Treatment Of Shell-shock

In discussing the question of treatment we do not propose to deal with general therapeutic measures which every physician in charge of nervous or mental patients is hardly likely to neglect. The importance of a generous and easily digested dietary is generally recognised: as also is the need for quiet and congenial surroundings, and for shielding patients from disturbances, such as noises and the sight of wounded, which are likely to evoke painful emotions and vivid memories of their experiences at the front. It is also obviously important that the physician should deal promptly and discreetly with any bodily ailments from which the patient is suffering, being careful neither to minimise their gravity and so, give him any reason for the grievance that he is not receiving proper attention, nor by exaggerating them to add this anxiety to his other troubles. These are questions which may confidently he left to the discretion of the physician in charge.

Firmness and Sympathy: But there are certain other therapeutic measures commonly recommended in text-books for application in the cases of patients suffering from neurasthenic and hysterical troubles, which cannot be thus summarily dismissed. As many of these patients are irritable and childishly peevish, it is necessary that they should be treated with sympathetic firmness, tact and insight.

But unfortunately, the words "firmness" and "sympathy" are interpreted in a great variety of ways. While it is important, for purely therapeutic reasons, that discipline should be maintained, and that when the physician has decided what he considers the proper treatment for the patient this should be vigorously carried out, it is manifestly disturbing and injurious in many cases for the officer to insist upon all the exacting details of military rules and regulations. For the mentally healthy soldier, obedience to stern and even harshly rigid regulations is often vitally important; but an attempt by a medical officer to treat a ward of neurasthenia patients in this way usually has disastrous results.

Quite apart, however, from the military aspects of the case, the physician, without really investigating the history of a patient, may .label his trouble "hysteria" and forthwith adopt a course of "firmness." He may assume the attitude of doubting the genuineness of symptoms which are very real to the sufferer. Under the plea of helping to cure the patient the officer may assure him that there is nothing much the matter with him and that if he tries he will soon be all right. Such advice may be justifiable if based on a real insight into the state of the individual sufferer, but this knowledge can be gained only by a patient investigation of the cause of his trouble. If the advice is given without this insight, it is a mere shot in the dark. The fact that the device succeeds in a certain number of cases is no excuse for its general adoption. And when it "misfires" no one realises the fact more quickly than the patient himself. He realises that the officer does not appreciate his condition and his confidence is thereby destroyed. It is useful, too, to consider for a moment the nature of treatment by "sympathy." When we used the phrase "sympathetic firmness" we intended to indicate the insistence upon a strict observance of such methods of treatment as a real insight into the patient's condition may suggest. The word "sympathy" was used in its literal sense of "feeling with" the sufferer. But there is no class of patients upon whom sympathy, of the injudicious kind is more prone to work serious harm than the psychoneurotic. The knowledge of this fact is often the excuse for the adoption of the opposite attitude and the prescription of "firmness" which, as we have seen, may be equally unintelligent and injudicious.

But sympathy of the injudicious kind is not real sympathy. For unless the sympathiser has a true appreciation of the patient's condition, and can look at things from his point of view, he cannot rea1ly feel with the sufferer. The latter may arouse in the would-be sympathiser tender emotions and sympathetic "pain," but unless the sympathiser have insight, the pain, to, put it crudely, is not likely to be "in the same place" as that of the patient. Such misplaced emotion and false sympathy, whether on the part of the doctor, the nurse, or the patient's relations, may do much harm.

In mild cases of mental trouble, however, where the patient still retains a goodly portion of self-confidence and self-respect, this "petting" variety of sympathy may sometimes be effective. Such a patient may be cheered up by the presence of people sufficiently interested in him to be sorry for his condition; and it may, help him to look on the brighter side of things and to forget his worries and anxieties. But often it is apt, by suggestion, to aggravate his troubles or even to discourage him from trying to recover. Perhaps it would be more accurate to say that such treatment gives him no inducement to get better.

There are still not a few physicians who regard the group of functional troubles commonly labelled "hysteria" as something closely akin to malingering. If it would not be considered invidious we could quote the opinions of well-known physicians published within the last five years, suggesting that there is no real line of demarcation. (It is not uncommon to meet the expression "detecting," instead of diagnosing hysteria) But even among those who regard these serious affections as something more than mere simulation there is a tendency to look upon any form of sympathy as a dangerous pandering to the patient's lack of will power. This attitude often finds expression in leaving the patient alone to get better by his own efforts, or in suggesting to him that he is not so ill as he thinks he is, and that all he needs is some work to occupy his attention.

