlechtsleben und Geschlechtskrankheiten in den
Heeren im Krieg und Friede. Berliner klinische Wochen-
schrift, Nos. 14. 1915.
INTRODUCTION 13
occasionally there is a pathological increase even
to the production of perverse sexual tendencies and
actions. He says that the stage of long marches
and battles and the trenches offer no inducement
for sex-action, but during camp life, and especially
after the occupation of large cities, there is abun-
dant opportunity. Juliusberger 3 finds that certain
cases of absence of love of the fatherland, absence
of interest in the war, and want of understanding
about the war, are due to a pathological sexual
infantility .
As careful an investigation as the circumstances
permitted has been made into the family and per-
sonal antecedents of the patients. Whenever there
has been the slightest evidence of a bad family
history or of earlier psycho-neurotic trouble, quite
apart from any actual illness or " break-down," dis-
cerned either in the preliminary case-taking or in
the later psychological enquiry, the case has been
set down as having pre-war antecedents. It is to be
noted that all the cases of psychasthenia had an
antebellum history. The analysis shows :
With pre-war history (family or personal) 30
Without ( = war-shock) ... 70
These figures contrast very strongly with those
given by other observers. Laudenheimer, 4 for
instance, says that out of 52 cases of psycho-neurosis
there was in 90 per cent, a predisposition either by
congenital constitution or by disease acquired before
the war. Forsyth 5 has found, " In all cases coming
under the writer's notice with symptoms which were
more than mild and transitory a history of some
3 Zur Kenntniss der Kriegsneurosen, Monat. f. Psych, u.
Neurologie. 38, No. 15, 1915.
4 Miinch. med. Wochenschrift, No. 38. 1915.
5 "Functional Nerve Disease and the Shock of Battle."
David Forsyth ; Lancet, Dec. 25th, 1915, p. 1401.
I 4 WAR-SHOCK
earlier nervous trouble, slight or severe, was forth-
coming."
Mott 6 says, that " in a certain proportion a little
more than one-third, the cumulative effects of stress
of active service, combined with repeated and pro-
longed exposure to shell fire or high explosive
projectiles, apparently had induced a neurasthenic
or hysteric condition in the nervous system of a
potentially sound individual."
Mott's conclusions are for cases of shell-shock
only. Taking for comparison the 19 cases of shell-
shock alone out of my 100 cases the following figures
are obtained :
With previous pre-war history (family or
personal) ... ... ... 8
Without any ,, ,, ,, 11
Moreover, the estimates given by Mott and Lauden-
heimer are based upon the anamnesis ; a psycho-
logical examination, which begins when the anam-
nesis ends, brings to light neuropathic traits un-
suspected and incapable of recognition by the
methods used by those observers. My figures are
based upon a psychological examination sufficient to
bring out any latent neuropathic traits.
Harry Campbell 7 says that it is chiefly among
the unstable nervous systems that the neuroses are
met with in war.
On the other hand, and entirely in accordance with
my own results, Elliot Smith 8 says: "It would be a
gross misrepresentation of the facts of the case to
label all the soldiers who suffer from mental troubles
as weaklings. The strongest man when exposed to
sufficiently intense and frequent stimuli may become
6 Transactions of the Royal Society of Medicine, February,
1916. Sections of Psychiatry and Neurology, p. 5.
7 The Practitioner, May, 1916.
8 Loc. cit., p. 855.
INTRODUCTION IS
subject to mental derangement. It is quite common
to find among the patients suffering from shock, senior
non-commissioned officers, who have been in the army
for fifteen or twenty years . . . and have stood this
severe strain. Such men can hardly be called
weaklings."
Nonne 9 admits that the hysterical syndrome is
more easily aroused by adventitious factors than was
thought. Mann l agrees that the healthy can become
momentarily hysteric, and Hoche 2 contends that
every combatant can become hysterical under appro-
priate experiences.
Grasset 3 is of the same opinion. " Les antecedents
personnels antebellum et hereditaires ont relative-
ment peu d'importance dans le developpement des
psychonevroses de guerre. Ma conclusion serait
differente si j'avais a m'occuper des psychoses des
guerres."
Those acquainted with the works of Freud and
Jung will find nothing new in these statements which
do but confirm the antebellum findings of psycho-
analysis.
My own view, founded before I had been able to
consult the war literature on the subject, was expressed
in an address in April, 1916, to the Malta Medical
Conference, 4 where the case of a patient suffering
from hysteria consequent on severe fighting, for which
he had been recommended for the V.C., was quoted:
" In most cases the neurosis has arisen under the
strain of quite extraordinary conditions. I would
remind you that our Army is not composed of fight-
ing men, in the technical sense. The men come from
9 Archiv. f. Psych, u. Nerv. 56, Heft. 1, 1915.
1 Deuts. Med. Wochenschrift, No. 4, 1915.
2 Archiv. f. Psych, u. Nervenheil, 56, Heft. 1, 1915.
3 Loc. cit.,p. 107.
4 The Psycho-Pathology of the War Neuroses. Lancet,
August 12, 1916, p. 168.
!6 WAR-SHOCK
the mill, the mine, the farm, the counting house, the
country house ; every trade is represented and every
class. Thus, men brought up to a quite other avocation
are suddenly, with scant training, called upon to make
a new adaptation. In the stress and strain of their
normal life they would probably have been equal to
any emergency. But for some among the very
best the new conditions called out to them to strain
themselves to the very utmost, and this was just a
little too much. . . . Napoleon used to say that the
British are a nation of lions led by asses. The lion
is still there, and let me remind you lest, post bellum,
you forget, that the lion is just our old friend, the
British working man. Eighteen months ago the
hero of the bayonet wounds (Case No. 24) was a
plumber!"
It should be remembered in connection with the
comparative large number of well-seasoned N.C.O.'s
who suffered from hysteria, that their responsibilities
in this war have often been very great ; that many are
men who, having left the army after fine service, had
married and settled down into good positions. Throw-
ing up these, they have had the additional anxiety of
feeling that at their time of life they may not be able,
should their positions be lost, to find the same security
for their families and themselves.
It should not be difficult to understand why hysterical
shell-shock is rare among the seriously wounded. In
these patients the psychical energy is sufficiently
occupied with something very concrete and real ;
there is none to spare for the creation of phantasies
and the conversion of these phantasies into the
hysterical symptom.
In regard to the common statement that hysteria
is a sign of degeneracy, and the statement, which was
not made in Germany but by writers in this country
who claimed to speak with authority, that the
INTRODUCTION 17
English people are "a degenerate race," it is worth
noting that 19 out of the 100 cases were Anzacs, and
the majority of these 19 were not men from the
cities but from the bush. Unless the relative pro-
portions of the Anzacs to British troops employed on
the Peninsula were known, no argument can be drawn
from these figures. But one can say that the up
country Anzac is not immune, in war anyway, from
hysteria.
And this again is in accordance with the pre-war
expectations of those who understood these conditions.
A psycho-neurosis occurs in two kinds of persons,
those who are inherently below the level of the
civilization, who may be called degenerates, but are
more properly to be regarded as backwards, and those
who are ethically in advance of their age. The latter
are the harbingers of a new world, of the dawning
civilization which may only (or may never) materialise
centuries hence. Hence their conscious and uncon-
scious selves are in constant conflict. It is the lot of
the neurotic frequently to be in unstable equilibrium
by reason of these inner conflicts. Such conflicts
seem to be necessitated by the very essence of man.
In so far as to-morrow will be like to-day, and it will
be so in regard to a large number of mental pro-
cesses, man is served by his experiences ; but to man
is given the gift not only of creating something in the
morrow which is quite unlike to-day, dissimilar from
his experiences, but also of foreshadowing that new
creation. That forecast of the new he relates to his
known experiences by means of symbols, with some
of which we shall deal later.
The war might at least rescue the word neurotic
from its present use as a term of reproach : without
the neurotic the mind of man would be stationary.
The war may teach those who have not already
learned the lesson by what slightly graded steps
IS
WAR-SHOCK
the normal differs from what we call the abnormal.
The following table shows the results of treat-
ment:
100 CASES.
Treatment.
Cured.
Im-
proved.
No
change.
Total.
Suggestion under hypnotism
70
7
2
79
Suggestion without hypnotism ...
3
2
5
Suggestion under anaesthetic
6
6
Psycho-analysis
*
i
4
5
Other methods
1
1
2
No treatment (referred for diagno-
sis etc.)
F31
3
lJ
80
14
3 [6]
100
Thus out of 97 cases submitted to treatment, 80
were relieved altogether of their symptoms and 14
improved, What is meant exactly by cured and im-
proved I shall discuss in the final chapter. These
results were obtained under conditions which were
not the most favourable for psychotherapy. The
patients were 2,000 or more miles from home, they
did not know whether they were to be sent back to
the front or would go home first. Though everything
possible was done in the way of entertainment by the
residents of Malta, this island could not, of course,
offer the many attractions arranged at home nor could
our make-shift hospitals vie with the beauties and
amenities of such places as Netley, or the 4th
London General Hospital, where nerve patients are
treated. The particular hospital where my patients
were sent was regarded as an infectious hospital, and
INTRODUCTION 19
the patients for some time were not allowed out of
the limited hospital grounds. It speaks well for the
patients, I think, that only three did not improve in
their condition.
The next chapter, II, describes the clinical mani-
festations of conversion-hysteria; chapter III the
psychological mechanisms of these phenomena. In
chapter IV some cases of anxiety- hysteria are
described and explained ; chapter V deals with
psychasthenia in the same way. The last chapters
deal with the general diagnosis and treatment of
these disorders.
CHAPTER II
CONVERSION-HYSTERIA
THE war has enabled us to see examples of almost all
varieties of hysterical symptoms, varieties which,
indeed, a special hospital would only be able to
exhibit during the course of years. So protean are
these symptoms that for the sake of easier following
it becomes desirable to classify these manifestations
according to the prominence of the symptoms.
A useful division is into
A. Conversion-Hysteria (Freud), where the somatic
disturbance focusses the attention of the observer,
and
B. Anxiety-Hysteria, where the psychical elements
claim pre-eminence.
In both forms it need scarcely be said that physical
and mental symptoms always co-exist, and that it is
the mental state which demands explanation and
requires treatment.
This chapter will be chiefly limited to describing
the various somatic disturbances, leaving their psy-
chological explanation, the psycho-pathology, to the
next chapter.
SENSORY SYMPTOMS
My experience does not agree with that of Bins-
wanger, 1 who says that pure sensory disturbances
1 Hysterosomatische Krankheitserscheinungen bei der Kriegs-
hysterie. Monat. f. Psych, u. Neurol., 38 Heft. 1, 2, 1915.
CONVERSION-HYSTERIA 21
were not found in true cases of war-shock (war
hysteria) ; disturbances of sensation were always
accompanied by motor disorders. I agree with Bins-
wanger in his conclusion that the war hysteric is not,
in the majority of cases, a constitutional hysteric.
This conclusion is sound, but not so the premises;
the following is a case where hyperaesthesia was the
most prominent symptom.
No. 3. 2 A corporal, aged 37, who after 16 years in
army service, had rejoined, and was wounded in May,
1915, in the right forearm, left nipple region, and else-
where. The wounds were superficial and had apparently
quite healed, but the site of the wound on the chest
remained painful. Some months later the scar over
the left chest reopened, and when it again healed the
pain over the scar was so severe that he was unable
to carry his equipment. When examined some eight
months after the original injury he presented a scar
3^ in. long, running along the fifth intercostal space,
with its inner end 2 in. from the sternum . The scar and
the skin immediately adjacent were acutely tender to
pressure he could not bear the slightest touch here.
To cotton wool touches, universal anaesthesia, save for
a small area below inguinal folds on both sides, a patch
1 in. below and external to angle of left scapula. To
pin pricks universal analgesia except (1) just below
left scapula, (2) over scar and area 2 in. below it,
(3) two small areas in lower abdominal region on a
level with scrotum.
It will be seen that the anaesthesia and analgesia
were almost complete and that the zone of hyperaes-
thesia was strictly limited to the area of scar.
Joint sense normal. Pupils normal. Smell normal.
Hearing, contact L., Rt at 3". Vibration sense lost in
lower limbs, normal elsewhere. Reflexes : right
2 The numbers refer to the numbers in the appendix, p. 146
where a summary of the cases will be found.
32 WAR-SHOCK
plantar absent at toes and thighs (were present at a later
examination) ; the left normal ; abdominal reflexes,
lower absent the other reflexes normal.
There were no other symptoms ; there was no other
indication of disease of the nervous system. The
scar and the skin adjacent were removed by operation
in February, 1915; the wound healed by first inten-
tion. The operation did not alter the condition.
The pain was still present, as were also the analgesia
and anaesthesia. About a month later, ten months
after the wound had been received, the patient was
treated by suggestion under hypnotism. At the
second sitting the symptoms entirely disappeared ;
the normal sensation returned in the analgesic area.
For several days the corporal was rather dubious
about the pain not returning, and he went through
various manoeuvres to assure himself that he was now
all right. There had been no return when he left
the hospital some time later.
General over-reaction and hypercesthesia, fol-
lowing shell-shock, has been described by Myers 3 in a
young stretcher bearer, when even the lightest touch of
cotton wool on the limbs or head produced very little
movement whilst a pin prick produced a series of
most violent spasms, almost amounting to a convulsion.
