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427 THE LANCET. LONDON: SATURDAY, MARCH 15, 1919. The Rapid Cure of Hysterical Disabilities. ONE of the many peculiarities of hysteria is that the methods in vogue for its treatment are almost as diverse as its clinical manifestations. While the suggestionist extols his technique as the method par excellence for hysterical cures, the psycho- analyst regards suggestion as a positive hindrance in the way of therapeutic success. There is also the hypnotist, who claims 90 per cent. cures, or over, by his particular ceremonial, and the faradic- battery expert, who gets 100 per cent. cures; there is the advocate of simple persuasion and re-educa- tion combined with manipulation, who, similarly, is disappointed if complete recovery does not occur at a single seance, measured often only in minutes. Meanwhile, it may be supposed, the psycho-analyst, accustomed to delving in the unconscious for months, not to say years, wonders what sort of "cures" these may be, as the man in the street may wonder at the apparent uselessness of all methods alike, when he reads in his morning paper that the hysterically mute soldier suddenly recovers, after two years’ resistance to all thera- peutic endeavour, because someone stands on his favourite corn in a crowded tramcar. It would be easy to quote chapter and verse for the conflicting statements of these exponents of rival procedures who thus push their wares in the medical market-place; but the dissimilarities are more apparent than real. The essence of cures by hypnotism, electricity, laying on of hands, and what not, is the influencing of the patient’s mind by the mind of another, call it what we will. Even in regard to psycho-analysis it is by no means clear that suggestion can be put out of court as a therapeutic factor; for that matter there is some- thing almost painful in the determined effort of FERENCzi and others to reduce suggestion to a sexual phenomenon and to delete the word from the therapeutic vocabulary. No doubt the trouble lies in the variety of meanings attached to the word " cure." The suggeationist holds that dis- appearance of symptoms constitutes a cure, in hysteria above all diseases, since somehow the fact of this disappearance reacts, or seems to react, on the patient’s mind in a salutary way, so that much more is thereby effected than mere symptomato- logical improvement; the soldier who recently recovered his speech at a cinema and who was heard to utter a heart-felt " Thank God, I can speak! " has surely undergone a more radical change than is implied in return of innervation in an isolated neural mechanism. If we bear in mind the fact that the vast majority of the war cases of hysteria are comparatively simple in type, relatively short in duration, not obscure in causation, and uncomplicated by elusive- ness of unconscious motive, we can readily under- stand both the ease with which cases clear up in expert hands and the claim the operators make for permanence in results. We see no special reason to doubt the likelihood of the cures persisting, but the majority of those who have had much to do with civil cases in private and hospital practice will, we believe, be inclined to hold that not all cases can thus be summarily treated, or, at least, that the disappearance of a symptom or symptoms under the force majeure of persuasion does not necessarily entail a favourable modification of the underlying psychical basis of the affection. There are certain important varieties of the psycho- neurosis to which treatment by persuasion re- education, and manipulation does not appear to be specially applicable. Cases’of hysterical fits, hysterical fugues, and alternating personality are among the more difficult and complex manifesta- tions of the disease, and often call for the most persistent and painstaking treatment. To get at the underlying, the hidden, springs of the affection, to unmask the unconscious trends and motives perpetuating the clinical phenomena, to solve the apparently insoluble contradictions between the patient’s overtly expressed desire to get better and his unconscious desire not to, is surely to reach a more permanent basis of cure. It is, perhaps, scarcely an exaggeration to say that hysterical cases, therapeutically considered, are either very easy or very difficult. When all is said, the chronic hysterical patient may resist every therapeutic endeavour, and, nursing infirmity to the end. defeat the physician by very feebleness. One of the interesting questions aroused by a consideration of rapid cures in cases of some little duration is, How comes it that the nervous mechanisms are, as it were, ready to resume duty at a moment’s notice-ready after, it may be, some years of disuse ? The matter must not, of course, be taken too literally; experience shows there is commonly a period of awkwardness of use-e.g., in the case of hysterical paraplegia the patient usually requires an appreciable time to take up his bed and walk. But in other cases, say of aphonia, apparently no such interval of transi- tion is necessary. In most cases there can be no doubt that unconscious or subconscious innervation keeps the mechanisms in working order; the hysterical paraplegic will draw up his legs in sleep. For other cases, possibly, no such explanation is quite feasible, though at least some hysterical aphonics and mutes are known to have muttered in their dreams. As permanently un- conscious nerve mechanisms are kept in tone by proprioceptive stimuli, so may conscious mechanisms, deprived temporarily of the conscious element, be played on by automatic or involuntary processes arising from centres normally in abey- ance. Be all this as it may, we must admit that in chronic cases active trophic changes may take place, from disuse mainly, handicapping full and

The Rapid Cure of Hysterical Disabilities

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THE LANCET.

LONDON: SATURDAY, MARCH 15, 1919.

The Rapid Cure of HystericalDisabilities.