The attempt is often made to justify such methods by the plea that it is "bad for the patient to talk to him of his worries." But how a physician is to rid a patient of the very root of all his trouble without first discovering and then discussing it with him is not apparent. Nor, again, is it any more rational merely to tell a man who is weighed down with some very real anxiety to "cheer up," or to "work in the garden," or "take a walking tour."

We are not maintaining that such methods do not often meet with success in the case of many patients who are only mildly affected and earnestly want to get better. But experience shows that such advice is often fraught with danger, and, in severe cases of mental affection is worse than useless. The experience of those, physicians who have been treating such patients with sympathetic insight during the last two years affords a striking condemnation of the theory that it is generally "bad to talk to them of their worries." It has repeatedly happened that as soon as the patient was asked about his troubles he made a full statement of all that was troubling him and was obviously relieved to confess his worries to someone who took an intelligent interest in his welfare.

In many cases the mere unburdening of this weight of anxiety and the removal by the physician of quite trivial misunderstandings which were the original causes of it, were sufficient to cheer up the patient and to start complete recovery. Yet many of these men had been inmates of a series of hospitals in which no attempt had been made to discover what was the real source of all the trouble. Thus to their other worries and anxieties was added the real additional grievance that they were being neglected and were of no account. in many cases this constituted a serious aggravation of the patient's mental disturbance and encouraged him to believe that his state was already beyond help.

Those physicians who look upon such milder psychoses as varieties of simulation should be reminded that the methods we have just mentioned are not often likely to be effective in cases of real malingering. In discussing the therapeutic use of "firmness" we have not thought it necessary to mention those applications of this method which at times are practised by combatant officers at the front. The use of military authority to suppress the minor manifestations of nervousness, or the resort to such expedients as unexpectedly firing off a gun alongside a man afflicted with functional deafness, are merely examples of the application of "suggestion." They are akin to the use of "firmness" by the physician who has not investigated the cause of the patient's trouble. The results of such expedients are as erratic in the one case as in the other. But there is no need for us to discuss this practice further, except to add that the knowledge that such "treatment by military authority" has been tried before, still further diminishes the justification for resorting to such measures when the patient reaches the home hospital.

 Isolation. Many physicians regard isolation as an appropriate method of treatment for soldiers suffering from shock, and they urge in justification of such a procedure the success which often attends its use in civil cases. We do not deny the utility of isolation for suitable cases, and success has attended its use when the patient's condition obviously required it. But the circumstances which were responsible for causing the mental disturbance in the soldier may be of a totally different nature from those which have upset the civilian; and therapeutic measures which may be appropriate in eliminating the civilian's sources of irritation might be wholly unsuitable, if not positively harmful, in the case of soldiers. It cannot be too strongly emphasised in connection with this subject that most of the theory and practice of treating hysteria by isolation has been developed in civil life, and in very many cases with reference to well- to-do women living in the lap of luxury. When such persons develop hysterical symptoms, some sources of irritation in the home or the social environment are often responsible. By isolation the patient is removed from the noxious influence of both domestic worries and mistaken sympathy; his or her whims and fancies are compulsorily subordinated by self-discipline and consideration for others. At home it is impossible satisfactorily to enforce such measures and the attempt to do so will almost inevitably fail, because sympathy, curiosity and anxiety on the part of various relatives hinder the attainment of these objects. By isolation the patient is removed from these unfavourable psychical influences. Through the freedom from such disturbing stimuli, the abnormally intense reaction of the mind is reduced. And in many patients of this class the desire to be cured or to be active, which is produced by the boredom of isolation, works favourably.

But in most soldiers the circumstances are altogether different. In the first place, the patient secures the change of surroundings by his removal from the trenches to the hospital. Isolation, therefore, can hardly be justified on that score. At the same time, the removal to a military hospital at any rate should obviate all danger of his being pestered by foolish relatives and friends with their mistaken sympathy or excessive attention. And as regards the importance of discipline and routine, the soldier is in a position very different from that of the wealthy society lady, for he has already been subjected to such training.

In some instances, however, just as in the civil cases, the boredom of isolation may produce the good effects noted above. But there is the corresponding disadvantage that if you isolate a man and put a special nurse to look after him it is impossible to convince him that his case is not serious. It may, indeed, help him to persuade himself that he is really going insane. As a matter of experience, it is found that very many men cannot stand isolation for long; they feel that they must break out, even if they realise that punishment is certain for doing so.

(This explanation of the reasons for the use of isolation is taken from Mohr's article in Lewandowsky's Handbuch der Neurologie.)

