108. By orthopedists and mechanotherapeutists too much stress may indeed be laid on non-psychiatric measures, as Duprat hints. Yet perhaps neuropsychiatrists may need as much coaching in the opposite direction. One must remember the non-psychopathic fraction of these Shell-shock disorders and their need of diathermy (Babinski). Duprat says that the centers for physiotherapy cannot effectively do the work of all Shell-shock therapy, as the physiotherapists have their aims fixed on nerves and muscles rather than the mind. Each case requiring psychotherapy ought to be studied in an experimental psychological laboratory from a number of points of view such as mechano-motor capacity, the sensibility, emotional and intellectual sides, memory, impulses and the like. Testing apparatus should be available together with dynamometers, sphygmometers, chronoscopes, ergographs, pneumographs, cardiographs and recording apparatus.
Chart 19
PSYCHOELECTRIC AND REËDUCATIVE TREATMENT
| Phase | I. | PERSUASIVE TALK IN CONSULTING ROOM |
| Phase | II. | ISOLATION, REST IN BED, MILK DIET (a few days) |
| Phase | III. | FARADIZATION |
| Phase | IV. | REËDUCATION (Physiotherapy and Psychotherapy) |
| Phase | V. | AFTER-CARE |
Curing a psychoneuropath means victory in a moral battle!
After Roussy and Lhermitte
Chart 20
TREATMENT FOR INVETERATE HYSTERICS
| Phase | I. | “TORPILLAGE” AND INTENSIVE REËDUCATION |
| Phase | II. | FIXATION OF PROGRESS BY EXERCISES |
| Phase | III. | PROLONGED SPECIAL TRAINING |
After Clovis Vincent
Specialists for consultation should be available, including ophthalmologists, otologists, laryngologists and electrical specialists. The tests over, the patient should be examined as it were, in a free state and his habits and character noted. Hypnosis may be tried but it should not be prolonged. Psychic contagion is to be avoided especially in the case of subjects with epileptoid crises.
It would be well to establish for the cases regarded as susceptible to psychotherapy, reëducation centers like those for the re-adaptation of the tuberculous. The improved tuberculous are sent to health centers under the Ministry of the Interior for three months at the maximum and emerge much better able to support the exigencies of life. According to Duprat, there ought to be psychotherapy centers which should not in any sense recall asylums for the insane. Set in the country but not far from the city, managed by the psychological physicians and “médecins psychologues, plus éducateurs que médecins.” The personnel should consist of students going into psychiatry and of teachers whose pedagogical practice ought to enable them to second the efforts of the psychiatrists. In this way we might avoid the perpetuation of some of the psychopathies of war.
109. Possibly “putting forward the best foot” may yield a wrong impression of the proportion of what I have termed “miracle cures.” Other devices of a slower nature are mentioned throughout the book. Perhaps much depends on the temperament of the psychotherapeutist, as e.g., Laignel-Lavastine has remarked about the method of psychotherapy by means of conversation: that one might easily remain in a honeymoon state in military psychotherapy. When hundreds and thousands of functional nervous cases pass through one’s hands it is necessary to remember that behind the conversation there stands the imposing finger of material force.
Compare the work of Clovis Vincent, Yealland, Kaufmann.
110. On the other hand, Rows points out that shock is a term that does not explain at all adequately the great variety of mental illnesses occurring in the soldiers at the front. The term is popularly used for cases which recover quickly, but in the majority of cases there is a residuum after the shock has disappeared. Accordingly Rows’ work has dealt chiefly with underlying causes, conditions, and factors. Here we may consider
(a) The war strain before breakdown;
(b) Special causes of shock, such as death of comrades near by, near-by shell explosions and blowing up of trenches;
(c) Fatigue and exhaustion with lowered capacity of resistance.
The men themselves find that they have
(d) undergone a change of character, having become irascible, unable to sustain interest and attention; solitary and morose, and less capable of self-control. Anxiety, worry and a state of morbid expectancy set in. Everyday trifles are exaggerated.
But below these cases are still deeper ones, such as
(e) revival of horrible memories and terrifying dreams of war scenes, together with memories of incidents of past life.
(Rows attributes to Dejerine the idea that the cause of all cases of hysteria and neurasthenia must be sought in antecedent emotion.)
Emotion compels attention, and to such a degree in some cases that the memories and attendant fears and anxieties cannot be expelled. Hallucinations and delusions may then develop. The patient is largely incapable of reasoning about his status; he lacks “insight into the nature and mode of origin of his mental illness. This insight can be provided by explaining to him in plain language the mechanism of simple mental processes, by enabling him to understand that every incident is accompanied by its own special emotional state, and that this emotional state can be re-awakened by the revival of the incident in memory.” The patient and the physician now “begin to realize that they have some ground in common.… The mystery of the illness will be swept away and the physician will be able to … show him how he can educate himself to regain that which was lost.” “The patient can be induced to face the trouble.” “The excessive emotional tone will thus be stripped away and the patient will thus become able to appreciate the real value of the incident.” “The reëducation must vary with each case in order to overcome the difficulties connected with the specific cause which has been discovered.”