Analgesia and anaesthesia are very common,
though more frequently accompanied by functional
motor disturbances. This is not invariable, as shown
in the following case of hemiancesthesia. No. 1
was a powerful muscular man of 22, formerly a collier.
There was complete left-sided hemianaesthesia,
together with atrophy or absence of the subcutaneous
tissues on the left side of the face, upper part of
left chest, and the left limbs ; possibly the meta-
carpal bones and phalanges of the left hand were
3 Charles S. Myers. The Lancet. March 18, 1916. Contri-
butions to the Study of Shell-Shock, p. 608.
CONVERSION-HYSTERIA 23
smaller than those of the right. There was no
muscular wasting and no loss of power either in the
left arm or leg. He had fractured the left forearm
three years previously, and attributed the lessened
size of the forearm to that accident. His attention
was drawn to the much smaller size of the left wrist
by a mate and he then became much alarmed, believing
that he would lose all power. He was not aware,
until examination in hospital, that other parts of the
left side were also smaller than the right side.
A similar sensory condition was shown by No. 2,
a corporal with over seven years' service, who was
admitted for persistent headache which had lasted
for nine months. He had been "gassed " in France,
was three days unconscious, woke up with bad
headache, and began to vomit " nasty green stuff."
After three months he went back to the front, where
he complained of pain in the chest and shortness of
breath, "could not move without his head swinging
round." He was at a rest camp for some time and
then went to Salonica. The headache had never left
him. A few days after his arrival at Salonica he
went into hospital, and after a month was sent to
Malta.
Examination showed a complete left-sided hemi-
analgesia, and a slight degree of simple myopic astig-
matism (vision 9 in both eyes without glasses).
These and the headache were the only symptoms.
Suggestion under hypnotism soon relieved the
patient of his headache, the hemianalgesia disappear-
ing rapidly, and the patient was in a few days sent
to a convalescent camp. Four weeks later he was
well and about to return to the front.
Both these patients were right-handed and the
hemianaesthesia was, as is usual in functional diseases,
on the left side.
More commonly the sensory is associated with
24 WAR-SHOCK
motor disturbance, as in the following case of left
hemiplegia and complete mutism.
No. 21. An N.C.O., in the R.A.M.C., aged 36,
who had seen 15 years' service. Four weeks before
admission to Malta, whilst on duty at a hospital, he
suddenly lost consciousness ; on recovering he found
he had lost power in the left arm and leg. Two
weeks later, on admission to a hospital ship, he had
another fit and on recovery found he had lost
speech.
There was complete left hemianaesthesia, including
the face, strictly limited to the middle line anteriorly
and posteriorly.
The left visual field was contracted and there
were loss of hearing, of smell, and taste on the left
side. The tongue protruded to the left, but could
be moved to the right at once on command.
The reflexes were normal. The dumbness was
absolute ; the patient could not whisper, laugh or
cough. But he heard and understood everything and
could write perfectly.
It was considered advisable to relieve the symp-
toms of paralysis and mutism as soon as possible.
The patient was therefore treated by suggestion
under hypnotism a few hours after his admission to
our department. Speech and normal sensation were
recovered at once, and after a second treatment
on the next day the free movement of the limbs was
obtained. Naturally the patient, who was a highly
intelligent man (he was about to get a commission),
and had had a long experience in the R.A.M.C.,
had taken a very gloomy view of his condition.
It would seem that the aphasia following the
hemiplegia had been a little misleading, but of course
the fact that the hemiplegia was left-sided and the
patient right-handed told very much against an
organic disease, for which one would have to suppose
CONVERSION-HYSTERIA 25
a lesion of the right hemisphere of the brain, fol-
lowed two weeks later by one of the left side.
The following instance of total hemiancesthesia
occurred on the right side in a left-handed soldier.
Its mode of development is of interest.
No. 4, a soldier aged 23, was with 23 men in
a sap which was attacked by some 200 Turks. He
and a sergeant leaped out of the trench and engaged
in a hand-to-hand fight with the enemy who were
eventually driven off. He received 15 bayonet
wounds in the fight ; seven of these were penetrat-
ing; 14 of the wounds were on the right side of
the body. When examined one month later the
wounds were all healed, but the fingers of the
right hand were semi-flexed and could not be
extended (claw-hand). Col. Purves Stewart had
made the following note : to pin pricks anaesthesia-
analgesia of the whole right upper limb as high
as shoulder. At beginning of examination patient
felt pin pricks at wrist, as examination continued
the boundary of anaesthesia steadily receded until
it reached the shoulder, by which time the pre-
vious sensitive spots were now anaesthetic; further
examination showed a complete right-sided hemi-
anaesthesia.
In another soldier, No. 19, aged 31, paresis of the
left of the body, with complete left-sided hemianaes-
thesia, had followed an attack of dental neuralgia;
he had been through the Gallipoli campaign without
other injury than having the tip of a helmet taken
off by a piece of shrapnel.
In a Welsh lad of 21, with loss of power in both
legs, the anaesthesia and analgesia extended from
toes to mid-thighs. (Case No. 10.)
In many cases the sensory affection is much more
restricted; thus in a soldier, No. 23, with drop wrist
of the left hand, which followed two days after receiv-
26 WAR-SHOCK
ing a slight gun-shot wound of the right hand, the
loss of feeling and pain extended to 1 in. above the
wrist. In another case, No. 22, with limitation of
movements of elbow and inability to flex the fingers,
the anaesthesia extended to 1 in. above the wrist.
HYSTERICAL CONTRACTURE OF KNEE.
No. 32, with 1^ years service; felt great pain
in the back and in the right leg on the morning of
November 29th, two days after the great storms in
Gallipoli, where he was in the trenches and up to
the chest in water. He was admitted to hospital on
December 6th. The pains in the back gradually
improved, but the knee grew worse flexed, stiff,
every movement being attended by great pain,
especially in flexion. He was confined to bed and
examined by the late Colonel Barker, A.M.S.,
under an anaesthetic, when no disease was found.
[The increased pain on flexion was against the
joint being tuberculous.] As his condition grew
worse rather than better, he was sent for treatment, on
January 30th, to the Psycho-Neurological Department:
a skiagram was taken and showed an apparently
normal healthy joint.
On the 31st January he was brought into deep
hypnosis, when, under suggestion, he readily moved
his knee in all directions. That afternoon, after
waking, he felt no pain but still walked with the knee
bent. The next day he was again hypnotised. After
getting him to walk, I said (he was an Edinburgh lad
in a Scotch regiment): "Now dance a Scotch reel."
He stood stock still, not moving a muscle. I repeated
the suggestion, but got no response. I then said:
" Now waltz." He immediately gave a very credit-
able performance.
He was quite cured, no further treatment was
necessary, he went to a convalescent camp and so to
CONVERSION-HYSTERIA 27
the front. The explanation of his response to the
waltz suggestion, and lack of response to the Scottish
dance suggestion is that he had learnt how to waltz
but not how to perform a reel ; investigation showed
also that his " local patriotism " was divided in allegi-
ance, his mother being English, his father Scotch.
This experiment tends to show that the suggestion
must be one to which the subject is not strenuously
opposed, and helps us to understand why criminal
suggestions are very rarely effective. If the criminal
suggestion happens to coincide with a very strong
wish, for the execution of which only courage has
been lacking, it may be carried out, but if it is one
which evokes opposition, the suggestion as a rule
fails.
ASTASIA-ABASIA.
In other cases the motor symptom may exist or
persist without any sensory disturbances, at least by
the time the patient is examined.
No. 33. A corporal, of over 13 years' service, was
riding along a mountain road when his horse backed
and fell with him over the cliff. He probably dropped
some five feet on to a ledge. He lost consciousness
and awoke some hours later in a hospital. When
seen five weeks later, sensation was everywhere
normal. The grasp of the left hand was feeble. The
legs could be moved whilst he lay in bed, but he
could not walk or even stand without supporting
himself (astasia-abasia). Treated by suggestion
under light hypnosis, he was at once able to walk
and quite recovered in two days.
DISORDERS OF SPEECH.
The most striking occurrence is complete loss 01
speech mutism. This seems also to be the commonest
28 WAR-SHOCK
of the speech disorders. Out of my own 16
cases there were ten of mutism, three of aphasia, and
three of stammering. This mutism may be associ-
ated with deafness (four out of ten), and may be
quite complete. Mott says, "about one in twenty of
those suffering with shell-shock and having no visible
signs of injury have lost their speech, and yet are
quite able on admission to write a lucid account of
their experiences." *
That is to say, the patients cannot cough, whistle,
make any sound when laughing, and in severe cases
there is difficulty in putting out the tongue, and in
one case of swallowing (Mott, ibid}. They are able
to express themselves well in writing, their reading
is not affected. Sometimes they speak in their sleep
or under an anaesthetic.
In several cases (six out of the ten) the mutism
followed a shell explosion. A shell burst within a few
feet of a young officer (No. 42) ; he did not lose con-
sciousness but his speech went completely. Another
soldier (No. 38) gave the following account: "My
mate was killed a yard in front of me on August /th ;
we had enlisted together and been together all the
time. I was in the trench at the time. I lost my
head that day and the sergeant had to stop me from
going over the parapet. Three days later the acci-
dent occurred to me, a shell burst a couple of yards
away. I lost consciousness. Some said afterwards
that I was buried, others that I was shot upwards. I
did not recover my consciousness till five days later,
when I found myself on the ship going to Lemnos
and unable to speak."
There need be neither shell-shock (i.e., exposure to
forces generated by high explosives), nor burial as a
4 Shell-shock without Visible Signs of Injury. Proceedings
of the Royal Society of Medicine, Vol. IX., No. 4. Sections of
Psychology and Neurology, p. xvi.
CONVERSION-HYSTERIA 29
prominent factor. In No. 40, mutism followed a
shrapnel wound of the leg; the wound was slight and
soon healed, but the mutism remained and was cured
by suggestion under hypnotism.
The right hemiplegic and mute R.A.M.C, N.C.O.,
already referred to (p. 24) presented the same absolute
mutism as the shell-shock cases. In a private (No. 43),
aged 2J, the loss of speech occurred 36 hours after
receiving a kick on the left lower jaw. He had been
admitted to hospital, and was taking part in a sing-
song, when he suddenly found he could not utter
another sound ; he remained dumb for three days,
when, on awakening, he was able to whisper to the
nurse to bring his breakfast. This case is discussed
more fully in the next chapter.
An Australian, No. 37, had been mute and deaf for
five weeks after two months' service in the Dardanelles ;
he had been in the support trenches and was of course
under shell fire all the time, but had not himself been
exposed to explosions in his immediate neighbourhood.
Sometimes the same symptoms have been present
on some previous occasion. The young officer, for
instance, had some months before, whilst on board
ship, lost his voice for two hours ; it then returned
spontaneously. The mute who had been kicked had
recurrent attacks after this first occasion ; he became
very excited playing cards one afternoon ; he was
winning and his speech left him. Another time he had
become excited at church, went to bed in the ward
feeling rather dizzy, and in the morning speech was
quite gone. He would remain mute for one to four
days.
No. 39, a soldier who was mute after a shell
explosion, had been a miner. Eight years before
there was an explosion which killed his brother work-
ing in the same mine, and he became mute, the con-
dition being absolute for 15 months, when speech
30 WAR-SHOCK
partially returned. It took another three months to
recover entirely,
APHONIA.
In some cases, instead of complete loss of speech,
the patient is just able to whisper, In No. 44, this
followed an explosion ; he was blown sQme feet into
the air by a shell but was not rendered unconscious.
He then noticed that he could only whisper. In
another case (No. 46), the only one of the kind that
came under our observation, the condition arose
during convalescence from typhoid fever.
STAMMERING
May be the primary speech defect in war-
shock, or may follow mutism. (Cases of stam-
mering before military service are excluded). In
In a soldier, No. 47, of six years' service, stammering
began after he had been invalided from France for
gastric trouble; a year later he still stammered, and
presented some vasomotor symptoms, tachycardia,
and fine tremors of the hands. A younger brother
(not in the army) was also a stammerer.
No. 48, an Australian, aged 21, was on board a
ship that was torpedoed ; he was not hurt but received
a "mental shock." Fourteen days later, whilst in
the trenches, he began to stammer. He had never
stammered before; his mother and mother's brother
stammered.
No. 25 was wounded by a bullet which entered
Y in. to left of mid line behind, between D1-D2
spines; exit 2 in. external to left nipple and
1 in. above; after being shot he was first helped by
a mate, then walked himself for half a mile. He
lost consciousness and woke up the next day to find
himself in hospital, with complete loss of speech and
inability to use his right hand. He remained mute
for four months, his speech then gradually began to
recover and he went back to service ; when examined
CONVERSION-HYSTERIA 31
16 months later he stammered rather badly ;
there was paresis of the right hand with glove
analgesia and anaesthesia. He could not use his
fingers for delicate operations like shaving, buttoning,
or putting the cartridges in the rifle. Under treat-
ment the full power of the hand was soon restored,
the patient announcing gleefully a few days after his
admission that he had shaved himself for the first
time for 16 months. The stammering, however,
did not mend with corresponding rapidity.
Generally speaking, the apparently most serious
speech defects are those most rapidly cured. Out of
the ten cases of complete mutism nine responded
immediately to treatment, as did one case of aphonia
(No. 44), the other two cases of aphonia recovered
24 and 48 hours after treatment, whilst treatment
effected far less for the stammerers ; improvement
occurred in one (No. 25), under treatment that quite
cured the palsy of the hand.