 The conversation of patients who are undergoing treatment by isolation is often perfectly frank about it. They tell the medical officer they will break out at the first opportunity; that the few hours of freedom would more than compensate for the punishment which would come afterwards. Again, it must be apparent that, when the trouble is due in any considerable measure to the re- awakening of emotions linked up with some painful earlier experience, isolation is not likely to be effective in many cases, and may be definitely harmful. Neither should it be forgotten that such measures fail to isolate the patient from his worst enemy, himself.

Even in those cases in which it is useful, isolation, if unduly prolonged, may spoil its own good effects. It may so accustom the patient to a solitary mode of existence that the presence of other persons may make him irritable when at the end of his time of seclusion he is compelled to associate with his fellows.

There is another fact which has to be taken into consideration - and this applies especially in civil practice - where the patient or his family have to pay for the treatment. We refer to the expensiveness of treatment by isolation. Unless it can be shown that it is the best or the only hopeful method to adopt, the physician must feel some hesitancy in the majority of cases, in pre- scribing such costly measures.

Dejerine and Gauckler ("The Psychoneuroses and their Treatment by Psychotherapy", translated from the French by Jelliffe, 2nd Edition, 1913, p. 311) have given an admirable account of the use of isolation in the treatment of neurasthenia and hysteria. They are careful to point out, however, that even in the case of civilian patients, with whom of course their treatise is concerned, "isolation, even accompanied by rest and overfeeding, is never enough." It is merely an adjunct, though, under certain circumstances, a necessary one, of the treatment by persuasion. But "it would be irrational to look upon the isolation of neuropaths as a therapeutic necessity from which one might never depart. It only applies to particular cases." In proceeding to define the class of civilian patients for whom such methods are appropriate they emphasise the value of isolation for those whose troubles axe due to, or aggravated by, "a bad family environment." In most cases the circumstances of the war-stricken soldier do not come within the categories which they suggest as justifying isolation. Moreover, most of the benefits which they attribute to this therapeutic measure, i.e., removal from home surroundings and from the particular worries and anxieties which have caused the mischief, are attained (as we have already pointed out) when the soldier is an inmate of a special- or, in fact, of any - hospital.

When Dejerine and Gauckler proceed to define the different degrees in which the method of isolation may be practised; viz.:

(i) strict isolation;

(2) absolute isolation from one's family circle and environment, and

(3) isolation from one's family circle alone, or from one's usual environment alone--

it becomes clear that the treatment of every soldier who enters any hospital inevitably comes within the scope of categories 2 and 3.

Even when writing of hysterical women these French physicians tell us that - "to show how slightly (their) experience has inclined (them) towards any systematic treatment of the psychoneuroses by isolation, isolation has not seemed (to the doctors) to be necessary for " at least a third of the neuropathic women who have been cared for at the Salpetriere. Again, it must be added that, of the patients admitted , a certain number have been received at the hospital and naturally submitted to the discipline which belongs to an isolation ward much more for humanitarian and social reasons than because absolute isolation seemed to be formally indicated."

From the completely different nature of the circumstances of the nerve-stricken soldier and civilian respectively it is clear that such total isolation can be considered necessary for soldiers only in very few cases, even though the modified forms of isolation, to which reference has been made, may be useful for most of such patients. The important point that emerges from this discussion is the necessity which is laid upon the physician of determining, in the case of each individual patient, whether isolation of any kind is desirable, what form it should take, and especially when it should be used, modified or discontinued.

Suggestion and Hypnosis. We have already touched briefly on the need for sympathetic firmness and for inspiring the patient with confidence that he will recover. But such firmness can be useful only when it is supported by respect for and confidence in the physician. In most cases such respect can be gained only by acquiring a real insight into the patient's condition and by treating him tactfully and reasonably. It is too often forgotten that the neurasthenic patient's continual and intense criticism of himself makes him especially quick at intuitively becoming conscious of the physician's failings. Under such circumstances, if the doctor does not secure the patient's respect and convince him that he really understands his condition, the former's firmness and confident assurances will avail him nothing: he has shown his hand; his failure will excite contempt; and the patient's intractable, enlightened stubbornness will be fatal to any further hope of influence on the part of that particular physician. Ever since mankind first sought help from his fellows for his afflictions of body or mind, confidence in the efficiency of the adviser's ability has been an essential factor in leech-craft. To be able to convince a patient that he is going to recover and that medical advice will help towards that end is certainly not the least of the physician's qualifications. But unless the assurances given him are based upon real insight and understanding, the process of securing the patient's confidence is not very different from the charlatan's blatant boasting. In other words, it is analogous to the confidence trick.

