40 TH &TESO ERSS

THECONVERSION NEUROSIS.*

BY

ERNEST SNOWDEN, M.B. LOND.,LECTURER ON CLINICAL PSYCHOLOGY, WEST LONDON

POST-GRADUATE COLLEGE.

HUMANITY is divided into two parts: Thosewho are controlled, unemotional, and pass throughthe difficult times of their lives without very muchobvious evidence of the disturbance that they,doubtless, must feel. Such people tend to developneurasthenia. The other part is composed of thosewho readily display their feelings, who are liableto emotional attacks, and who respond obviouslyto anything which disturbs their minds. Suchpeople are called hysterical and they tend to developthe conversion neurosis. A broad distinction likethis must naturally contain many exceptions, butit is a useful division from the point of view of thepractical treatment of the patient.The first of these is, generally speaking, composed

of the more intelligent and better educated classes.It was in this manner that the strain of the fightingduring the war usually showed itself in the officerclass. The second part includes the less well-educated or well-trained section of the community,and was the manner in which the strain of thefighting was shown among the rank and file. Thisdivision again is quite a loose one, but is usefulin practice.

It has been already pointed out that the develop-ment of mankind from the mental as well as fromthe physical point of view has followed that ofthe other animals, that we are born with certaininstincts, and that the three most important are:(1) the instinct of self-preservation, (2) the instinctof reproduction, and (3) the instinct of protectingour own property, which we may call the instinctof protection. It was recognised that these instinctswere aroused by: (1) the presence in the environ-ment of something dangerous to ourselves, (2) thepresence of a suitable mate, and (3) the presenceof something dangerous to our property.These instinctive processes are associated with

certain emotibnal states, changes which occur inthe physical state of the human body whenever theinstincts are aroused. These emotional states area preparation in the human body for the physicalresponse to that which stimulated the instinct.We observe these physical changes in ourselves,and the change that is associated (1) with the instinctof self-preservation we call panic or fear, (2) withthe reproductive instinct we call sex, and (3) withthe protective instinct we ca11 rage or anger.The infant is born with these three instinctive

processes which, if they are allowed full freedomof expression, would make it impossible for him tolive with his fellow men when his physical strengthcomes to be developed. He would be unable to

* A Lecture delivered at the West London Post-GraduateCollege on July 22nd, 1926.

fit into the civilisation, which has very slowlydeveloped through long ages of communal life,or into the particular class of life into which heis born, so that control of these instincts is forcedupon him throughout his whole life almost fromthe moment of his birth until he ceases to exist.He is taught control in the nursery by finding theattitude of those around him to be opposed tothe direct manifestation of his instincts and thiscontrolling influence confronts him at every stagethroughout his whole life. It is suggested that thiscontrolling force corresponds with what iis called" public opinion," and that this is the means bywhich society maintains its existence.

It is clear that this repression which is learnt solaboriously is not complete, that it is no morethan a control of the instincts, and that they areonly held in check by the social ideal. Thus abrave man under a stimulus sufficiently sudden,unexpected, or violent will run with the cowardin blind panic, or a civilised man under sufficientprovocation will "see red " and destroy an opponentin rage. This demonstrates that our civilisationis an artificial state, that it exists because of thecontrol exerted over the manifestation of theinstinctive processes by the social ideal, and, mostimportant of all, that there must be a constant con-flict occurring in the mind between the primitiveimpulse on the one hand and the civilisation whichholds it in check on the other. This conflict isuniversal and constant, and only those of us whoare strong enough physically or who can avoidthe more profound mental shocks can remainhealthy-minded.

Those, however, who are exposed to a very violentor to a prolonged stimulus to one or other of theirprimitive instincts, or who suffer from some dis-turbing illness, or who are exposed to both condi-tions simultaneously, develop symptoms which wehave come to recognise as the result of this mentalstrain.

It is the purpose of this lecture to consider thesecond class of patient, those who respond to thestrain just mentioned by the development of aphysical symptom without any appropriate physio-logical or pathological change to accompany it,a disturbance of function, a conversion neurosis.