It is interesting also that speech can be re-
covered despite the patient's conscious objection to
treatment. In No. 39, where the disability was of
six weeks' standing, all treatment was refused. He
would not consent to hypnotism nor to being placed
under an anaesthetic. He wrote that God had cured
him without a doctor on the first occasion and he
would prefer to wait for a natural cure this time
also. It was pointed out that he had suffered 18
months on the earlier occasion, now he could get
well in a few minutes. Finally he assented, but
maintained that he was not expecting any help. He
was lightly anaesthetized and suggestions were then
made. He was hardly recovered from the anaesthetic
when he asked the nurse in a whisper for a glass of
water. In a couple of hours the voice was normal,
but there remained hesitation in speech and loss of
memory for some simple words. Suggestion under
32 WAR-SHOCK
hypnotism, carried out the next day with the patient's
hearty consent, restored perfect speech.
WAR-AMBLYOPIA.
Loss of sight (the retinal anaesthesias of the older
clinicians) may be partial or complete.
PERSISTENT AMBLYOPIA.
No. 55. In 1901, in South Africa, a pebble flung
from a horse's hoof struck the right eye, and its
vision has been defective since. He was discharged
from the service. On the 6th May, 1915, at Hellas,
a shell burst near him ; he was knocked down, but
not unconscious. An hour later he vomited blood.
He returned to duty. About the middle of June,
1915, the vision of the left eye began to be defec-
tive. This defect had progressed. On July 26th,
1916, examination showed : pupils equal and active ;
eye movements normal ; tension in each eye normal.
JL. J*
R V 60 Hm + 5.50 spl. L V 36 Hm + 5.50 spl.
After homatropine and cocaine.
RVc + 4.50spl. _6 LVc + 4.00 spl. c 6
+ 1.75 cyL ex. 20/ = 60 + 2.50 cyl. ex. 10/=36
Fundi normal.
Fields of vision concentrically contracted, especially
in the left eye. (Fig. I, p. 34).
He was later on treated by suggestion under
hypnotism ; treatment being at first directed mainly
to the left eye. Ten days later the vision was
+ .3~c J5 L V 4- 3.85 c~ .6
R V c + 1.75 ex. 20 = 18 + 1.50 ex 10/ = 12
The visual fields were as shown in Fig. 2 5 (p. 35)
5 For the report and the perimeter charts I am indebted to
Capt. A. D. Griffith, R.A.M.C. Specialist in Ophthalmology,
Malta.
CONVERSION-HYSTERIA 33
A feeble-minded lad, 15 who was wearing dark blue
glasses, without which he said he could see nothing,
I found reading small print in the dusk. His vision
was R and L = ? 4 with his own dark glasses ; with
neutral tinted glasses from the test case he could not
see 6/60.
Probably more common than double amblyopia is
unilateral amblyopia; I shall record later an in-
teresting example of complete blindness in one eye
coming on very suddenly whilst sniping. Sometimes
the amblyopia is accompanied by photophobia and
intense pain.
Diminished visual acuity is seen in quite a number
of soldiers, sometimes without previous physical dis-
order, sometimes following injuries which may be
slight, or such diseases as typhoid or dysentery. If
these patients are not rapidly improving under the
usual general treatment, suggestive therapy generally
clears up the condition in two or three days.
No. 56 complained of bad sight and blurring of
objects in October, 1915. Admitted later to Malta
for "rheumatic pains in knees." Vision on December
29th, 1915, was R V =s 6 5 L V = &. He was sent to
rest camp and re-examined on March 16th, 1916, R V
= yts L V = a 6 ff. Slight astigmatism not improved by
glasses ; fundi normal. After psychotherapeutic
treatment, examination showed on March 19th, RV
= 3$- L V = 5. The right eye was amblyopic from
disuse.
The hysterical symptoms were not, of course, always
confined to the eyes. An Australian, No. 52, with
amblyopia of the left eye was also paraplegic ; he
had hemianaesthesia of the left side of the body,
6 This case is not in the Appendix ; it is not included in the
100 cases. He was under my charge in the mental ward which
was quite separate. The " functional " patients were scattered
among the general wards.
34
WAR-SHOCK
CONVERSION-HYSTERIA
35
36 WAR-SHOCK
although hearing, smell, and taste were normal.
The patient was right-handed. He was in an
extremely " jumpy " condition when seen three
months after the following experience :
"We were three in a trench, which was under shell
fire. Two were standing ; 1 was huddled up. Ob-
server sang out that a shell was coming. I was on
the ground and put my head between my ankles.
The next thing I knew was that I heard them saying:
' It's no use digging any more,' and then a second
shell burst. I came to on the boat, and found my
left arm in a splint. The arm had not been fractured
and the splint was taken off next day, but I had been
buried under seven feet of earth. I was unconscious
about half an hour."
Although there was no history of an earlier break-
down, there were plenty of traces of a psychopathic
disposition ; the patient recovered rapidly, but he
was not suitable for the front line.
Hemeralopia is not infrequent in a mild form,
objects being less distinctly seen at night than formerly ;
total blindness at night also occurred. In an albino 7
with absence of pigment in the eyes there was also
intense photophobia; according to the patient's state-
ment there had been no trouble with the eyes, no
hemeralopia until the Salonica campaign. The heme-
ralopia improved, but it did not completely recover
whilst under treatment (10 days). Hysterical stra-
bismus has been also observed. Westphal 8 records
the following extensive hysterical eye symptoms.
After a slight injury to the back of the head there
occurred ophthalmoplegia externa, which alternated
with spastic contracture of the rectus internus, miosis
7 Not included in the Appendix. He came under my care
when having temporary charge of the eye department.
8. Quoted in Zeitshrift f . d. gesammte Neurologic u. Psychia-
trie, Bd. 12. Heft 4, 1916. p. 340.
CONVERSION-HYSTERIA 37
and increased reaction to light. Further, blepharo-
clonus, intense contraction of the visual field, central
scotoma for all colours, convergent spasm in any
light, analgesia, aguisia, with convulsive attacks
when excited, pronounced hysterical state and inhibi-
tion of thought. The symptoms were dependent on
and influenced by the examination. [Which side of
the head was injured and which eye was affected are
not stated in the abstract.]
DEAFNESS.
Deafness is in many cases associated with other
symptoms. I have already alluded to its occurrence
with mutism and hemiansesthetic states.
No. 49 was blown into the air by a shell, but not
rendered unconscious. He immediately became deaf
in both ears. When seen a fortnight later he was
completely deaf. There had been no previous history
of ear trouble, and nothing on examination beyond
a little cerumen in both ears (removed without any
improvement of the deafness). The sense of smell
was absent, but sight and taste were normal.
Analgesia of the head and upper part of the neck
to the collar line. Speech, writing and reading
unimpaired. Under suggestion in the waking state
the patient a few days later regained his hearing as
suddenly as he had lost it.
Commoner than partial or total deafness is increased
sensitiveness to sound ; the patient starts at the
slightest sound, he seems to be afraid, as it is said,
of his own voice.
SMELL.
Smell may be absent altogether, as in the deaf man
just quoted, or, more frequently, it is absent on one
side and that usually the left side. As in most of the
hysterical disturbances of the senses this is associated
3 8 WAR-SHOCK
with other stigmata, e.g., anaesthesia of the correspond-
ing side of the body. Hypersensitiveness to smell is
also found; some horrible smell may persist in the
memory, as in Mann's case 9 of trance condition, which
followed the digging and filling up of pits for masses
of corpses. The patient could hardly react to exter-
nal stimuli, only saying from time to time, " What a
smell leave me alone,"
TASTE.
Taste may be entirely lost or absent on one,
pre-eminently the left, side. A constant "bad" taste
in the mouth is a common complaint. An Aus-
tralian had constant pain in the back after a fall from
his horse in camp. This got better and he had then bad
abdominal discomfort. After a time the symptoms dis-
appeared, to return whilst in the trenches ; they finally
left him, but he had a "nasty taste in the mouth."
It was so bad and his appetite and his general health
were so much affected that he was sent to hospital.
The teeth were good, nor could anything be dis-
covered amiss on physical examination. The choicest
foods having failed to remove the "nasty taste,"
recourse was had to suggestion under hypnotism. The
success in this case must not be regarded as a possible
addition to the normal commissariat arrangements.
TICS.
My experience agrees with that of others, e.g.,
W. Schmidt 1 that tics are more especially found in
the muscles of the face, neck and shoulders.
No. 60 had a slight superficial wound of the right
knee, followed the next day by pains in the back and
9. Mann. Ueber Granatexplosiven Storungen. Arcb. f.
Psychol., 56. Heft 1.
1 Schmidt. Die paychischen und nervosen Folgestande
nach Qranatexplosionen. etc. Zeitsch. f . d. G-es. Neurologie und
Psych., 29. H. 5, 1915.
CONVERSION-HYSTERIA 39
shoulders; he was sent into hospital for "nervous
debility." In addition to the symptoms of anxiety-
hysteria, to be described later, he had a twitch of the
lower jaw. This was rather slowly depressed and
the mouth opened with a sigh as if about to yawn or
take a deep breath.
Spasms occurred at irregular intervals, but some-
times two or three times in a minute and then left
off for 10 minutes or longer. Among numerous symp-
toms was diminished visual acuity, ^ R. and L. An
officer to whom this man was most attached, and whom
he had known in England before the war (both came
from the same place), was killed alongside him in the
trenches ; the patient had seen his officer gasping for
breath in the death agony. To use his own words, he
"had never seen such sights before." This neuro-
mimesis was, it need scarcely be said, quite un-
conscious.
No. 59. Blinking of the eyes followed an attack
of conjunctivitis in a lad of 19. On December 10th,
Captain M. M. Townshend," R.A.M.C., reported his
R. V = 2 ? and L = SB and the defective sight as prob-
ably due to the constant blinking, since he was quite
unable to fix on anything. The fundus was normal
and there was less than a + 2 error of refraction.
There being no improvement, he was submitted to
psychotherapeutic treatment on January 12th; the
blinking stopped at once ; on January 14th Captain
Townshend examined him again and found V. R.
and L. = 6/6.
No. 77 had frequent myoclonic spasms of the left
face, wrist and shoulder girdle, with a great tendency
to elevate the left shoulder. It was as if he were con-
tinually shrugging one shoulder. This patient had
contraction of the field of vision, absence of smell and
taste, and diminished hearing on the left side, together
2 Specialist in Opthalinology at Hospital, Malta.
40 WAR-SHOCK
with complete left hemianaesthesia and analgesia. The
case is described in more detail on page ; we shall
deal with other instances of somatic disturbances in
the next chapter in the discussion of their psycho-
logical mechanisms. It would be wearisome to repeat
the clinical pictures of the functional war-palsies
which, as we have sufficiently illustrated, may affect
any part of the motor or sensory system.
GANSER TWILIGHT STATE.
Hysterial fits, fugues, autopsy chic amnesia and
somnambulism will be discussed more fully in relation
to the psychology of these conditions ; here a brief
clinical account of one such case will be given.
No. 76 had a shrapnel wound in the right calf;
the wound was not serious and was almost healed
when he came under observation some weeks later.
Shortly after his admission to hospital for the wound
his mind became a complete blank. He had a
strange dazed expression ; when spoken to he stared
at the speaker as if trying to gather some impression,
and would then shake his head, making some irre-
levant response. It was difficult to make a satis-
factory physical examination, but one could be satis-
fied that there was less response to pain on the left
side of the body than on the right (probably complete
left hemianalgesia). The reflexes were normal and
there were no motor disturbances.
Speech was normal, and as far as could be ascer-
tained so were hearing and sight ; taste and smell
were not affected,
Memory. Personal. The patient did not know
his name, address, whence he had come, that he
had been engaged in a war, where he had been
fighting; he had no recollection of going to school.
Recognition. He could recognize the use of
objects ; if, for example, told to make his bed or put
CONVERSION-HYSTERIA 41
on his boots, he would execute the order. He knew
what to do with matches, cigarettes, and so on
there was no apraxia.
Response to questions of the simplest kind could
not be obtained.
Have you got a pair of boots ? I don't know.
Do you want cigarettes ? I don't know. (He
would take them when offered.)
How many fingers have you ? Four.
Where is the wound ? Don't know.
There were no hallucinations, and the patient was
able to find his way about the wards and grounds ;
he would even keep appointments correctly with me
at my room, so that in a practical sense he was not
disorientated as to time and space. Ganser 3 first
called attention to this peculiarity of response in
certain twilight states associated with hysterical stig-
mata, and the condition has been since frequently
observed. I am not acquainted with any case where,
as here, there was no neuropathic basis, and, to a
very large extent, practical sense was preserved.
The patient made a complete recovery under
hypnotic suggestion.
A group of clinical interest is provided by the
AFFECTIONS OF THE VEGETATIVE NERVOUS
SYSTEM.
These may be simple or multiple ; of the former,
hysterical vomiting, enuresis, diarrhcea, nervous
indigestion, and the soldier's heart demand con-
sideration here.
HYSTERICAL VOMITING.
No. 65, 28 years of age, began vomiting after food
in August, 1915, whilst at M.; this took place two
3 Ganser. Ueber einen eigenartigen hysterischen Dammer-
zustand. Archiv. f . Psychiatrie, 1898. Bd. 30, p. 633.