Rows’ work has been done at the Red Cross Hospital at Maghull, and several of the Maghull cases have been reported in Elliot Smith and T. H. Pear’s book on Shell-shock. A somewhat similar point of view has been maintained by Wm. Brown, who has suggested the neat term autognosis for psychoanalysis. W. A. Turner speaks of the Maghull point of view as one of modified psychoanalysis.
111. Or again a species of combination of the manière forte and the manière douce (operations, shall we say with William James, of the “tough-minded” and the “tender-minded” respectively?) may be used as in the formula
SYMPATHY + FIRMNESS (Mott).
112. More special devices, suggesting faintly the methods of animal training, may be used, as described in the following account of a new isolation and psychotherapeutic service established in May, 1915, at the Salpêtrière for soldiers with functional nervous diseases. The basic idea has long been held by Dejerine,—the avoidance of heterosuggestion by other patients, imitation, ill effects of visits from members of the family. The functional additions that come from near-by organic patients are among the disadvantages of the ordinary treatment. The isolation service of the neurological center is composed of 34 beds, arranged in two halls, with three extra rooms. Each bed is isolated. The régime in one of the rooms is more rigorous than in the other, and it is an advance for a patient to be moved from the first to the second room. The patient on wakening has no right to leave his box or communicate with his neighbors. He leaves only to be treated by hydrotherapy or electrotherapy. He takes his meals in isolation, receives no calls, and has no leave to go out. The physician sees the patient twice a day and carries on psychotherapy and motor reëducation, as well as special treatments.
Women nurses care for the patients. A system of control and of progressive rewards has been installed, being a sort of metric evaluation of the process of cure. As the cure proceeds the patient’s lot is progressively mitigated, or if he gets worse the regime is clamped down. Suppose a man a victim of paralysis of leg—the height to which he can lift his leg is measured in centimeters daily as well as the time during which he can hold the leg in air; or, the progress of an ankle, or of the forearm or the arm in a case of arm contracture, is measured. The grade obtained by our scholar in psychotherapy is inscribed upon a slate. Finally, walks, concerts, visits and eventually permission to go out into the town are granted.
113. Can Shell-shock neuroses be prevented, other than by stopping or modifying the war or by weeding out Shell-shock candidates as they volunteer or are drafted? Morton Prince offers points of some suggestive value. The very various proportions of neurosis observed in different units and arms of the service suggest that various degrees of preparedness may have played a part. Bernheim says suggestion is an idea accepted. Aside from a possible increase of simulation, much might depend on what idea administered really got accepted! Morton Prince’s plan is that the prevention must be based upon the education of the mind. This therapeutic education should be based, however, on a preliminary systematic study by a board of specialists in the psychoneuroses of (a) the mental attitude of minds generally toward shell fire, and (b) clinical varieties of this “shock” neurosis as it occurs in trench warfare, (c) its frequency and disabling incidence, and (d) the state of mind previous to the trauma of those suffering from it.
On the basis of the findings of such a study, first, the regimental surgeon through lectures and clinical demonstrations would be instructed systematically in the symptoms and pathology of the disease and the methods of psychotherapy for its prevention.
Second, soldiers, including officers, could then, in units of say 100, in turn be instructed in the nature of the disease through lectures by regimental surgeons. Shell-shock, they should be told, is a form of hysteria caused by mental factors. The work of the instruction should be done in France in the atmosphere of the war, wherein would be formed an attitude of healthy mental preparedness instead of an attitude of fear and mystery. Has mental hygiene this great scope? Is morale merely education?
114. What after all, is Morale? We hope to learn a little about it from this war for use hereafter, when we can say with the Florentine
BIBLIOGRAPHY
These references were collected in the main by Sergeant Norman Fenton both before and after his entering the army, in connection with preparations for the work of one of the Neuropsychiatric Training Schools (that at Boston), established by the Division of Neurology and Psychiatry of the Surgeon-General’s Office, U. S. Army. The work, through the year 1917, at least, is not a mere vernis de bibliographe, but is based on a first-hand search through journals available in the Boston Medical Library and the New York Academy of Medicine (to whose officers thanks are due for very special privileges accorded). After Sergeant Fenton’s departure for service in the war neurosis hospital, 117, American E. F., France, the work was finished by the writer in considerable haste by skimming the current indexes and gathering the more prominent titles for 1918 (some for 1919). The titles, be it noted, go beyond the scope of the case-material in the body of the book and cover also a variety of reconstructional, reëducational, clinical-neurological, neurosurgical, and other topics bearing indirectly on neuropsychiatry. These auxiliary subjects are by no means completely covered, but it was thought the titles might help other inquirers. Under the war conditions numerous errors have no doubt crept into the references, which errors we hope will not, by reason of the short space of time covered by the bibliography, prove particularly misleading. The auxiliary topics can be referred to in the Index under page-numbers after the word “Bib.”
E. E. S.