ONE of the many peculiarities of hysteria is thatthe methods in vogue for its treatment are almostas diverse as its clinical manifestations. While the

suggestionist extols his technique as the methodpar excellence for hysterical cures, the psycho-analyst regards suggestion as a positive hindrancein the way of therapeutic success. There is alsothe hypnotist, who claims 90 per cent. cures, orover, by his particular ceremonial, and the faradic-battery expert, who gets 100 per cent. cures; thereis the advocate of simple persuasion and re-educa-tion combined with manipulation, who, similarly,is disappointed if complete recovery does not occurat a single seance, measured often only in minutes.Meanwhile, it may be supposed, the psycho-analyst,accustomed to delving in the unconscious for

months, not to say years, wonders what sort of"cures" these may be, as the man in the streetmay wonder at the apparent uselessness of allmethods alike, when he reads in his morning paperthat the hysterically mute soldier suddenlyrecovers, after two years’ resistance to all thera-

peutic endeavour, because someone stands on hisfavourite corn in a crowded tramcar.

It would be easy to quote chapter and verse forthe conflicting statements of these exponents ofrival procedures who thus push their wares in themedical market-place; but the dissimilarities aremore apparent than real. The essence of cures byhypnotism, electricity, laying on of hands, andwhat not, is the influencing of the patient’s mindby the mind of another, call it what we will. Evenin regard to psycho-analysis it is by no means clearthat suggestion can be put out of court as a

therapeutic factor; for that matter there is some-thing almost painful in the determined effort ofFERENCzi and others to reduce suggestion to asexual phenomenon and to delete the word fromthe therapeutic vocabulary. No doubt the troublelies in the variety of meanings attached to theword " cure." The suggeationist holds that dis-

appearance of symptoms constitutes a cure, in

hysteria above all diseases, since somehow the factof this disappearance reacts, or seems to react, onthe patient’s mind in a salutary way, so that muchmore is thereby effected than mere symptomato-logical improvement; the soldier who recentlyrecovered his speech at a cinema and whowas heard to utter a heart-felt " Thank God,I can speak!

" has surely undergone a more

radical change than is implied in return ofinnervation in an isolated neural mechanism.If we bear in mind the fact that the vast majority

of the war cases of hysteria are comparativelysimple in type, relatively short in duration, notobscure in causation, and uncomplicated by elusive-ness of unconscious motive, we can readily under-stand both the ease with which cases clear up in

expert hands and the claim the operators make forpermanence in results. We see no special reasonto doubt the likelihood of the cures persisting, butthe majority of those who have had much to dowith civil cases in private and hospital practicewill, we believe, be inclined to hold that not allcases can thus be summarily treated, or, at least,that the disappearance of a symptom or symptomsunder the force majeure of persuasion does not

necessarily entail a favourable modification of theunderlying psychical basis of the affection. Thereare certain important varieties of the psycho-neurosis to which treatment by persuasion re-

education, and manipulation does not appear tobe specially applicable. Cases’of hysterical fits,hysterical fugues, and alternating personality areamong the more difficult and complex manifesta-tions of the disease, and often call for the mostpersistent and painstaking treatment. To get atthe underlying, the hidden, springs of the affection,to unmask the unconscious trends and motives

perpetuating the clinical phenomena, to solve theapparently insoluble contradictions between the

patient’s overtly expressed desire to get better andhis unconscious desire not to, is surely to reach amore permanent basis of cure. It is, perhaps,scarcely an exaggeration to say that hystericalcases, therapeutically considered, are either veryeasy or very difficult. When all is said, the chronichysterical patient may resist every therapeuticendeavour, and, nursing infirmity to the end.defeat the physician by very feebleness.One of the interesting questions aroused by a

consideration of rapid cures in cases of some littleduration is, How comes it that the nervous

mechanisms are, as it were, ready to resume dutyat a moment’s notice-ready after, it may be, someyears of disuse ? The matter must not, of course,be taken too literally; experience shows there iscommonly a period of awkwardness of use-e.g., inthe case of hysterical paraplegia the patientusually requires an appreciable time to takeup his bed and walk. But in other cases, sayof aphonia, apparently no such interval of transi-tion is necessary. In most cases there can

be no doubt that unconscious or subconsciousinnervation keeps the mechanisms in workingorder; the hysterical paraplegic will draw up hislegs in sleep. For other cases, possibly, no suchexplanation is quite feasible, though at least somehysterical aphonics and mutes are known to havemuttered in their dreams. As permanently un-conscious nerve mechanisms are kept in tone

by proprioceptive stimuli, so may conscious

mechanisms, deprived temporarily of the consciouselement, be played on by automatic or involuntaryprocesses arising from centres normally in abey-ance. Be all this as it may, we must admit thatin chronic cases active trophic changes may takeplace, from disuse mainly, handicapping full and

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428

rapid restoration and necessitating physical as

well as psychical treatment. Comparatively littleattention has been directed to the actual physio-logical nature of the production of hysterical sym-ptoms, although the late Dr. CHARLTON BASTIAN andthe late Dr. T. D. SAVILL devoted much thoughtto this topic, and their conclusions are worthy ofconsideration. The disadvantage of psychologicaltheories of hysteria is that the physiologicalanomalies are apt to be ignored owing to pre-

occupation with the psychical anomalies. In

BABINSKI’S minute examination of the phenomenaof so-called reflex paralysis we have a useful illus-tration and precedent for research, notwithstandingthat, or because, reflex paralysis may really be aform of hysteria.