42 WAR-SHOCK
hours after food; on the Peninsula he got worse.
He continued doing ordinary duty till November,
when he was sent to Malta. Vomiting had now
become continuous, nothing, not even water, could be
kept down. He had been kept in bed for some weeks
and various diets had been tried, including neglect
(purposeful) without any relief. Examination on Feb-
ruary 3rd, 1916, showed a well-nourished body without
any signs of emaciation or physical condition to
account for the sickness. The anamnesis disclosed
that the vomiting was a neuro-mimesis from identi-
fication with the patient's favourite brother, who
suffered from frequent "bilious attacks" attended
by vomiting, in many of which attacks the patient
had acted as nurse to his brother. This know-
ledge was used in suggestion under hypnosis. The
vomiting ceased on the third day of treatment, the
patient being put on ordinary diet.
ENURE3IS.
Enuresis yielded to psychotherapeutic treatment
in a case (No. 63) where the condition had arisen
after joining the army; in another case (No. 67),
in a patient aged 20, where the enuresis had existed
as long as he could remember, no improvement
resulted.
DIARRHOEA AND INDIGESTION.
Diarrhoea and indigestion are most frequently
connected with other vaso-motor troubles ; sometimes
with vomiting (No. 64).
THE SOLDIER'S HEART.
As Punch says, cardiology "must be far and away
the most popular subject at the present time," and
perhaps many of my readers may even agree with
CONVERSION-HYSTERIA 43
Punch, who had " an idea that the finest experts are
not attached to the Medical profession."
The particular variety of the soldier's heart, where
perhaps Punch's non-medical expert may be more
successful in her treatment than the professional
adviser, will be familiar to all military doctors.
The following is the picture given by Sir James
MacKenzie 4 :
" When we see the soldiers in this country invalided
because of heart trouble, we find a good deal of
variation in their appearance and symptoms. The
face is often lined and drawn ; many are spare and
thin with a great vaso-motor instability, as shown by
the manner in which the peripheral circulation varies
the hands and fingers at times going pale and cold ;
at other times the fingers are thick and red, and the
nose likewise becomes red and even blue with slight
exposure to cold. If they have been treated for some
months by rest and feeding, some become pale, fat
and scant of breath.
" The chief complaint is an absence of the feeling
of being well they often feel out of sorts; 'rotten'
is a term frequently employed. A sense of fatigue
or exhaustion easily induced is common to all.
Breathlessness on moderate exertion is frequent;
pain over the region of the heart less frequent. The
physical signs are variable. The heart's rate is often
not increased, in some it is persistently increased, as
frequent as 120 per minute. More frequently at rest
the rate may be quite moderate, but exertion, some-
times slight, may produce an undue rapidity, and it
is in consequence of this excitability that the term
' irritable heart ' has been used. Murmurs, systolic
in time and heard in different regions, are frequent,
4 Proceedings of Royal Society of Medicine Vol. IV., No. 4.
July 1916, Therapeutical and Pharmacological Section, p. 28,
el seq.
44 WAR-SHOCK
while an increase in size, usually slight, is not un-
common. In a few cases there is a slight cedema of
the legs. The mental condition is somewhat varied.
Periods of depression are not infrequent, and the
patients are often very irritable. They accept the
view that they have something wrong with their
hearts and readily yield to all restrictions, and are
often content to lie in bed and brood over their woes."
MacKenzie says that the condition is not really
cardiac in origin, but is "the outcome of an injury to
other systems as well as the heart, such as the cen-
tral nervous system." He recommended that these
patients should be treated by fresh air and judicious
exercise in the open air ; fishing, riding, golf, etc.,
for those who could afford it, bowls, quoits, or skittles
and so on for the less fortunate. ' ' As soon as signs
of improvement are shown, the soldier should begin
drilling." He recognised that it is the mental con-
dition of the patient that chiefly requires attention
to take the patient "out of himself;" that "the
sense of exhaustion is the predominant symptom
and that it is probably vaso-motor in origin, due to
the irritation of the cerebral nervous system."
Freud 5 has described exactly this condition occur-
ring among civilians; it may be the chief and only
symptom of anxiety -neurosis and anxiety-hysteria ;
disturbances of the heart's action, palpitation and
brief arrhythmia, with longer attacks of tachycardia
up to severe conditions of cardiac weakness, the
differentiation of which from organic affections of the
heart is not always easy, attended by depression,
anxiety, and other mental conditions. A special and
5 Freud. "Ueber die Berechtigung vender Neurasthenie
einen bestimmten Symptomencomplex als Angstneurose
abzutrennen," " Neurologische Zentralblatt," 1895, No. 2.
See also" Anxiety-Neurosis" in Selected Papers on Hysteria,
by S. Freud, translated by Dr. A. A. Brill, New York : The
Journal of Nervous and Mental Disease Publishing Co., 1912.
CONVERSION-HYSTERIA 45
unnecessary name (phrenocardia) was coined by
Herz 6 in 1909 for this same condition.
It is important to remember, as Ley ton 7 has pointed
out, that the soldier's heart may arise from disease of
the heart or disease of the vaso-motor system. " In
some cases the two sounds of the heart were of equal
intensity, and these I believe were suffering from
myocardial alteration, probably of toxic origin. In
other cases, however, there was no alteration in the
ratio of intensity, and in these I am under the impres-
sion that the disease was of the vaso-motor system.
It would be of considerable interest to determine how
far the observations of this type could be corroborated
when applied to very large numbers, and whether, as
predicted, nervous shocks such as those produced by
high explosives led to disturbance of the vaso-motor
system, which may last for a considerable period,
whilst toxins of bacterial and other origin, such as
gases, cause disease of the myocardium." For this
disease, of course, psychotherapy would not be the
treatment. We will describe briefly some cases of
"soldier's heart" i.e., of functional heart attacks,
corresponding to MacKenzie's picture, which were
treated and cured by psychotherapy.
No. 68. An Australian, aged 23, was blown up
by a mine in a trench, knocked some yards, and
remained unconscious for several hours. This was
not his first "shell-shock." Has been sleepless and
unnerved ever since ; much pain over the heart.
This gets worse on the slightest exertion, his heart
then beats violently. There is a fine tremor of the
hands (eight per second) and some tremor of the legs
when he walks. A systolic murmur heard at the
apex. Physical examination otherwise negative.
6 M. Herz. "Die sexuelle psychogene Herzneurose(Phreno-
kardie)." Vienna : Braumuller, 1909.
7 Proceedings of Royal Scy. of Medicine. Loc. rit. p. 49-50.
4 6 WAR-SHOCK
The patient is a teacher in a town in Australia
where he was born and where he has lived all his
life. He regards fighting as an ignoble profession.
He enlisted in a burst of enthusiasm, but has regretted
it ever since.
So much for the conscious attitude. A different
attitude was shown in the unconscious. Here we had
to do with an extremely aggressive and primitively
savage type. He dreamed of attacks upon the
Turks, he is leading on his men. He had a recurring
phantasy of plunging a dagger into the navel of an
enemy and turning him round as upon a spit. We
had no means of giving the patient the excellent
treatment advocated by MacKenzie but by the help
of suggestion, in the waking state, his condition
improved. After 20 days he was sent to a con-
valescent camp and rejoined his unit six weeks
later.
No. 70, a soldier aged 31, who had been in the Galli-
poli campaign, was sent into hospital for " rheumatic "
pains in the legs. He suffered from sleeplessness,
breathlessness and such intense exhaustion that " lift-
ing one leg in the bed quite does me up." The thyroid
was diffusely enlarged ; no ocular signs of Grave's
disease. Fine tremors of the legs. No other signs
of disease of the cerebral nervous system.
The blood pressure was high, 160/90; tachycardia,
irregular pulse, no displacement of the heart, and no
murmurs.
Besides the vaso-motor signs mentioned, there were
sweating of the palms, pollakuria, occasional diarrhoea.
Under hypnotic suggestion the patient was in eight
days able to get about and his symptoms, the ex-
haustion and sleeplessness, disappeared. The tremors
and tachycardia were slower in removal, but
eventually ceased. It was my opinion, as well as
that of other observers, that the thyroid had diminished
CONVERSION-HYSTERIA 47
considerably, but unfortunately no measurement was
taken on his earlier examination.
We shall return, however, to the consideration of
enlargement of the thyroid when discussing the other
variety of hysteria.
CHAPTER III
PSYCHOLOGICAL MECHANISMS IN CONVERSION-
HYSTERIA
AUTO-MIMICRY
THAT the hysterical manifestation is frequently a
mimicry of symptoms seen in others is, of course,
well known. It is also to-day understood that such
mimicry is not conscious. It is, I believe, less well
recognised that the hysteric may mimic the symptoms
of an illness from which he has himself suffered.
Ziehen seems to have used the term auto-mimicry, I
presume in the sense in which it is here employed,
although I have not been able to trace the passage.
Gatti J gives a case of this kind in a girl who in
childhood suffered from epileptic fits, and at the age
of 18 had hysterical attacks which mimicked the
earlier epilepsy.
The following cases show this auto-mimicry some-
what clearly :
No. 20, aged 21, of four years' service, was
admitted on March 14th, 1916, to hospital, Malta,
with a diagnosis of traumatic epilepsy.
The following history is as given by himself. In
the middle of November, at Gallipoli, he was wounded
in the left side of the head and at the back of the head
1 Lodovico Gatti. "II fenomeno di auto -imitazi one nelle
associazioni istero-organiche " : Ri vista italiano di Neuropato-
logia. 1913, Vol. VI., p. 159.
PSYCHOLOGICAL MECHANISMS 49
by a piece of shrapnel, He was unconscious for five
days and woke up as he was being taken ashore at
Alexandria. On awaking he had to satisfy himself
by looking and touching that he had not lost his right
arm and leg. He had no feeling in those limbs and
was unable to move either the arm or leg for three
weeks ; the leg gradually got better and then the arm
began to improve. He states that he stammered for
some days. Two operations were done upon him
(nature unknown, probably not of surgical severity).
He remained in hospital till the end of January, the
first weeks in bed. He suffered a good deal from
headache (frontal). On leaving the hospital he says
he was able to walk, but the right leg was weak ; he
had no power or feeling in the right arm. From
Alexandria he was sent to camp in Mudros. Here
he had three fits.
1st. About first week in February, 1915, when,
after a little dispute, his " head went dizzy" and he
lost himself. The orderly told him he was violent ;
he does not know how long the fit lasted; it was
followed by a headache.
2nd. About February 20th, he was in a billet with
some others when again, after a little dispute, his head
was dizzy, he had a buzzing in both ears, and on
awaking recalls being slapped by a doctor.
3rd. At the beginning of March, in the same place,
he was repairing a telephone and was being "hustled"
by the driver of a motor-lorry outside ; again felt
dizzy and buzzing in the ears, and remembers doctor's
presence on his awaking.
In none of the fits was there any incontinence of
urine, nor did he hurt himself nor was the tongue sore.
Only after the first fit did he speak of a headache
following the attack.
Examination : Patient is a right-handed man of
powerful physique ; speech and articulation normal.
50 WAR-SHOCK
There is a small circular scar, *4 in,, over the left
upper temporal region, X i n behind Rolandic line
and 2 l /2 in. vertically above tip of left mastoid.
Pupils and cranial nerves are normal,
The fundi are normal, as are the visual fields.
There is anaesthesia and analgesia of the right side
of face to middle line, of the whole of the right fore-
quarter and of the right lower limb from the toes to
a hand's breadth above patella,
Though patient does not feel the pricks of a pin
(the pin can be driven and left in the skin), when told
to place his left hand (the eyes being shut) on spots
indicated by the examiner's hand, he is able to locate
with his hand the area so touched. Grasp of right
hand is feeble ; the leg appears of normal strength.
Joint sense deficient in fingers, wrist, elbow,
shoulder and toes of right limbs.
Astereognosis : fails to recognise hair-brush, knife
or key in hand or foot.
Gait normal.
The right hand cannot be used, e.g., cannot hold a
spoon, fork, or cut with a knife.
Reflexes: supinator and ankle jerks are present.
No ankle clonus. The plantar reflexes are present.
Abdominal reflexes are present and equal.
The muscles of fingers and wrist react normally to
faradism.
X-ray examination showed a piece of metal in the
diplce immediately beneath the scar.
A diagnosis of hysterical (functional) anaesthesia
and paresis of the right hand was made from the
distribution of the analgesia and the electrical
reaction. The fits were concluded to be hysterical.
But that the patient had had a temporary organic
hemiplegia immediately following the injury is clear
from (1) history, especially his looking and touching
to see if the limbs were present. In my experience
PSYCHOLOGICAL MECHANISMS 51
this is unusual in purely hysterical conditions, in
accordance with what would be expected from the
psycho-pathology of this condition. (2) The site of
the injury as shown by the presence of metal. (3) The
disorder of speech (stammering) immediately after
the injury.
On March 1 6th suggestion under hypnotism was
carried out, when the analgesia disappeared from
face, right shoulder, and leg.
March 18th, second treatment by suggestion under
hypnotism, analgesia confined to forearm.
March 23rd, complete disappearance of analgesia
and recovery of use of hand.
The patient remained perfectly well from April 9th,
when I last examined him.
The diagnosis was confirmed by Col. Purves
Stewart, A. M.S., consulting physician, and by Col.
