Early mental disease.

Date:
1912
Catalogue details

Licence: In copyright

Credit: Early mental disease. Source: Wellcome Collection.

Provider: This material has been provided by King’s College London. The original may be consulted at King’s College London.

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    The patient with a well-marked hysterical disability is usually placid ; he has none of the bodily manifestations of anxiety such as cardiac discomfort, indigestion, or insomnia. The reason is that as a rule the disability has taken him out of some struggle for which he jfiad not felt equal. You cannot expect a man to go into a coal-mine if he has become paraplegic ; you cannot expect a woman to continue the struggle of earning her living by sewing if she has lost the use of an arm. Someone or some agency will have to take care of such a person. It must be clearly understood that the patient has no inkhng of the truth of what has happened. If he has, he is not an hysteric, but a malingerer. To such a patient it seems that for excellent reasons he has lost the power of his limbs ; he received a blow on the back, his legs thereafter felt weak. He knows that the power to move the legs resides in the spine, and he has seen mates, who had their spines injured, lose the use of their legs for ever. The weakness in his own legs has gradually increased till he cannot use them at all. His spine is certainly damaged. Many doctors have been dubious, but there were usually enough of them uncertain to make him feel quite certain that the damage was severe ; and by the time he is badly paralysed his mind is quite made up about it. With all the modern apparatus for the relief of industrial catastrophe, he is at first at least free from financial anxiety. He is certainly in no hurry to resume a disagreeable occupation, and therefore he is quite placid about the whole affair. There is a whole- hearted belief that he truly cannot move his legs, and this belief is the immediate cause of the disability; it must be a first aim of treatment to alter this belief, and when this has been done the patient will lose his disability. How is this to be done ? The history of the case must be taken with the same care as was advised in the sections on the anxiety states. When this has been done periods of stress will be found which ultimately culminated in something which gave rise to the disabihty. A workman unhappy at home, encounters a slight strain to his back and develops paraplegia. If the history of the accident merely is gone into the domestic factor will certainly be missed. It will not occur to the patient that it can possibly have anything to do with the illness, and yet it may be a factor of importance in keeping up the disabihty even greater than that of the Work- men's Compensation Act itself. The paralysis gets the man into hospital away from the hated environ- ment, and he may be in no hurry to get home. The history then will take several interviews, and at the end when the doctor knows his patient and has carefully examined him, he will probably be able to make his patient believe that the condition exists because it is not wholly wished that it should disappear. If this has been done gently and with the patient's full consent the disabihty will usually vanish. This is probably the best method of dealing with a gross hysterical disability. It makes the patient see that the illness depended on himself, it gives the opportunity of discussing and therefore of readjusting a series of important stresses and strains, which were imdermining the patient's resistance to the onset of nervous symptoms. If other methods such as those of electricity or hypnotism are employed, the patient learns nothing, and he will always beheve that his mental attitude had nothing to do with either the illness or its recovery; that it was someone else's business to cure him, and that someone else actually did so. On relapse the results may not repeat them- selves. Moreover, if as is here put forward, the hysterical state is only a camouflaged anxiety state, the patient should on the removal of the hysterical symptoms pass into the anxiety state which itself is at the same time being treated. Other hysterical symptoms of a bodily natiu-e, and some mental ones, are usually amenable to a therapy of this kind—i.e., persuasion after the history is known ; but others are not open to it as the sjonptoms involve loss of memory; but the amnesias of hysteria are no more essentially real than is hysterical paraplegia. In both conditions the patient carmot perform the function in question, and in both he can be induced to do so. Something in each case is inhibiting the function ; in amnesia there is something which is too painful to be remembered. If the rest of the history is obtained the doctor with experience may be able to make a shrewd guess at the cause of the amnesia, but in amnesic patients some process which approaches hypnotism gives fuUer results. Patients with amnesic periods are easy to hypnotise ; they have already been practising the same thing on themselves. If they are asked to lie on a sofa relaxed in mind and body and told to become drowsy, they will usually become sufficiently hypnotised for the purpose in hand. They may then be led through the amnesic period starting from the last thing they remember. The recovery of the memory will reveal some constellation of ideas which they are not facing. They are told that they will now remember all about it on waking ; the ideas can then be faced and some attempt made to deal with them. The other mental symptoms and the bodily fits all involve and are dependent on amnesia, and are aU amenable to treatment of this sort. The rest of the treatment of hysterical states is to be conducted on lines similar to those indicated for the treatment of anxiety states.