THE CONVERSION NEUROSIS IN TIME OF WAR.The conversion neurosis is so called from the

fact that the psychological disturbance is convertedinto a bodily symptom which is usually a disturb-ance of function in some part of the body. It mustbe remembered that the conscious mind may beperfectly willing to keep up the fight against theprimitive impulse, as is shown, for example, in thecase of the soldier in the trenches. He is goingthrough a conflict between his civilised wish to bebrave and his primitive wish to run away. Theprimitive wish is repressed or subconscious, andthe aim of the subconscious mind is to remove himfrom the conditions which give rise to this conflict.The conscious mind refuses permission for the

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THE CONVERSION NEUROSIS. 41

subconscious wish to be gratified. This would bethe condition of every soldier under the strain ofwarfare.

It now comes to a contest to decide which is:strongest, the primitive wish or the civilised wish,and there are certain auxiliaries to assist each side.The conscious mind is assisted by discipline, by the-example of others as well as by the condition ofearly training, and also by the knowledge that ifhe does run away he will be shot. The subconsciousmind is assisted in its efforts to produce his removalfrom the conflict by lowered general health, by anyextraordinary strain, by the element of suddenness,.and by the example of others in a general panic.

It becomes obvious that the conscious mind mustbe deceived, that a symptom must be imposed uponthe body which the conscious mind will accept. This;symptom must be disabling-that is, it must be ofsuch a nature that not only does it call attentionto the conflict that is going on, but it must be'sufficient to remove the individual from the,circumstances of the conflict as soon as possible.

These conditions apply to the soldier undergoingthe strain of war, where the need for the escapefrom danger is urgent, but they also apply to everycase of conversion neurosis. This can be shown inthe form of a simple diagram:

Diagram illustrating Production of a ConversionNeurosis.

CONVERSION SYMPTOM(Replacing Physicol Outlet)

'CONSCIOUSMIND

CONCEPTIONAL ; : PHYSICALINLET /. -, OUTLET

EMOTIONAL (Obstructed)CONTENT

( Increased)Every thought process consists of three parts:

.a conceptual inlet, something we observe-" I see

.a lion come in at the window "; an emotionalcontent, a sensation in the body-" I feel afraid ";.a physical outlet, some action that we take-" I runout of the door." The soldier under shell-fire,observes the effect of the shells, he feels afraid, heruns away. Now, if he can run away there is no,conflict, the whole process is complete and themental strain does not occur. But he cannot run.away; if he runs away he will be shot, so that theemotional content of the mind becomes increasedowing to the fact that the physical outlet is denied.He will now develop a symptom which will servethe same purpose as running away would have done.and in this way satisfy his subconscious wish.

It must be remembered that the whole of theprocess occurs at a level below consciousness, andthat the soldier is completely unaware of it. Allthat he observes is that without warning he loses-the function of some part of his body and, therefore,

to him the symptom is quite genuine. He does notwant it and is consciously almost as distressed atits appearance as if it were a genuine physicalsymptom, but his subconscious mind wishes toretain it, and it is for this reason that in every caseof conversion neurosis two diagnostic signs arealways evident: first, the individual resists theremoval of the symptom so long as the conditionswhich gave rise to it are still in existence, andsecond the individual is complacent-that is, thedisablement does not make him unhappy in thesame way that a real physical disablement willdo. These diagnostic signs will be referred to againpresently.As a rule the decision as to what the symptom

shall be is the result of chance. It is suggestedto the individual by some outside circumstance,some chance suggestion. He has a sore throat,speech is difficult, and he develops aphonia ormutism. He has an attack of gastritis and developsa persistent functional vomiting. In the case ofa soldier a sandbag falls upon and bruises hisshoulder and he loses the use of his arm.