Thorburn, A. M.S., consulting surgeon to the Malta
command, who also agreed with me that surgical
interference was unnecessary.
The first hemiplegia was presumably due to a
haemorrhage, following the shrapnel wound ; this
rapidly cleared up and was succeeded (apparently
without a break) by the functional hemianaesthesia
and paresis.
Case No. 31. Aged 24. l-j% years service; was
wounded on January 7th, on the back of the right
wrist and right side of face. Both wounds were
superficial and healed in about ten days. The day
following the injury the left hand began to hang
down ; he first noticed it hanging on going down to
the boat for embarkation to Malta.
Patient is a right-handed man.
Examination on January 27th presented a typical
drop-wrist of the left hand. There was analgesia (to
pin pricks) to one inch above the wrist. Supinator
reflex present. The wrist cannot be extended and
52 WAR-SHOCK
no movements of thumb and fingers can be performed.
Movements of elbow and forearm are normal. All
the muscles of hand react to faradism. There is a
small scar on dorsum of right hand.
The patient states that the right hand dropped a
little immediately after the injury, but only for a
short while, and it recovered at once.
January 28th. Treatment by suggestion under
hypnosis ; readily hypnotised and feeble movements
of thumbs and fingers obtained.
An attack of paratyphoid interrupted further treat-
ment till March 16th ; in the meantime the movements
of fingers and thumb became slightly more extensive,
but the wrist could not be extended. Abduction and
adduction of fingers were quite impossible.
March 16th. Treatment resumed, and on March
28th a note says he has now complete movements of
wrist and fingers, there is no analgesia ; the grasp is
still rather feeble. Massage was now used and the
full power of hand soon restored.
That the functional disorder occurred on the left
side (and not on the right) is in accordance with the
rule that functional disorders are preponderantly on
the left side in right-handed persons.
Here we again see that the hysterical lesion mimics
the original physical trauma.
No. 22, aged 23, wounded on December 27th, in
Gallipoli, by a shrapnel bullet at the left elbow ; the
wound of entry being 1^ in. above and 1^ in. in
front of external condyle ; the exit wound was ^ in.
above and 1% in. in front of internal condyle,
Bullet track crossed beneath tendon of biceps
emerging behind the brachial artery. There was no
injury to the bone.
He complained of pain from palm of hand to tips
of fingers.
The elbow was flexed to an acute angle and could
PSYCHOLOGICAL MECHANISMS 53
be only slightly extended by passive movement which
caused great pain, the biceps tendon becoming very
tense. He could not flex, without great difficulty,
any of the interphalangeal joints ; the terminal
phalanx of thumb and index finger could not be
flexed at all. Supination was fair.
Analgesia and anaesthesia extended from finger-
tips to one inch above wrist, on both aspects ; vibra-
tion sense was lost in fingers but, not in radius or
ulna.
All muscles of forearm and hand reacted normally
to faradism.
The patient is a right-handed man. He says that
the arm jumped up directly it was hit ; he at first
thought he had lost the arm ; from the time it went
up he had been unable to bend it.
He was first hypnotised on January 27th, when
under suggestion he was able, although with signs of
pain and resistance, to move the elbow and the fingers
more freely. The analgesia receded and was present
only over thumb and index fingers and their corre-
sponding metacarpal bones. This patient was under
treatment till February 15th, by which time the
analgesia had disappeared, the elbow, wrist and
finger movements were perfectly restored. He still
had difficulty in flexing the distal phalanx of thumb,
but he was able to bend it with effort.
From the position of the wound, and the immediate
flexion of the elbow and fingers, it seems clear that
there must have been some passing injury to the
biceps tendon and the median nerve.
This passed off, but the " memory " of the pain
persisted, leading to a mimicry of the original physical
injury.
The relationship of shell-shock of the physical
injury to other functional affections, such as mutism,
has a similar explanation. The explosion produces
54 WAR-SHOCK
a commotio cerebri causing loss of consciousness ;
this physical condition lasts a certain time. On
recovery there is a hysterical mimicry of this condi-
tion which is sometimes complete, when there is entire
loss of consciousness with amnesia for the period ;
in other cases it is less complete or the one state
may gradually pass into the other and the patient
remains partly shut off from the external world,
dumb, deaf and dumb, paralysed and so on. These
patients are mimes, they are acting the part they
played when they were hit.
Sometimes (No. 36), this proceeds from a wish to
remain unconscious (to be dead); "he would rather
die than have to go through it all again," as this
patient put it to me. The motive, however, varies
and we shall deal later with some of these motives.
2 . HETERO-MIMICRY.
An instance of the more common form of neuro-
mimesis has been given on page , in the corporal
with the tic of the lower jaw, a mimicry of the death
spasm of an officer to whom he was devoted. Another
example was supplied by No. 65, briefly mentioned
on page 41, whose history is worth a little further
study.
a. Identification with a brother. No. 65, a
private, 28 years of age, suffered from hysterical
vomiting. The history showed identity with a
brother, who suffered from some form of gastric trouble
accompanied by vomiting. This favourite brother
had often been seen by the patient in these attacks
during which he at times sat up all night with him.
The patient had been brought up in an orphanage
till, at the age of 17, he was discovered by this much
older and married brother, who then took the lad to
live with him and " did everything for me." What this
"everything" meant here may be gathered from the
PSYCHOLOGICAL MECHANISMS 55
patient's account that up till 17 he had never been
allowed out by himself, he had never been into a shop
to buy anything. The authorities of the orphanage
took entire control of the children in this case until
the age of 17. Thus, when claimed by the brother,
the lad's entire education for life had to begin. He
was really a child emotionally, still very backward
nor can I say that he had, in compensation, been
intellectually stimulated. His brother had found a
trade for him, and he lived financially free, but in
other ways most dependent upon the brother until he
enlisted. He remained well in England, and on
board ship, but very soon after arriving at Mudros,
preparatory to the Peninsula campaign, the vomiting
began.
This slight sketch of his life will show, I think,
that early environment was adverse to the man's
acquiring mental self-dependence ; placed under the
new conditions of life it is not surprising that he
developed this "sympathetic" vomiting, betraying
his need for the brother, the helper and consoler.
The unconscious imitation of another's passions,
dress, language, tricks, illnesses, is an endeavour to
identify oneself with the object. Such identification
may be, of course, partial, the subject identifying
himself with the object in some particular quality,
often symbolised by a particular piece of mimicry ;
in other cases the imitation is complete, one "plays
the sedulous ape " to some reverenced or adored
personality. In this soldier, the identification with
the brother's illness had a further significance which
was brought out in the course of his examination.
If he were ill like his brother, that is, if he were the
brother, he would be in England, not fighting in
Gallipoli. He therefore becomes the brother.
b. Identification ivith a horse. An interesting
instance of this variety of hetero-mimesis, which
56 WAR-SHOCK
plays so large a part in the totems and taboos of
primitive man, was furnished by a patient in whom
such identification managed consciously to dispose of
a very natural fear fear which Charcot called the
agent provocateur of hysteria. The case is dis-
cussed on page 79.
A development of the condition shown in hetero-
mimicry is the identification of a third person with
the loved object. A hysteric, for instance, still
emotionally under the influence of his love towards
his father, will find in some other more or less suit-
able (dramatically suitable we might call it) person
all the qualities bestowed upon his father ; he identifies
the third person with the father and takes up the
filial position towards him. The bystander may find
very little evidence of the similarity between the
father and the other person, but with a certain
emotional attitude, with the need to possess a father,
phantasy will bridge all the difficulties. Oh, that he
were my father ! Oh, that my father were alive !
soon becomes He is my father ! My father is alive
and can help me ! This mental process, and the
importance of its recognition, has been dealt with by
Freud under the name of
TRANSFERENCE,
a good instance of which is furnished by the blinking
boy, No. 59, p. 39.
He was cured, by suggestion, of the blinking of both
eyes and amblyopia, after the relation of his history.
His father was an immensely powerful man who
used " to lift horses and carts with his teeth." Every
night his father would come to the bedside and talk
with him, bringing him presents. When the patient was
aged 4, his father was brought home one Christmas
morning by the police ; he had been found in a field
unconscious, with an injury to the head ; he died a
PSYCHOLOGICAL MECHANISMS 57
few minutes after being brought home. There was
strong suspicion of foul play, but nothing was dis-
covered. His mother used to talk to the boy very
much about his father, dilating on his great strength,
his goodness and tragic end. This lad had been four
months in the Peninsula ; the vision of his father was
constantly before him, especially his being brought
in by the police, and the death scene. He tried
to think of something else and tried to close his eyes
to avoid the sight. The blinking is thus seen to be
here symbolical of a desire to shut out a visual
memory picture ; it is common enough to close the
eyes when any gruesome picture looms up. The
revival of the memory of the father, the strong man,
had many determinants. It took him back to child-
hood, with a wish that the strong father might be there
by his side ; then the enemy would be overcome and
he would have no fear. Again, the death scene : he
was strong and well himself, but like his father he
might be killed suddenly and by some unknown hand.
His mother would not know any more about the
details of his death wound than she did about his
father's.
This history, with a great deal more about his home
and his early life he was a very good boy and took all
his earnings to his mother, who had married again
since his enlistment the lad related to me amid great
emotional distress. He burst into a flood of weeping
as he told me the story and at the end of an
examination and talk, which lasted some two hours, he
was cured. The blinking ceased forthwith ; we dis-
covered subsequently that he had identified me with
his father, and transferred the feelings he had
experienced towards his father to me. His father
was not dead then, his father was alive and must look
after him. Doubtless, the air habitual to a middle-
aged paterfamilias, my sympathetic interest in the
5 8 WAR-SHOCK
boy, and perhaps a something in my personal appear-
ance, were sufficient to set the boy's mind weaving its
phantasies around me. I may add that during the
next few weeks, when he remained in hospital, his
filial attitude to me (in the best sense) persisted, and
he would seek my opinion and prattle with me about
all sorts of matters.
SYMBOLIC CONVERSION.
This patient, by his blinking, gave expression to
his unconscious ideas in the oldest form of language
gesture. It is to Freud that we owe our understand-
ing of the meaning of these symbolic actions. It is
in the unconscious that we find the springs of action
and of thought a region (this and similar terms are
used figuratively) of the mind whose rich and varied
emotional nature we are beginning to appreciate a
region less under the control of the conscious intellect
than had been heretofore supposed. Emotions
inhibited from transference into action do not pass
into nothingness, but persist in the unconscious, often
influencing the whole life of the individual in some
distorted and irregular way, perhaps biding the time
till opportunity occurs for their manifestation.
No. 24. The Irish soldier with the 15 bayonet
wounds (see page 25) had a functional claw-hand
(main en griffe).
In recounting the story, which he did with much
vigour, I noticed his repeated and emphatic state-
ment : " In such fighting you must clutch your rifle
very firmly and never let it go, guarding yourself
all the time." The explanation of his contracture
becomes obvious. Grasping the rifle was the very
attitude his hand still assumed ; in the unconscious he
was still clutching the rifle ; he was still fighting the
good fight, and this desire was symbolised by the
grasping hand. I was able to confirm this view under
PSYCHOLOGICAL MECHANISMS 59
hypnosis, for on suggesting to him that the fight was
over and he could let go the rifle, his hand imme-
diately relaxed. We then got a little deeper into
the meaning of this persistence of the unconscious
desire for a continuance of the fighting by the
patient's remark that when he takes up a thing he
likes to carry it through to the best possible extent.
He especially prided himself on his bayonet work.
The following is one of the many dreams he related
to me:
" / saw a person walking along a muddy bank.
He had on a long gown; he was a priest. Some
Turks caught hold of him, only they were dressed in
khaki; they were going to torture him when I arrived
with others"
This and other dreams suggest there was a still
deeper motivation for the hysterical symptoms than
I have given, but it was not possible to penetrate
into this as the symptoms promptly disappeared
under hypnotic suggestion.
THE MEANING OF HEMIANALGESIA.
Some authorities, following Babinski, consider that
hysterical anaesthesia is produced by the suggestion of
the examining physician ; the above case seems to be
at first one in point. At the beginning of the ex-
amination there was no analgesia at the right wrist,
but on re-examining the wrist analgesia was present.
The fundamental difference between an organic and
a hysterical anaesthesia is this : In organic anaesthesia
there is interference with sensory conduction on the
physical side ; in hysterical anaesthesia there is no
such interference. Sensation reaches the unconscious
but is there inhibited from reaching consciousness.
In this case there was nothing amiss with the skin,
the sensory nerves, the brain ; in fact, the uncon-
60 WAR-SHOCK
scious did feel the light touches and the pin pricks but
refused to make the conscious mind aware of them.
What is the meaning of this refusal ? The anam-
nesis showed that during the fight he felt no pain, he
did not indeed know he had been wounded until, on
being taken away much exhausted after his exertions,
his attention was called to the blood coming from
him. This young Irishman was a highly strung young
man, sensitive to pain as he admitted. Had his con-
scious self felt pain on the battlefield he would either
have had to retire from the struggle or let go his rifle
and be killed. The whole of the exposed area (the
right side of the body) was in this case not admitted
into the field of consciousness. The motive was the
same as Nelson's conscious motive in putting up his
telescope to the blind eye at the Battle of the Sound.