The confidence which is inspired in the patient by his conviction of the physician's real understanding of his condition is an altogether different matter. Such "suggestion" necessarily enters into all successful treatment and this applies in a very special manner to the cure of mental ailments.

But the question arises, is it useful or desirable to supplement these measures of suggestion which are incidental to all human intercourse, by more positive measures of induced "suggestion" or hypnotism? There are wide discrepancies of opinion with regard to this matter. And, in endeavouring to come to a conclusion concerning it, it is important to eliminate as far as possible the emotional tone which the warm discussion of this question has aroused in the past.

The positive usefulness of hypnosis in relieving many of the acute symptoms in recent cases of sheu-shock has been fully demonstrated by the important series of articles by G. S. Myers, in the Lancet.(Feb. 13th, I915 (p. 316); Jan. 8th, 1916 (p. 65); Mar. 18th, 1916 (p. 608); and Sept. 9th, 1916 (p.461)

 When it is possible by such means to restore to the patient his lost memory or speech or banish his dependency it often proves that the only hindrance to the complete restoration of his normal personality has been removed

"It may be argued," to quote Myers's own account, "that mutism, rhythmical spasms, anaesthesia, and similar purely functional disturbances disappear after a time without specific treatment. But no one who has witnessed the unfeigned delight with which these patients, on waking from hypnosis, hail their recovery from such disorders can have any hesitation as to the impetus thus given towards a final cure. More especially is this the case in regard to the restoration of lost memories. Enough has already been said here about the striking changes in temperament, thought, and behaviour which follow on recovery from the amnesia. . . . The restoration to the normal self of the memories of scenes, at one time dominant, now inhibited, and later tending to find occasional relief in abnormal states of consciousness or in disguised modes of expression - such restoration of past emotional scenes constitutes a first step towards obtaining that volitional control over them which the individual must finally acquire if he is to be healed.

Thus the minimal value that can be claimed for hypnosis in the treatment of shock cases consists in the preparation and facilitation of the path towards a complete recovery."

 Even if we admit that other measures, such as the administration of chloroform for the cure of hysterical mutism, may in some cases effect similar improvements, this should not blind us to the incontrovertible fact that hypnotism has been proved to be a valuable therapeutic agent in the early stages of shell-shock.

As a cure for certain patients who have passed the acute stages of shell-shock or other forms of war- strain, its use requires great discrimination in the selection of suitable cases and extreme care in its practice. It is very probable, too, that hypnotic suggestion by itself should never be regarded as sufficient treatment for these cases, though undoubtedly it may be of great use as a part of such treatment.

A view endorsed by some well-known physicians is that all psychotherapy should be addressed to the functions of consciousness, and that hypnosis, which is addressed to the functions of automatism, is therefore undesirable. As a general statement this is undoubtedly true of a great number of cases, but them occur instances in which it seems that this sensible rule may be wisely and judiciously broken. In some cases hypnosis helps in more quickly breaking down resistances, which occur in patients too beset by their own auto-suggestion and false beliefs to be able easily to grasp the arguments and persuasions which the physician may have spent days and weeks in vainly endeavouring to get accepted. Thus assistance may be sought without in any way interfering with subsequent treatment of the patient by psychological analysis and re-education.

The following instance illustrates the use of hypnotic suggestion in the manner described above. The case was one of violent spasmodic tremor in the right arm of a soldier. When in a state of convalescence from a wound and shell-shock he suddenly encountered his company officer, to whom he was greatly attached. This officer had lost his right arm since he was last seen in France by the patient. The shock of suddenly meeting the officer in this condition set up the man's tremor. The case came under psycho- therapeutic treatment some weeks later, when the patient, who was an extremely emotional individual, had lost all hope of recovery. Any attempt at purposive movements of the right hand and arm threw all the muscles of the right side of the body into a violent state of jerky tremor. Long continued treatment by persuasion failed to effect any improvement whatsoever. The medical officer in charge of the case therefore decided to try hypnotic suggestion. This was easily carried out; the hypnotic state being moderately deep, though the patient was still in touch with his environment. Hope, courage and assurance of recovery following his own effort, together with determination to make every endeavour, were suggested to him. The patient was assured at each sitting that his nerves and muscles would every day respond more and more to his efforts at self-control. After a very few short sittings the man's hopeless attitude became changed to one of hope, effort and attention in the waking stage, and there was a slight but decided improvement in his voluntary power. Hypnotic suggestion was then given up, and the treatment was continued by means of encouragement, exercises and explanation of his trouble, with the result that two months later hie was fit for discharge from the hospital.