IN PEACE TIME.We have taken as our example a very simple

type of condition where the cause of the conflictis obvious and where the motive for the productionof the symptom is perfectly easy to understand.When we come to deal with the cases that arisein peace time and in civil life, it usually occurs thatneither the motive nor the cause for the symptomcan be recognised so easily. This failure to recognisethe symptom is naturally due to the greater com-plexity of the life of the ordinary civilian, orperhaps, to the greater trouble that we have inunderstanding the difficulties that arise in the livesof other people, but the same principle that we havejust studied applies to every case of this nature.What I have here called the subconscious mind

for the purpose of simplifying the explanation, isintended to convey the idea of all those mentalprocesses which occur outside the purely consciouslevel, and for our present purpose it is sufficientif we recognise that the part of the subconsciousmind with which we are dealing is simple, direct,and child-like.The child sees something it wants, feels the wish

to possess it, and attempts to take the thing.Let us say that the child is prevented from doingthis, it will show disappointment by anger or tears. Ifthis principle is applied to the grown-up mind youget the same wish and the same impulse as you didin the child, but the activity is inhibited by theconscious mind of the grown-up. In the grown-upmind control has been so developed that all ideaof the wish may have been prevented from reachingconsciousness, but the discomfort and dissatisfactionremain to be expressed by consciousness although thechildish subconscious wish originates the process.

If now you recognise the enormous number ofwishes in the child's mind and the constant necessityfor checking in the child the actions to which these

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THE CONVERSION NEUROSIS.

wishes give rise, you will appreciate how constantlythe conflict that we are considering is present inthe subconscious mind of the adult. This simpleexample will give us a guide to the cause of a mentaldisturbance in any patient and should be theaspect from which we view our patient when weare confronted with a case of conversion neurosis.

DIAGNOSIS.The diagnosis of a conversion neurosis does not,

as a rule, offer very great difficulties. Somephysical disability is simulated which is more or lesswithin the patient's knowledge, and the symptomsare only as complete as the patient's knowledge ofdisease allows. Thus, an an2esthesia will be of theglove or stocking type because the patient doesnot know the distribution of the cutaneolus nerves;a paralysis will be flaccid because the patient wouldnot recognise spasticity as a disablement; thehysterical aphonic makes no attempt to use hisvocal cords, and the mute makes no attempt atspeech whatever.While we are dealing with these simulations of

disturbances in the nervous system, it would be aswell to consider the one condition with which theymay be confused. The patient with disseminatedsclerosis is often mentally disturbed as a result ofthe direct interferences by the disease process withthe higher centres of the nervous system, and thesymptoms of the disease occurring in the spinalcord are in the early stages of the disease vagueand obscure, while they are sometimes associatedwith definite hysterical phenomena. There is,however, one diagnostic sign which will alwaysdecide the question, and it is this: An extensorresponse of the plantar reflex, Babinski's sign, isnever present in a case of conversion neurosis uncom-plicated by actual disease of the nervous system.

it has just been mentioned that the symptom inthe case of a conversion neurosis can be of anynature that is compatible with the absence ofphysical signs of the cause, but this statementrequires this modification, that a conversionsymptom may be super-imposed upon' a definitedefect. The symptom of the conversion neurosisis suggested to the patient by some chance causeor it may be by some simple illness that is alreadypresent as occurred in the example just mentionedof the case of gastritis that developed functionalvomiting, and the best guide to such a conditionis the effect of treatment.

In any case, if the symptom persists after allsign of disease has disappeared, it should besuspected that you are dealing with a case ofconversion neurosis and that some disturbance isoccurring in the mind of the patient which must beremoved before the patient can be cured.The attitude of the physician is often at fault with

regard to these patients. There is a tendency for theconversion symptom to be looked upon in some wayas the patient's own fault, and when the conditionhas been diagnosed as functional for the physicianto be satisfied with the diagnosis and to look upon

the patient as rather stupid and troublesome andas not requiring further treatment. In actual factthere could be no greater error. These patientsare very seriously disabled, they suffer very greatlyand they can be cured, usually in a very simplemanner, and it is the object of this lecture toproduce towards the conversion neurosis theattitude that far from being irritating and obscurethey are, in fact, extremely interesting and simpleto treat. ILLUSTRATIVE CASES. *