Nelson wanted to go on fighting. So did this soldier ;
he was not to be put off by feeling the pain from
ever so many bayonet wounds. He would not allow
himself to feel pain.
The analgesia disappeared a few days later. Its
revival under the pin pricks of Col. Stewart is
readily understandable. The unconscious is, as will
be abundantly shown, archaic and primitive ; it is
not finely discriminating. Here it did not distinguish
the harmless pin pricks of Col. Purves Stewart from
the harmful bayonet thrusts of the Turks. It took
no notice of the first prick or two, but as the jabs
continued up the arm the earlier memory was revived
and the unconscious was on guard : The Turks are
at it again ! Returning to a similar experience the
unconscious developed the same mechanism of defence,
whilst the perception did not pass from the uncon-
scious into the conscious. Counter suggestion soon
restored the normal condition.
In another case, one of vomiting (No, 64), this
symptom expressed the patient's disgust at the scenes
PSYCHOLOGICAL MECHANISMS 61
he had witnessed in war ; "loathsome" was the word
he constantly used to me in describing these scenes.
The expression " sick with horror " is more than a
metaphor. In my patient it expressed physically his
repugnance to war.
ANALGESIA AS AN AN/ESTHETIC.
Another motive for the anaesthesia where ignor-
ance is bliss is shown in No. 1 (see p. 22), where
the anaesthesia prevented any direction of the patient's
attention to the affected side ; a defence mechanism
which prevented worrying. The patient had always,
in his own words, been as strong as anything, and never
ailed a day barring the accident. Under hypnosis
the suggestion that he could feel normally every-
where was at once responded to. There was no
motive in maintaining the anaesthesia now that the
patient had discovered his own trouble. A little later
he began to have sleepless nights, and he came to me
complaining of a change in his character irritation
without adequate provocation. This was the result of
his discovery, for having, through accidental causes, to
be kept in the hospital rather longer than was intended,
he assumed that he would be discharged unfit. He
was reassured and remained quite well during the
rest of his stay in hospital (10 days), but the trouble
is not unlikely to recur in other forms.
WHY FUNCTIONAL ANESTHESIAS ARE LEFT-SIDED.
The left is the side of election for hysterical mani-
festations," in war as in peace. It may be said
generally that if the hysterical symptom occurs on
the right side there is some particular cause the
patient is left-handed or the symptom is grafted on
to some earlier or still existing organic defect, or the
2 Purves Stewart. " The Diagnosis of Nervous Diseases," 4th
Edition, p. 392. London : Edwin Arnold.
62 WAR-SHOCK
right side is physiologically adapted to the psycho-
logical motive.
In No. 24 the patient is left-handed and the right
half of the body was advanced in the bayonet fighting ;
it was on this side that he received fourteen out of
his fifteen bayonet wounds. In such cases as Nos. 2,
19, 20, 21, 23, the selection of the left side seems
quite arbitrary.
Oppenheim 3 attributes the greater preponderance
of left-sided over right-sided symptoms to the rela-
tively low vitality of the right hemisphere of the brain,
a statement without any physiological value and of
course having no psychological meaning.
Lewandowsky 4 suggests that the left-sided selec-
tion has a psychic factor the much greater incon-
venience of the paralysis of the right side. It is,
however, to Stekel's 5 analysis of dreams, of hysterical
fits and giddiness with the tendency to fall on the left
side, that we must look for the full meaning. He
pointed out that right and left are used not only of
direction, but are terms denoting mental and moral
judgments. We say, " He's all right " " To get out
of bed with the left foot foremost." In the posters
of "The Girl who took the Wrong Turning," the
artist depicted the beautiful but naughty heroine
turning to the left at the cross-roads. The left-sided
phenomenon is a symbolical expression meaning that
things are wrong with one. "Up" and "down"
are used similarly by the unconscious we speak of
a fallen woman, an elevating book, down in the
dumps. Every observer, of course, pays attention to
the general bearing of his patient, noting whether
he walks with an erect posture, head and eyes
3 Berl. klin. Wochenschrift. November 3rd, 1915.
4 Zeitschrift fur die gesamte Neurologic und Psychiatrie,
1916. Vol. XII.. No. 4, p. 427.
5 Stekel, W. Jabrbuch f. psychoanalytische u. psychopath.
Forschungen, Vol. I., p. 467.
PSYCHOLOGICAL MECHANISMS 63
uplifted, or slouches along with bent back and down-
cast eyes.
SYMBOLIC GESTURE.
The translation of mental processes, verbal state-
ments, moral judgments and so on, into their physical
equivalents, plays a large part in the dream mechanism ;
it is worth studying some other instances of this
process in hysterical symptoms.
No. 9. An Australian, aged 36, was admitted on
January 24th, for stiffness and pain in the back and
paraplegia. The sensory and motor disturbances in
the legs improved considerably, but the back remained
as stiff as a ramrod and more painful. The history
he gave betrayed much feeling at what he considered
inadequate treatment after a high-explosive shell had
burst some yards from him on November 10th. He
walked down to the dressing station and was given
some pills and sent back to the trenches. The next
day his back was painful, but he says he showed him-
self to the doctor, who again sent him back. In the
trenches he was unable to move. On the fourth day
he was sent into hospital and thence to Malta.
It must be understood that I am repeating this
history not to criticise the medical officer, nor need we
accept the patient's story as the account of what
really took place. We accept it for its psychological
value it expresses what the patient felt on the
subject, a feeling which gave rise to much emotional
bitterness, even under hypnosis. The clue as to the
meaning of this rigid back was obtained one day when
he said in hypnosis : " The doctor put my back up."
There unfortunately the back remained when, having
recovered the power of his legs, he was sent back to
Australia, where one hopes it will come down under
the mollifying influence of his wife and children.
Another instance of this symbolism occurred in
64 WAR-SHOCK
No. 43, the case of recurrent mutism referred to on
p. 29.
This is the lad who was kicked on the left jaw by
a horse on December 31st. (He also complained of
inadequate treatment.) On January 1st, having been
then admitted to hospital, he, whilst in bed, was
taking part in a sing-song when he suddenly found
he could not utter another sound. He remained
dumb till the morning of the 4th, when on awaking he
found he could whisper that he wanted his breakfast .
This is a pretty instance of one of Dr. Gee's
aphorisms: "It is an interesting reflection that
powerful emotion promotes eloquence and sometimes
takes speech away." Whether the patient was an
eloquent speaker I am not able to say, but I presume
he was something of the sort ; he was in the habit of
preaching both before and since joining the army.
On one occasion after joining the army he spoke for
one and a half hours on the duties of a Christian
soldier. He was always talking to his comrades, and
nothing pleased him better than discussion or argu-
ment. Over and over again he had been told to shut
up, hold his jaw. Now, after receiving the kick he
went to his medical officer literally holding his jaw,
and after the wound had been stitched was sent back
to his tent. He felt inclined to remonstrate (to jaw),
but thought it better to hold his jaw. Later in the
afternoon the pain was so bad in the jaw that he was
visited by the doctor and sent into hospital. The
next evening, however, he found himself taking part
in a sing-song an inconsistency to which the un-
conscious promptly replied by "holding his jaw"
figuratively.
THE MATERIALISATION OF WORDS.
It must be remembered that we are here dealing
with what is archaic and crude in the unconscious,
PSYCHOLOGICAL MECHANISMS 65
with what links us, the heirs of all the ages, mentally
with primitive man. In this lower culture there is
no clear distinction between words and the objects
they denote.
Sir J. G. Frazer 6 writes: " Unable to discriminate
clearly between words and things, the savage com-
monly fancies that the link between a name and
the person or thing denominated by it, is not a mere
arbitrary and ideal association, but a real and sub-
stantial bond which unites the two."
The utterance of the correct word, the power of
the word, has a magical effect ; the " Open Sesame "
and " Rumpelstiltskin " of the fairy stories have been
believed and carried out in our childhood's play. A
Central Australian has but to get the magician doctor
to pronounce a curse on his enemy: "May your
heart be rent asunder ; may your backbone be split "
and the enemy's backbone is split unless he get on
his side a more powerful magician to ward off the
words.
" When the Sulka of New Britain are near the terri-
tory of their enemies the Gaktei, they take care not
to mention them by their proper name, believing that
were they to do so, their foes would attack and slay
them. Hence in those circumstances they speak of
the Gaktei as o lapsiek, that is, the ' rotten tree trunks,'
and they imagine that by calling them that they make
the limbs of their dreaded enemies ponderous and
clumsy like logs. This example illustrates the
extremely materialistic view which these savages
take of the nature of words ; they suppose that the
mere utterance of an expression signifying clumsi-
ness will homceopathically affect with clumsiness
the limbs of their distant foemen." Frazer, ibid,
P. 331.
6 ' ' The Golden Bough, ' ' Vol. III. " Taboo and the Perils of
the Soul." 3rd Edition, p. 331.
66 WAR-SHOCK
A SPEECH-COMPLEX. 7
The mutism can, in this patient (No. 43) be traced to
early difficulty in his speech, for he began to speak
late not till after five and he could not speak
properly until he was ten years old.
I have pointed out elsewhere 8 that it is from the
mother that the child gets his first encouragement to
speak and that later on, in certain cases, resistance may
arise against anything learned from the mother
against speaking altogether. There was in this case
much opposition between him and his mother ; on
account of this he was brought up to a large extent
by other relations. After the birth of a brother,
when he was returning to his own home, he told his
mother that she was not his mother at all now that
she had another child. Although he had never been
dumb till the accident on December 31st, 1914, when
annoyed at home or in the workshop he would take
refuge in silence, sometimes not speaking to anyone
for several hours. After the accident the subsequent
attacks of mutism (four in two weeks) occurred after
some excitement, such as winning at cards, attending
church. There was a great deal in his history show-
ing conflict between himself and his parents, a number
of things which wounded the too sensitive disposition
of the child. He took religion seriously (Wesley an)
at the age of 11, his parents being non-religious
Church of England people. Without going into great
detail the evidence may be summed up as showing
strong conflict, conscious and unconscious, between
son and mother in a person of sensitive predisposition.
Though he remained free for some time after
his last attack, which was immediately stopped by
7 A complex is a system of ideas, dynamically active
emotionally charged from an unconscious source.
8 Stammering as a Psycho-Neurosis, 17th International Con-
gress of Medicine, 1913. Section on Psychiatry.
PSYCHOLOGICAL MECHANISMS 67
suggestion (without hypnotism), it is doubtful whether
the same or other symptoms will not recur.
PSYCHOLOGICAL COMPENSATION.
This patient illustrates the mechanism which Jung
terms psychological compensation/ and which Dr. Gee
noted in the above quoted aphorism. This young man
compensates for his verbosity by recurrent attacks of
mutism; a phenomenon which, in a milder degree, had
often been present. Thus, after an evening's heated
talk (in his pre-soldier days), he had frequently lapsed
into sudden and absolute silence, recalling Sydney
Smith's discovery of Macaulay's brilliant flashes of
silence, when he would resent any attempt at getting
into conversation with him.
In another patient (No. 13) the paraplegia, which
followed a mild degree of frost-bite, was an unconscious
compensation for having been, in his opinion, over-
worked at trench-digging and road-making.
Compensation has a wide scope in mental life. For
example, persons who are pedantically accurate in their
choice of words, dealing sledge-hammer blows at
any, even the slightest departure, from meticulous
verbal accuracy, have not infrequently been found
to be grossly careless as to their facts, or distorting
the facts and juggling with quotations to meet their
own ends. Not only the Puritans
" Compound for sins they are inclined to
By damning those they have no mind to."
COMPROMISE FORMATION IN HYSTERIA.
The hysterical manifestation is, according to Freud,
a compromise between a repressed wish and an inhibi-
tion ; the result of a mental conflict between the ego
9 "Collected Papers on Analytical Psychology," by C. G-
Jung. Translation edited by Dr. Constance E. Long. London
Bailliere, Tindall & Cox, 1916. P. 280.
68 WAR-SHOCK
and the gregarious instinct termed by Mr. W.
Trotter 1 the "herd instinct." A good instance of
this compromise is furnished by
No. 54, a young Australian private, aged 19,
suffering from what Captain A. D. Griffith 2 has termed
" War-amblyopia.*'
He was admitted for loss of sight in the right eye,
with normal vision in the left. There was a right
ptosis present from childhood. He had been seen
by Colonel Purves Stewart and by the eye specialists,
Captain M. M. Townshend and Captain Griffith. In
the right eye on January /th there was perception
of light and nothing more ; the defect had begun on
November 1 5th. This is the history he gave me :
On November 15th he was sniping through a loop-
hole when an enemy bullet knocked a piece off the
stock of his rifle. He continued at his post; five
shots later another bullet struck the sand around the
loophole. The right eye began to water. He shut
the loophole and went away for an hour. He then
returned, the eye being better, opened the loophole,
posed his rifle, and then found he could not see the
sights on the rifle. There was obviously nothing to
do but go to the doctor. The vision got rapidly
worse, and in a few hours he had lost perception of
light. Let me add that he was a lad of great, almost
reckless, courage and of great independence of spirit.
This Australian is a type with the gregarious instinct
highly developed his soldier's quality is strong. A
bullet hits the stock of his rifle whilst sniping
the enemy have located him. It must be remem-
bered that he is sniping, so that to go away would
have been quite allowable. But he does not give up.