It may reasonably be doubted whether methods of persuasion alone would have cured this man. In any case, it is clear that it would have taken a very long time. It is also probable that hypnotic suggestion alone, if continued, would very quickly have removed the symptoms. It may be doubted, however, whether it would have effected a permanent cure in a person so open to auto-suggestion. It seems, therefore, that a judicious combination of methods was advisable.

We are of the opinion that hypnotic treatment, when used with skill, discretion, and discrimination, has its place in the treatment of shell-shock and similar conditions, both in the acute and chronic stages,.

In the majority of cases of some considerable duration, however, and in practically all those in which the trouble is due to some ante-war worry or emotion, it may be regarded as probable that hypnosis alone will be of relatively slight use and in many cases may be positively harmful, for under such circumstances, even with the most favourable conditions, it would result merely in

the removal of symptoms; and the removal of one may be followed by the appearance of another, which may even be induced by the process of hypnosis. More-over, in cases where there is a tendency to the development of a double personality hypnosis may have the effect of increasing the risk. Further, if the patient has sufficient of his own will-power to enable the process of re-education to be carried out, it is clearly undesirable, both on psychological and ethical grounds, for the, doctor to impress his influence from without.

In considering the possibility of the usefulness of hypnotic suggestion it is important to bear in mind that various factors may come into play in impressing an event upon the patient's memory, or in determining the effect of the shock from which he is suffering when he arrives in hospital. In the first place there is the vividness or intensity of the stimulus; in the second, the degree of recency; in the third, the frequency of the stimulus; and in the fourth its relevancy. By the latter is meant the extent to which a given event appeals to the individual's past experience, and becomes integrated into his personality.

A patient who has recently received a severe shock, the effects of which alone represent the real trouble, without the disturbance of any antecedent experience, might quite well be relieved by hypnotic suggestion from sleeplessness, pain, or amnesia; and in some cases this removal of the acute symptoms which determine the persistence of the shock effects may lead to complete recovery. A single and sudden wholly irrelevant experience, such as the bursting of a shell, which has no relationship whatever to the, patient's past experience, and produces effects by its vividness and its recency, might quite well be neutralised by another kind of wholly irrelevant intrusion, such as hypnotic suggestion. This argument may perhaps be made more intelligible by a homely analogy. A temperate man walking along the street might be thrown temporarily into a condition of faintness or collapse by seeing some ghastly accident, but by taking a "brandy and soda," which to such a man would be a wholly irrelevant experience, the physiological expressions of his emotions might be controlled and he might be able to proceed on his way, and to overcome completely the effects of the transitory occurrence. But in the case of a man who, for example, had been greatly worried by monetary troubles for a number of years, the "brandy and soda" would not produce anything more than a temporary alleviation of his troubles. The latter illustration represents the chronic psychosis which, as Dejerine has so admirably explained, is quite unsuitable for hypnotic treatment. But the distinguished French neurologist's statements do not seem to apply to the former type of case, due to a vivid recent shock, in the symptomatology of which troubles before the shock play no part. In such cases the results bf hypnotic suggestion are often brilliant, if erratic, as is the "brandy and soda cure" for the man who is overcome by a sudden terrible experience in the street.

There are, however, patients who have not sufficient will-power or intelligence to be properly re-educated, to whom a certain amount of suggestion may be of some use.

Those who have used hypnosis in civil practice are aware that in certain individual cases of long-.standing trouble, such, for example, as chronic alcoholism, hypnotic treatment is of unquestionable value. Among soldiers suffering from the long-standing effects of shell- shock, hypnosis may he able in some cases to help in the restoration of health with an effectiveness that no other method can rival.

Both the danger and the possible usefulness of hypnotism may be illustrated by an actual case. it is that of a man all of whose companions were destroyed by the bursting of a shell, and who suffered for months afterwards from complete loss of memory. A medical man hypnotised him, and perhaps with undue tactlessness, brought back the memory of the critical incident at the front, stripped of all the episodes which led up to or followed it. This excited in him the most violent emotions, and he became sick with terror; for the revived incident seemed perfectly real to him, or, as he described it afterwards, "it jumped up against him," and for weeks he was so utterly terrified that he would not go near the doctor. Even though he could not retain the memory of any other recent events the horror of that experience seemed to have made him remember his dread of a particular medical man. But by making use of the information gained during that revival under hypnosis of an incident unknown to anyone but the patient, which his amnesia up till then had kept scaled up, it became possible for another medical officer to bridge the gap between his memory of previous events and the experiences which the patient was known to have had in the military hospitals.