Scientific Education and its Cost.THE minutes of the proceedings of the deputa-

tion of representatives of the universities of the United Kingdom received on Nov. 23rd. 1918, by the l

President of the Board of Education and the Chancellor of the Exchequer, Mr. H. A. L. FISHER 1

and Mr. BONAR LAW, have been printed by the Universities Bureau of the British Empire, in order, no doubt, to preserve a fuller record of the 1

speeches than is to be found in the newspapers. The names of those who were present to representthe universities, and other institutions doing work i

of university standard, show that the occasion ofthe deputation was not regarded lightly by any ofthe interested parties, and this was what might havebeen expected, seeing that the subject brought before the Chancellor of the Exchequer and the President ]of the Board of Education -namely, the financial needs of higher education-is one that at no time in our national history has deserved closer and

more anxious attention. We are living in a period full of opportunity for

new progress and for development upon original lines in every direction, and we, as medical men, need not be ashamed to continue to remind ourselves of this obvious fact, so long as we see that there is a lack of unity and of promptitude in grasping the oppor-tunity. It should not be necessary to point out thatit is essential to recognise the facts and circum-stances of the situation at the outset; if failure occurs in obtaining for medicine its just claims now, i

fresh reconstruction and reorganisation in the nearfuture cannot be avoided; but time slips by and much yet wants discussion by the medical profes- sion. In general and in brief the deputation, to usea popular expression, was "out for money." Its

object was to secure State assistance in orderto obtain in our country’s interest the best brainsand the best apparatus for instructional purposes,and in order to bring in among the learners the bestof the young brains available. The coming Ministry of Health and the part which the medical profession must necessarily play in the carrying out of a healthpolicy make the question of medical education ofalmost paramount importance. The fact that a well-educated and enlightened medical profession is a national need should not want to be empha-sised at this juncture, but though medical men

may be tired of hearing it said, public repetition isnecessary. We must go on affirming these thingsuntil there is no doubt that a Government

responsible to the nation for the rebuilding ofits forces in a far-reaching and enlightenedmanner is awake- to what lies before it. The

development of sciences growing in number andextent every year, each adding to the need fora larger and increasingly skilled staff of scientificworkers, has to be provided for. Each new discoveryadds to the expense of teaching medicine andmakes it more dependent upon outside financialaid. Each year medical knowledge grows andbecomes more expensive to impart, and medicaleducation will lag behind unless adequatelyendowed.But it is not to be expected that such aid as the

State may afford to scientific education will fulfilall requirements, and wealthy and patriotic citizenswho desire to see the future progress of their

country assured among the nations of the worldhave now an unequalled opportunity for personalgenerosity. The.facts in respect to medical educa-tion display the debt of the public under this head-ing, and they should be brought forward regularlyand plainly. If the facts were understood webelieve money would be forthcoming at once bothfrom State and private sources. First, medicalmen pay a large sum for their professional educa-tion, which lasts at least six years, a sum which, aswe have seen, will in the near future inevitablybe larger; it is now about ;BlOOO. Secondly, thiseducation is conducted partly by lecturers on

special subjects, mainly ancillary to medicine, andpartly by medical men in practice, who are membersof the honorary staffs of the hospitals attached to theeducational centres. The first class of teachers is

very inadequately paid, the second class is at any rateto-day hardly paid at all, save indirectly, and thoughwe admit that this indirect payment is in somecases quite large, in most it is nothing of the sort.

Thirdly, medical men are not drawn from a wealthyclass of the community ; despite all the brave talkabout the splendour of our profession, only thosewho desire to work hard care to start on the medicallife. The promising list of entrances, however,among the students shows that the value of medical

cooperation in the great war has caused medicineto appear as our most potent influence in the resist-ance to national disasters. Fourthly, medical educa-tion is regulated and controlled by an importantstatutory body, but the expenses of maintainingthe Medical Register and standardising the exa-minational tests are borne entirely by the medicalprofession. Yet the Medical Acts, under whichthe General Medical Council was called into being,were devised and are worked for the protection ofthe public and not for the aggrandisement of medi-cine. These are the things which we should likeour readers to keep steadily before such publicmen and women as they come into contact with;they all converge to one point-that the publicowes a debt to medical education. Those in chargeof the Bill for the erection of the Ministry of

Health ought to find the public ready to pay thisdebt.