Then another bullet comes along. The unconscious,
acting on behalf of the ego instinct, sets the eye
1 The Herd Instinct in War and Peace.
2 The Lancet, June 24th. 1916, p. 124-6
PSYCHOLOGICAL MECHANISMS 69
awatering, forcing him to relinquish his post. Then
the soldier's instinct asserts itself, the eye ceases to
water, and he returns to the loophole. But here the
egocentric instinct, self-preservation, reasserts itself,
and the unconscious adopts a stronger attack. He is
stricken blind in the shooting eye (note, also, that it
is the seat of a congenital deformity). He is now
unable to carry out his conception of the soldier's
duty, and without loss of self-respect is able to retire,
his safety guaranteed. Shall we say that the com-
promise ends with the odd trick in favour of the
egocentric instinct ? Even so, it will be granted
from the measure adopted by the unconscious that
he must have been a first-class fighting man. Blind-
ness has always been regarded as one of the direst
calamities that could happen to youth, and for some
weeks he had believed that his right eyesight was
gone.
DUMBNESS TO DODGE THOUGHT.
Another instance of mutism originally due to con-
flict is that of case 39, described on page 29.
Just before the shell explosion which threw him into
the air and rendered him unconscious, his mate, with
whom he had just been talking, a man he knew in
England the two had enlisted together was killed
immediately in front of him. It was an explosion
not dissimilar to the one he had been through in a
pit in England eight years before, when his brother
(seven years older than himself) was killed in a pit
explosion, the patient escaping but remaining quite
dumb for 15 months. Investigation showed some
rivalry between the brothers that had continued from
childhood, side by side with much brotherly affection
and interest in each other. He had often wished
that he had no brother or that he would go away, or
he would weave phantasies of what might happen
were his brother very ill or dead.
70 WAR-SHOCK
The death of his brother and his own escape seemed
to him as if he had been making his thoughts real, a
conception as Frazer has shown common in primitive
man. His guilty conscience will prevent any such
wicked thoughts arising anew by taking away speech
altogether. He remained dumb for 15 months;
time did not permit any full investigation so that it is
impossible to say what eventually brought about
recovery. The circumstances under which the
mutism recurred are of the same type as the earlier
instance. The friend who was killed almost by his
side repeats the history of the brother's death ; there
is a revival of the feelings which had never been dis-
posed of in consciousness, and therewith the primi-
tive belief that if ideas are not expressed in words
they have not really been in the mind ; the dumb-
ness was here an endeavour to dodge thoughts which
came up unbidden and whose origin remained, of
course, unknown to the patient even after recovery.
Another primitive idea lay at the back of the resist-
ance to treatment ; the feeling that the affliction was
a punishment sent by God to be removed in God's good
time, when the sinner was fully repentant.
DEAF MUTISM AS A WISH-FULFILMENT.
Mutism can have other causes ; No. 36 was in the
trenches with a mate with whom he had enlisted in
Australia; this friend of many years standing was
killed by a machine-gun fired a yard in front of him.
He lost his head that day and felt unbalanced. He felt
he must get outside the trenches and climbed on to the
parapet, whence he was pulled back by the sergeant
several times. Two days later, after a shell explosion a
yard away, by which he was partially buried, he lost
consciousness. He recovered some days later to find
himself on board ship ; he could neither speak nor
hear and could hardly stand on his legs.
PSYCHOLOGICAL MECHANISMS 71
Under hypnosis he could recall whispering a few
words as he was being carried on board and had
then again relapsed into unconsciousness.
The wish for death can be gathered from this
history ; the attempt to climb on to the parapet
which was described by himself as suicidal ; the
relapse into loss of consciousness (taking the original
loss of consciousness as due to commotio cerebri)\
the inability to stand ; the deaf mutism which outlasts
the other symptoms as the wish for death weakens,
death which severs communication between man and
his fellows and is well symbolised by deafness and
speechlessness. Sometimes (No. 35) mutism by
itself is the symbol of this wish for death, to have
done with the horrors of the battlefield. It will be
gathered that this is quite consistent with bravery in
the battlefield or in the trenches, each representing
partial elements in the man's mental make-up.
Of course, if any investigator were stupid enough
to ask such patients did they want to die, they would
properly answer no ; they might even say they had
never thought of it, although closer investigation will
not infrequently show such a thought had been present,
though perhaps but fleetingly. Clearly the wish for
death is incomplete ; they do not die, they only more
or less simulate death.
PARAPLEGIA AS A WISH-FULFILMENT.
In No. 10 the paraplegia was a wish-fulfilment-
This patient was invalided to Malta for mild frost-
bite in the toes of the left foot. During this treat-
ment he suddenly lost power in the left lower limb ;
on being transferred to an infectious diseases hospital
(for scabies) he lost power of the right lower limb.
On examination seven weeks later there was a stocking
analgesia of both lower limbs, which were somewhat
rigid. There was a rapid clonic tremor of the anterior
72 WAR-SHOCK
thigh muscles. All the limbs could be moved
moderately as he lay in bed. Gait feeble and
shuffling, using two sticks and almost bent double.
Knee jerks exaggerated, with tendency to right ankle
clonus. Plantar reflexes absent at toes. All muscles
reacted normally to faradism.
On December 31st the patient was dressed, wait-
ing in the hospital grounds for embarkation to England,
as a cot case, the left leg being useless. He had
reported the scabies that morning. Then the order
for embarkation was cancelled ; he was carried back
to the ward and transferred by ambulance the next
morning as a " walking case " to the infectious diseases
hospital. He was able to hop into the ambulance,
but at the other end, some twenty minutes' drive, he
was unable to walk, the right leg had lost all power
in the interval. 3 He thought he was not receiving
proper attention, and wanted to show that he really
was ill. Hence the paraplegia. It was not malinger-
ing ; the analgesia and the alteration in the reflexes
showed this, as did the patient's gallant attempts to
walk. Under hypnosis, although complete move-
ments of the legs were obtained, walking could not
be suggested ; after the second seance, when he had
managed a couple of steps unsupported, he had an
attack of " grande hysteric." It was under hypnosis
that he expressed the thought that it was unfair to
send him as a walking case when the day before he
was a " cot " and his leg was no better.
Hypnotism was given up, as the patient was
not making any improvement; instead I made an
appeal to him, rousing an emotion that ended in a
3 It was of course quite in order that he should go to
England as a cot case this meant he would be carried from
the ambulance on to the lighter and thence to the hospital
ship. And of course he was quite suitable as a walking case
for transfer from one hospital to another.
PSYCHOLOGICAL MECHANISMS 73
flood of tears. He lay awake all that night making
up his mind that he would walk, and the next day the
sticks were relinquished ; he was cured of the para-
plegia. The analgesia had been progressively dis-
appearing in the way typical of hysteria. The
reflexes became normal. The recovery was helped
here by the presence of another paraplegic (hysterical)
No. 12, who had been subsequently admitted to an
adjoining ward and had made a quick recovery.
THE CEDIPUS MYTH.
Freud took the CEdipus myth as the type of the
infantile relationship to the parents. CEdipus is the
archetype of the son's unconscious incestuous love for
a mother and rivalry with a father. I am inclined to
regard this relationship in a rather different light.
Though in the phantasies or dreams of the adult one
gets evidence of this love towards the mother and
rivalry towards the father, this is rather to be viewed
as symbolic of a desire to return to the infantile
dependence upon the mother and the undisputed claim
to her whole care and tenderness, the rivalry towards
the father symbolising the resentment at the inter-
ference with this relationship. The deaf mute,
described on p. 69, is a typical instance, where
the brother simply stands as the surrogate of the
father.
The following case of loss of memory is an example
of this infantile relationship to the mother.
No. 79 had been suffering from complete loss of
memory for six weeks. When admitted he had a
vacant blank look, he did not know his name, and could
only answer " yes " and "no." His memory recovered
completely. The interest centres in the memories
that immediately preceded the amnesia. He was
only 1 7 when he was in Gallipoli ; he was invalided,
and it was whilst convalescent in Malta that the
74 WAR-SHOCK
attack came on, when he was visiting some friends
just at Christmas time. Mrs. X., a motherly, kindly
woman, was baking some cakes. His thoughts
travelled back to his people's home at Christmas, to
his mother. Then he saw himself, a child of five,
making cakes in the kitchen alongside his mother.
He saw himself putting one of the cakes on paper in
the oven. The cake was burnt, but " I ate it myself
all right, taking some strawberry jam out of the pot
for the cake." A little later he was very dizzy, with
a terrible headache ; a friend took him back to camp,
where it was at first thought he was drunk. But the
medical officer who was sent for of course recognised
his condition. He offered a piece of cake (from his
store) to the doctor the next morning, although with-
out being able to give any explanation. This amnesia
was clearly an attempt to blot out all the surrounding
associations with the war, to keep this lad back amid
the happy experiences of childhood. These and
many other scenes which were reproduced in hypnosis
were immediately told him on awaking ; and very
soon memory returned for the whole period. There
were other events, unsuitable to repeat here,
which showed that certain other responsibilities
had been placed upon him which were too much
for his age.
But that under sufficient stress of circumstances
there can be at any age a return to this infantile
adaptation may be read in the following sketch:
A sergeant (No. 26), 34 years of age, had been
1 6 years in the army; he was wounded in the left
frontal region by shrapnel. He was unconscious for 12
hours. About two weeks after the wound had healed
he lost power in the right hand. When he came under
observation, six weeks later, there was subjective
and objective feeling of cold in the right hand (he
wore a glove), and a '* tingling feeling as of a mild
PSYCHOLOGICAL MECHANISMS 75
electric current " ; analgesia-anaesthesia to 3 in. above
wrist ; loss of power in hand ; grasp feeble ; could
not fully flex fingers ; was unable to hold things in
the hand ; could not write with this hand. He was
to some extent ambidextrous by training. He
batted and shaved with either hand but was a left-
hand bowler and a right-hand writer.
With suggestion under hypnosis all abnormal sen-
sation disappeared and normal sensation returned;
the hand recovered its power. He gave a rather
interesting exhibition of rationalisation.* One day,
under hypnosis, I told him to write home to his
mother. He was unable to carry out the suggestion
post-hypnotically, telling me he had tried to write
but his hand was too tired. I then told him (again
under hypnosis) to write me a letter. The next day
he handed me a well-written letter. I thanked him
and said, ' ' But why did you write me since I see you
every day ? " He replied, " I thought it would be
nice to show you how I am getting on." He
was quite unaware of my suggestion and con-
sciously he did not know whence came the impulse
to write. As is so frequently the case, consciousness
proceeds to find a rational motive, a mental process
which should put us on our guard not only in our
dealings with others. The advice given by Lord
Mansfield to a newly - appointed judge will be
remembered : " Give your verdict, it is pretty sure
to be right; never adduce your reasons they are
equally sure to be wrong."
The paresis in the right hand had occurred suddenly
one day just as he was about to write a letter to his
mother. " I could not hold the pen ; there was
such a tired feeling in my hand." (This persisted
until treated.) He was about to write to his mother
4 See Ernest Jones : Rationalisation in Every-Day Life.
Papers on Psycho- Analysis. London : Bailliere, Tindall & Cox.
76 WAR-SHOCK
that he thought she need not be worried about the
condition of a younger brother who had become a
wreck after a bomb explosion at Y. The brother
would get better in time. He was not going to
mention his own injury as he did not want to worry
her. Under hypnosis he admitted that he would
have very much liked her to know about his accident,
he greatly wanted her love and sympathy.
Altruism, the wish not to give additional distress to his
mother, is here in conflict with the egocentric impulse.
Here again the hysterical symptom arises from a com-
promise between two opposed affective impulses
just as we saw in the case of the Australian sniper,
described on page 67. Paresis of the hand prevents
the gratification of either impulse, but with the balance
in favour of the more primitive instinct, since his
illness is now more severe, and his mother must be
written to by a third person who tells her of her son's
condition. But he does not write about it himself.
The history of this soldier of 16 years' service all
over the world shows how powerful was the maternal
allegiance. He had never been interested in any
woman, had never been engaged or even condescended
to kiss one, not even to hold a strange woman's hand
" so very little longer." He had once won a few
hundred pounds in a lottery and had sent it home to
his mother. I said to him, " I suppose after the war
you'll marry." " Not while there's mother to look
after." His father, I should add, was alive, and
they were not in bad circumstances. This history is
sufficient to understand the origin of the paresis ; any
deeper analysis of the hysteria is not my purpose
here. But I would point out that this is another case
in illustration of the thesis that hysteric must not be
read as degenerate. This patient is neurotic, but
he is a fine soldier, who had served in the South
African War, where he had been slightly wounded ;
PSYCHOLOGICAL MECHANISMS 77
a shell explosion had blown him up whilst in
France, for which he was invalided for four months,
and he then went to the Dardanelles. He is an
N.C.O. of charming manners, of good intelligence,
and a "neurotic."
CHAPTER IV
ANXIETY-HYSTERIA
WHILST in conversion-hysteria the most prominent
clinical symptom is somatic, in anxiety-hysteria the
most prominent symptoms are mental. A feeling of
anxiety, dread without adequate cause, a nameless
terror or some phobia, intense exhaustion after the
most trivial mental or physical effort, distinguish
this class of case; sleeplessness and headache are
common, whilst sensory motor disturbances, though
frequently present in the form of some analgesic area,
may be absent.