In speaking of the results of hypnotic treatment as being brilliant but erratic, it is important to remember that the same observations apply to suggestion without hypnosis. For instance, the application of electricity to the vocal cords in cases of hysterical aphonia affords an admirable illustration of the treatment by suggestion, even if the method savours of charlatanism. An excellent demonstration of the part which psychical factors play in such cases is afforded by the story of a sailor on the German battle-cruiser Derfflinger, recorded by Blassig.(Munchener Medizinische Wochenschrift, June 15th 1915, p. 335)

"A seaman from the Derfflinger was brought into a naval hospital with loss of voice on Dec. 22nd, 1914, and could speak only in a whisper. He said that he had always had good health, with the exception that as a child he had diphtheria, but recovered without tracheotomy or any complication. His voice had always been clear and well under control. At the beginning of December he had a slight cold, which he attributed to sea duty on deck in very stormy and wet weather. While in the ammunition chamber of the big guns he was greatly upset during the firing and suddenly lost his voice. After fourteen days he recovered his speech. On Feb. 12th, 1915, he returned to hospital with complete loss of voice, immediately after the naval engagement in the North Sea. On Feb. 15th he was treated with electricity, directly applied to the vocal cords, and on March 2oth he was discharged with complete recovery of his speech. But on returning to duty, as soon as he went on board his ship his voice was suddenly lost for the third time, and he remained aphonic."

This is clear evidence of the fact that his trauma was psychical. His previous history perhaps, contains the clue explaining why, in his case, it was his voice which was affected. The application of the faradic current was suggestion pure and simple.

In emphasising the limited usefulness and possible danger of suggestive therapeutics in many cases that are not quite recent, we have not been referring to that method of suggestion which is involved to a greater or less degree in all successful treatment of disease - the process of gaining the patient's confidence and impressing him with the idea that he is going to recover.

"The conversational attitude, the familiar manner of talking things over, the heart-to-heart discussion, where the physician must exert his good sense and feeling, and the patient be willing to be confidential" is the method which Dejerine calls 'psychotherapy by persuasion'. "It consists in explaining to the patient the true reasons for his condition, and the different functional manifestations which he presents, and above all, in establishing the patient's confidence in himself and awakening the different elements of his personality, so as to make them capable of becoming the starting-point of the effort which will enable him to regain his self-control. The exact comprehension of the phenomena which he presents must be gained by the patient by means of his own reasoning. ... the part that the physician plays is simply to recall, awaken, and direct . . . ."

No one who has not had the experience of guiding mental patients in the way so lucidly expounded by the French physicians can form any adequate conception of the remarkable efficacy of these common-sense methods in restoring to those who are afflicted a normal attitude of mind. It is certainly saying considerable numbers of soldiers from the fate of insanity. These methods are not novel, even if the fuller comprehension of their mode of operation is only dawning upon us now. This point has been admirably expounded by Dejerine and Gauckler, from whose book we must quote once more:-

"May we be permitted to quote a few lines in which Bernadin de St.Claire has defined, more exactly and better perhaps than we could do, and with a sort of prescience of what is needed, the very ro1e that we would like to see our physicians adopt towards their patients. I wish that there might be formed in large cities an establishment, somewhat resembling those which charitable physicians and wise Jurists have formed in Paris, to remedy the evils both of the body and of one's fortunes; I mean councils for consolation, where an unfortunate, sure of his secret being kept and even of his incognito, might bring up the subject of his troubles. We have, it is true, confessors and preachers to whom the sublime function of offering consolation to the unfortunate seems to be reserved. But the confessors are not always at the disposition of their penitents. As for the preachers, their sermons serve more as nourishment for souls than as a remedy, for they do not preach against boredom, or unhappiness, or scruples, or melancholy, or vexation, or ever so many other evils which affect the soul. It is not easy to find in a timid and depressed personality the exact point about which he is grieving, and to pour balm into his wounds with the hand of the Samaritan. It is an art known only to sensitive and sympathetic souls.

Oh! if only men who knew the science of grief could give unfortunate people the benefit of their experience and sympathy, many miserable souls would come to seek from them the consolation which they cannot get from preachers or all the books of philosophy in the world.. Often, to comfort the troubles of men, all that is necessary is to find out from what they are suffering." (Etude de ta Nature, 1784).

 Dejerine and Gauckler add

"One could not express any better, or any more directly, what we never cease to maintain, however lacking in science it may seem at the first-namely, the real therapeutic action of kindness.

 "Liberated morally, and having regained consciousness of self, and freed in addition from his functional manifestations by the appropriate processes the patient is cured. He is cured trom his actual attack. But his mental foundation, his psychological constitution, still remains in the same condition which permitted him under emotional influences to under emotional influences to become a neurasthenic. The ro1e of the physician is, therefore, not ended. He must still build up his patien's life, still practise prophylaxis, and get the patient into a condition where his character will be established."

 Rational Treatment. So far in this chapter we have been discussing what may be described as general methods of treatment, which do not necessarily involve any attempt to probe into distinctive individual symptoms and to discover the real fundamental cause or causes of the trouble. The measures so far considered are empirical rather than rational. But they are the only methods of treatment discussed in most of the text-books.

It is an axiom in medicine that correct diagnosis is the indispensable preliminary to the rational and intelligent treatment of disease. This fundamental principle is universally recognised in dealing with bodily affections; but it is the primary object of this book to insist that it is equally necessary to observe the same principle in the case of mental illness.

It may seem ironical to stress this elementary consideration, but it is notorious that accurate diagnosis is too often ignored in cases of incipient mental disturbance. It is idle to pretend that such a procedure is unnecessary, or to urge in extenuation of the failure to search for causes that many patients recover under the influence of nothing more than rest, quiet, and ample diet.

Many mild cases of illness, whether bodily or mental, may and do recover even if undiagnosed or untreated. But on the other hand many mild cases get worse; and it is the primary duty of the physician correctly to diagnose the nature of the trouble and to give a prognosis - to decide whether the illness is mild or severe. Some of the most serious cases of incipient mental trouble are those of patients who do not seem to be really ill, and are easily overlooked by a visiting physician. They are quiet and inoffensive and display no obvious signs of the insidious processes that are at work in them. But all the time they may be, and often are, brooding over some grievance or moral conflict, worrying about their feelings, misinterpreting them and gradually systematising these misunderstandings until they become set as definite delusions or hallucinations. If, acting on the belief that it is bad to talk about a patient's worries, the physician leaves such a man alone, he is clearly neglecting his obvious duty. For the whole trouble may be due to, some trivial misunderstanding which he could easily correct.

In the severer forms of mental disease, precise diagnosis is even more intimately related to treatment than in the case of bodily illness. For when a patient's illness is recognised as some bodily affliction, such as pneumonia or appendicitis, certain general lines of treatment are laid

down as soon as the appropriate label has been found for the complaint, though, in the case of the latter illness, there is added the further problem of whether or not surgical interference is indicated.

In cases of mental disturbance, however, the general lines of treatment cannot thus arbitrarily be determined merely by finding an appropriate label. It is true that as in the treatment of bodily disease, certain general principles must be observed, such as the provision of abundant and suitable food, and the protection of the patient from all disturbing influences. But the essence of the mentally afflicted patient's trouble is some particular form of anxiety or worry which is individual and personal. The aim of the diagnosis, therefore, should be not merely to determine the appropriate generic label for the affliction, but rather to discover the particular circumstances which have given rise to the present state. The special object of the physician should. be to remove or nullify the exciting cause of the disturbance; and in order to do this it is essential that he should discover the precise nature of the trouble. The diagnosis, therefore, must be of a different nature from that demanded in case of physical illness, where the condition may be adequately defined by sonic such generic term as "lobar pneumonia" or "acute appendicitis," and its gravity estimated by the general condition and physique of the patient. In the case of mental trouble, the physician has to make an individual diagnosis, based not only upon an insight into the personality but also into the particular anxieties of each patient.

But even when it is recognised that exact diagnosis of the particular circumstances of each individual patient is essential, if the trouble is to be treated rationally and with insight, there still remain many difficult problems as to procedure.

Amongst those whom experience has convinced of the efficacy of psychological treatment for this class of case, there are indications of a divergence of opinion in the matter of procedure. Some believe that it is sufficient if the medical man has discovered the real cause of the trouble and explained it to the patient. Other workers look upon a preliminary psychical examination merely as a means of diagnosis, the unveiling of the hidden cause of the trouble; and consider that the treatment should be the laborious and often lengthy process of re-educating the patient, and so restoring to him the proper control of himself. It is of the utmost importance to emphasise the undoubted fact that those who maintain either of these views to the exclusion of the other are committing a grievous and dangerous error, for there is no sharp line of demarcation between the two procedures.