The phobias and obsessions are of the most varied
kind ; Withermann l says the desire for the Iron Cross
is often of an obsessional nature. Steiner 2 cites the
Case of an N.C.O., a congenital psychopath, who
would not let his company fire upon the enemy in
consequence of the "obsession" that the enemy men
had women and children dependent upon them. He
was affected by a constant taste of blood and a smell
of corpses. Binswanger 3 mentions a similar case of
"obsession" where the following dream dialogues
were overheard: "Do you see the Englishman
there?" " Has he got parents? " " Has he a wife? "
" I won't shoot him dead "
1 Withermann quoted in Zeitschrif t fur die gesamte Neuro-
logie und Psychiatric. Band 12. Heft. 4. March, 1916.
2 Ibid, p. 30. H. 2/3. 1915.
3 Hysterosomatische Krankheitserscheinungen bei der
Kriegshysterie. Monat. f. Psych, u Neurol. 38. Heft. 1/2.
1915.
78
ANXIETY-HYSTERIA 79
Vaso-motor disturbances invariably accompany the
feeling of "anxious dread," which is perhaps the best
term one can find. These vaso-motor symptoms are
many and various; all the physiological systems
may be disturbed, though not all may be affected at
any one time. The commonest of these disturbances
are:
a. CIRCULATORY. Already described on page42
under the "Soldier's Heart ;" congestion of
the extremities aping Raynaud's disease.
b. RESPIRATORY. Feeling of suff ocation,breath-
lessness, air hunger, dyspnoea, hay fever,
asthmatic conditions.
c. INTESTINAL. Anorexia, vomiting, indiges-
tion colic diarrhoea (constipation more
rarely).
d. EXCRETORY. A sweating, especially of the
palms, urticaria transient cedemas polla-
kuria, colicky pains over the bladder.
e. NERVOUS SYSTEM. Headache, parsesthesias,
photophobia, hyperacusis, disturbances in
the sense of smell and taste.
/. MUSCULAR SYSTEM. Tremors, generally fine
and often confined to the hands.
The thyroid is not frequently enlarged, some-
times with slight exophthalmos ; more
rarely the ocular symptoms seen in Grave's
disease are found.
The blood count may show a total increase of the
white cells with a lymphocytosis.
v&The following is a fairly typical example of this
kind ; it is a case of
REPRESSION OF FEAR.
No. 84. The patient, aged 25, who had gone
through the Gallipoli campaign without a scratch and,
as he said, with practically no fears was later frost-
80 t WAR-SHOCK
bitten in Salonica. He was sent to hospital on
December 18th. When he came under me on
February 7th the finger of the right hand was well, but
there was some loss of grip. He was then suffering
from insomnia, terrifying dreams, and tremors of the
hands. On December 6th at K , when holding
horses on a flying bridge the animals started and
he was thrown into the water ; he was picked out none
the worse. The next day it happened that his horse
was shot under him, but he escaped. A few days later
the middle ringer got frost-bitten, and he was sent to
hospital, where his hands began trembling, sleepless-
ness came on and severe headaches.
The patient was a thick-set sturdy fellow, jovial and
kindly, the son of an agricultural labourer. The
thyroid was diffusely enlarged, but there were no
ocular signs of Graves's disease and no signs of
disease in the central nervous system, other than the
tremors. The blood pressure was high. There was
a fine tremor of the hands, six to the second. The
pulse was irregular and rapid, and there were not
infrequent attacks of cardiac palpitation almost
anginal in character.
Blood examination. 4
Total white cells, 11,500 per cmm.
Neutrophile polymorphs, 48 per cent.
Lymphocytes, small, 47 ,,
Lymphocytes, large, 3
Large mononuclears, 2
The extremities were cold and blue (only one
finger on one hand had been frost-bitten), he sweated
violently in the palms, there was hyper-sensitiveness
to sound, occasional attacks of dizziness and a feeling
of suffocation, making him gasp for breath. There
was frequent desire to micturate.
4 I am indebted to Major Arkwright, R.A.M.C., M.O. i/c
of the Pathological Laboratory, for the examination of the
blood in this and the other cases.
ANXIETY-HYSTERIA 81
This is very much like the description of a severe
state of fright, such as many have experienced in the
Examination Hall, when the hands get a little
tremulous and the palms sweaty ; and, as we know,
these dreadful infernos are provided by some thought-
ful architects with extra latrine accommodation.
His terrifying dream was always the same. " I see
a Frenchman digging a knife into a horse. He gets
off his cart to do this. It is in Serbia." Not only
at night but during the day this comes up as a vision.
It is an actual occurrence. He saw a French trans-
port soldier, drunk, get off the waggon and plunge a
knife into a mule to make it go. With some others
he stopped the Frenchman and drove the waggon into
quarters. (Note, the mule becomes a horse in the
dream.) The patient's feelings about horses were
very intense. He had been used to horses since
childhood; his earliest recollections are of driving
with his father or of being put up on the plough-
horse. As a boy he was engaged about the stables
and later became a groom. He wept profusely when
talking to .me of the sufferings experienced by the
wounded mules in Gallipoli, and when I suggested
that human beings suffered more he would not have
it so. Animals could not talk. No animals should
have been allowed there, he said. He never had any
trouble with horses, for he understood them exactly,
and he was always given the difficult ones to manage.
In short, he was as doting on horses as any maiden
lady over her Fido.
We suspect all exaggerated sentiments ; with Queen
Gertrude we feel "The lady doth protest too much."
Investigation soon showed that the suspicion was
justified. He identified himself with the horse. He
was the horse of the dream ; it is he who ought not
to have been in Gallipoli it is too much for him and
others. Consciously the soldier instinct in my patient
82 WAR-SHOCK
would know no fear for himself. But as the Latin
satirist says :
" Primus in orbe decs fecit timor."
Fear is a primary, natural instinct, and, like murder,
will out. So long as the patient was actively engaged
looking after the horses he could expend all his
mental excitement in pity for them i.e., himself.
But condemned to inactivity by the frost-bitten finger
this mental excitement (which even before had been
abnormally expressed) finds no outlet, emotionally or
actually. Could it have reached consciousness the
patient would have been able to deal with it, as he
subsequently did with our help. Such cases are often
due to fear not necessarily fear of shrapnel thus
bottled up, or repressed from consciousness. This fear
not being acknowledged or worked off becomes morbid
fear, morbid because it is no longer objective.
That the person should become a horse in the
unconscious will not startle anyone who has dipped
ever so little into the totems and taboos of the lower
races. The kangaroo tribe, for instance, as Sir J. G.
Frazer 5 shows, consists of kangaroos and kangaroo
men, who actually are kangaroos and delight to show
their identity by identity of action. But, indeed, it is
not necessary to travel to Australia. Which of us has
not galloped as a horse, pawed the air, impatiently
neighed, and chafed at the bit. And when some day
our child comes galloping into the room, kicks over a
5 " In the Alcheringa lived ancestors, who in the native mind
are so intimately associated with the animals or plants, the
names of which they bear, that an Alcheringa man of, say, the
kangaroo totem may sometimes be spoken of as a man-kangaroo
or as a kangaroo-man. The identity of the human individual
is often sunk in that of the animal or plant from which he is
supposed to have originated." Spencer and Gillen ("Native
Tribes of Central Australia," quoted by J. G. Frazer, loc. cit.,
"The Magic Art," Vol. I., p. 107); "There was no sharp line
of distinction drawn either in theory or in practice between a
man and his totem."
ANXIETY-HYSTERIA 83
chair, and seizes some food from the table with his
teeth we understand. We do not say, " Don't,
Dickie," but we pat the mettlesome steed on the
head, feed him from the hand with lumps of sugar
and bits of apple; we softly rub his nose. We
understand. The father is no longer everything that
is wonderful in strength and power ; there are other
great spirited creatures too. And, perchance, we
silently pray : May all future adaptations be as glee-
fully and successfully accomplished, as happily under-
stood by ourselves, and as little thwarted. 6
This patient recovered under treatment ; sleep
returned, he ceased to be disturbed by this particular
dream and vision, and therewith the physical
symptoms subsided. In this case unfortunately no
second blood-count was made, so it cannot be said if
any change is to be recorded. In another case, how-
ever (No. 60, see p. 38), there is a record of the
blood-counts made when the patient first came under
treatment and a fortnight later, when he was much
improved ; the facial tic had then ceased, the eyesight
was normal, and the vaso-motor symptoms (sweating,
pollakuria) troubled him no more.
Count on March 17th, 1916.
White cells, 14,000 per cmm.
Neutrophile polyrnorphs, 40 per cent.
Small lymphocytes, 43
Large lymphocytes, 13 ,,
Large mononuclears, 3 ,,
Transitionals, 1 , ,
March 31st, 1916.
White cells, 10,750 per cmm.
Neutrophile polymorphs, 35 per cent.
Small lymphocytes, 32 ,,
Large lymphocytes, 16 ,,
Large mononuclears, 13 ,,
Transitionals, 4 ,,
6 For a deeper significance of the symbolic meaning of the
sacrificial horse consult Jung ; "The Psychology of the Uncon
scions," p. 311-316.
84 WAR-SHOCK
The total number of white cells was much nearer
the normal, as was also the percentage of small
lymphocytes, but I am not competent to discuss the
physiological significance of the blood changes in
these states.
Though it does not come within the scope of this
book to treat in any detail of the relationship between
the mind and body, there are a few points which must
here be touched upon.
In the patient No. 84 we have repressed fear, with
certain vaso-motor signs seen in the emotional state
of fear, enlargement of the thyroid, and alterations
in the constituents of the blood. Cannon 7 has shown
experimentally that " clear evidence has been secured
that in pain and deep emotion the glands [adrenal]
do, in fact, pour out an excess of adrenin into the
circulating blood." He has shown that the adrenin
thus poured out in pain and fear produces exactly the
same effects that follow an injection of adrenin.
" Here, then, is a remarkable group of phenomena
a pair of glands stimulated to activity in times of
strong excitement, and by such nerve impulses as
themselves produce at such times profound changes
in the viscera ; and a secretion pours forth into the
blood stream by these glands, which is capable of
inducing by itself, or of augmenting, the nervous
influences which induce the very changes in the viscera
which accompany suffering and the major emotions "
(p. 64). "When adrenin is injected into the blood
it will cause pupils to dilate, hairs to stand erect,
blood vessels to be constricted, the activities of the
alimentary canal to be inhibited, and sugar to be
liberated from the liver" (p. 37).
Cannon also suggests (p. 63) that adrenin may
7 "Bodily Changes in Pain, Hunger, Fear and Rage," by
Walter B. Cannon. New York and London : D. Appleton and
Co., p. 64.
ANXIETY-HYSTERIA 85
co-operate with the products of other glands of
internal secretion ; the other glands of internal secre-
tion may be stimulated by sympathetic impulses
(p. 65). We have indeed clinical evidence that the
thyroid is changed in these emotional states. It can
be hardly otherwise, seeing the inter-relationship of
these glandular secretions, than that there is a stimulus
of all the glands, the glandular equilibrium being
disturbed throughout.
It is then conceivable that the alteration in the
blood cells, the lymphocytosis, is in these cases a
secondary consequence of this repressed fear or
other emotion. " If these results," says Cannon, 8
" are not ' worked off ' by action, it is conceivable
that the excessive adrenin and sugar in the blood
may have pathological effects." I have shown
that the emotion was not worked off in this patient
(No. 84).
The mental condition would be the primary cause
of the disease, but it does not follow that treatment
would necessarily remove at once all the remote
effects set up. Treatment directed to, say, any of
the symptoms, e.g., the enlargement of the thyroid,
can produce excellent results, as Dr. Florence A.
Stoney 9 has shown ; if the hyperthyroidism is subdued,
the vaso-motor symptoms, which are due to the dis-
turbance in the relationship of the internal secretions,
will disappear. It seems not unlikely that the treat-
ment by X rays, of which she is a strong advocate,
likewise may influence favourably the primary cause,
the mental condition. These patients, as will be
gathered from No. 84 and the others who were
cured or improved by suggestion, were extremely
suggestible.
8 Loc. cit,, p. 196, footnote.
9 Proc. Roy. Soc. of Med., I.e.; Section of Therapeutics,
p. 50
86 WAR-SHOCK
SOMNAMBULISM.
It is difficult in some cases to differentiate a som-
nambulism from that more extensive dissociation of
consciousness known as multiple personality. The
difficulty arises in the following case, more especially
because I lacked the opportunity of seeing the patient
in any of his more pronounced conditions.
No. 77. Aged 31, a private in the R.A.M.C.
Anamnesis. In autumn of 1914 the hospital to
which he was attached in France was shelled, and he
began to suffer from headache and exhaustion. In
January, 1915, he was invalided for "neurasthenia."
In April, 1915, he was sent for duty to Malta. In
August, 1915, he had an attack of sunstroke, dropped
down unconscious and lost his memory for seven to
eight hours. After 14 days in hospital he was sent
back to England . In November, 1 9 1 5, he returned for
service to Malta, and whilst on hospital duty in
February, 1916, he repeatedly wandered out of the
tents at night and "lost himself" for some hours.
These fugues had become very frequent of late.
He was brought before his O.C., who at once sent
him into hospital as a patient.
Examination a few days later:
Frequent myoclonic spasms of left face, neck and
shoulder girdle, much less marked in the left lower
limb. Constant shrugging of left shoulder. Pupils
R. >L., 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
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Paraplegia.
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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
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