A sensible and intelligent man, once the cause of his trouble has been made clear to him, may be competent to continue to cure himself, or, in other words, to re-educate himself, and completely to conquer the cause of his undoing. But the duller and stupider man may need a daily demonstration and renewal of confidence before he begins to make any progress. It is precisely analogous to the experience of every teacher of a class of students; the brilliant man will seize hold of a principle at once and learn to apply it without further help, whereas the dull man needs repeated and concrete demonstrations before it sinks into his understanding.

In dealing with soldiers, and this applies with especial force to the regular army, the conditions in many of the cases differ considerably from those of the civilians. Trifling forgetfulness in the civilian would perhaps not be a serious cause of worry, but in the soldier, inured by years of training to strict discipline, forgetfulness of even trivial instructions, or any difficulty in understanding complex orders, is likely to bring down upon his head condign punishment. Such lapses are regarded by the soldier as extremely serious offences, because years of training and discipline have inculcated this idea. When as the result of shock such soldiers are afflicted by even slight forgetfulness, they become worried by it much more than would the civilian and exaggerate its importance until it becomes a real terror to them. As the result of their training they may regard such phenomena as altogether abnormal; and by a process of rationalising what to them is a novel experience, they are apt to imagine that they are going mad. Such patients often dream about incidents in their army life when they had been forgetful and got into trouble; they become obsessed with the haunting fear that they are likely to get into perpetual difficulties, are worried by the thought that they are incompetent for the duties to which they have been accustomed, and may imagine themselves debarred from all useful work. However, they are easily reassured when the medical attendant explains to them that in ordinary life civilians are

frequently subject to such experiences, and that it is only the special circumstances of army life which make such trivial lapses seem serious to them. Not only is the soldier much more scared by such things than the civilian, but it is also a very remarkable phenomenon, and certainly one which came as a surprise, that the neurasthenia of a soldier is apt to be very much more serious than that of the civilian. For when a really brave man is stricken by fear he is more seriously affected by the terror of an experience which to him not only has a larger element of novelty than in the case of the civilian, but also wounds him more deeply by convincing him that he is lacking in that very quality which is most essential for his professional work.

The Therapeutic Value of Work. It should be unnecessary to emphasise the desirability of preventing the neurasthenic from dwelling upon his subjective troubles by occupying his mind with other things. This end may often be achieved by the provision of suitable occupation, and where possible, for many obvious reasons, this occupation should take the form of useful work. The worker then feels that he is not a mere burden upon the hospital which is treating him: the institution in its turn benefits materially. But it is necessary to sound a note of warning against the indiscriminate prescription of work as a panacea. First of all it should be certain that the work is of such a kind as really to interest the patient and to occupy his mind. There are many varieties of work, especially of manual labour, which can be performed mechanically, and do not succeed in distracting the attention from worries and anxieties. But more important even than this is the consideration that there are some mental troubles from which no form of work will distract the patient. Especially is this the case in many of the psychoneuroses caused by the war. The sufferer is often haunted day and night by memories which torture him not merely by their horror but also by another aspect which is even worse: the ever- increasing moral remorse which they induce. A patient may be troubled not only by the terrible nature of the memory but by the recurring thought, "If 1 had not don" this or that, "it might never have happened." The reader will easily see how such a thought may arise in the mind, especially of a nerve-stricken officer or NCO after weeks of brooding in private upon the memory of a disaster. Now, such self-reproaches are frequently based upon entirely insufficient evidence, and if the medical officer is given the opportunity of calmly discussing their foundations with the patient, the result is often to reassure him and to enable him to view his past in an entirely new light, it is then, and not before then, that he will be able cheerfully to enter upon useful occupation and to benefit by it. To suppose that the mere physical fatigue induced by a day's heard work will banish all forms of insomnia betrays an ignorance of one of the most important causes of this malady; viz., mental conflict. It is well known that bodily fatigue in the case of a mentally excited patient may merely increase his unrest at night. Again, anyone who has had a few months experience of receiving the confidence of these nerve-stricken soldiers will know that some of their troubles are so poignant that the attractions of the (apparently) most interesting kinds of occupation leave them cold.

 To sum up, the physician may confidently prescribe work when, by investigating the history of any particular case, he has satisfied himself that such occupation will be likely successfully and profitably to distract the patient's mind from his worries. But the prescription of work for the patient must be regarded as a sequel to, not as a substitute for, the performance of work by the doctor.