The description of a few cases will illustrate thiscondition.CASE 1.-A man, aged 37, who had been called up for

the army, was in training in England preparatory toproceeding abroad. During a practice attack on a trenchby night he reached the trench first and leapt down intoit, and the man immediately behind him jumped in ontop of him, landing on the back of the patient and causinga concussion of the spine. He became paralysed in bothlegs. This accident occurred in 1916, and in 1922 he wasstill suffering from paraplegia and his case came underreview for his transfer to the Star and Garter Hospital fortotally disabled patients. During the medical examinationthe doctor noticed that the patient's legs were not wastedand he was sent to the Ministry of Pensions clinic forobservation. It was found that his paraplegia was entirelyfunctional.The case at first sight suggested that the man had been

terrified of going abroad and that his subconscious mindhad chosen this as a method of preventing him fromdoing so, but a further examination disclosed the followingfacts: The patient and his wife were simple working peoplesome years before the war. At one time, when he wasunemployed, his wife maintained the household by takingin washing. She was intelligent and industrious and wassoon able to employ several of her neighbours. They thenstarted a small laundry with a number of girls to do thework, and these two people at the time the war startedwere in a position to take things easily and to look forwardto a comfortable old age.The effect of the war was disastrous to them. They

were unable to procure soap and other materials, theirassistants went off to make munitions, and the last andworst blow fell when the patient was called up for the,army. His wife wrote him pathetic letters, and he wasin this condition of mental distress when the accidenthappened which deprived him of the use of his legs. Themechanism presumably was that he recognised theiraffairs were in a very difficult state and that he was beingtaken away from his wife, he felt intense fear for theirfuture and grief for their loss, and he wanted to get backhome.When this was explained to the patient he eagerly

accepted the possibility of recovery. It was like a reprieveoffered to a man who had been condemned to a life'ssentence. He began to move his legs at the first interview,and at the second interview he was standing and takinga few steps holding on to a bar. At the third visit he waswalking and such was his eagerness that he made his feetso sore and swollen with the unusual exercise that he delayedhis recovery for a fortnight while he went back to bed forhis feet to recover. The case was easily cured because thecause for the patient's disturbance was ended and thesymptom was no longer required.

CASE 2.-An unmarried woman, aged 23, of the superiorartisan class ceased to menstruate after a visit to Londonof her sailor lover. Her letter announcing this fact to himcrossed in the post a letter from him in which he brokeoff the engagement. She was in despair and took a largequantity of oxalic acid, and she was admitted to St.Bartholomew's Hospital, where she was treated andrecovered from the poisoning. Following this her menstrua-tion became regular again, but a few days later she lostthe use of her left arm-a quite obvious functional para-

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THE ONVRSIO NEROSI.

lysis. There were some scars on the left fore-arm wherean old cellulitis had been opened, and it was clear thather left arm had always been weaker than her right arm,and was, in consequence, chosen for the conversionsymptom. It was demonstrated to her that her arm wasperfectly sound, and the paralysis disappeared as suddenlyas it had come. Two days later she started to vomit,ty-pical functional vomiting, the food never being allowedto remain in the stomach, but being regurgitated as soonas it was swallowed. Under observation it was recognisedthat this was again a conversion symptom, replacing theparalysis of the arm, but it was so persistent that in fourweeks the patient had lost two stone in weight, and whatis rather unusual in such cases, she complained very muchof hunger.

It seemed obvious that the cause must be the fact thatshe had been jilted and the shame of her condition, but shequite sincerely affirmed that she did not care any longerfor the man and that she was quite happy to have got ridof him. Eventually it came to light that her father, ofwhom she was very fond, had said that she must neverenter his house again and had disowned her. He hlad nevervisited her in hospital. The father explained that he hadtaken this action in order to protect her from anything ofthe same kind happening to her again, and the day thatthey were reconciled the vomiting ceased and she made acomplete and rapid recovery.CASE 3.-A man of 47, a head clerk, unmarried, and living

with his people. He devoted his leisure entirely to playingchess. He complained of an inability to use his right handfor writing. Any attempt to write or even to sign his namecaused a spasm of the muscles which jerked his hand offthe paper. He was able to do a certain amount of workby dictation, but he was faced with the prospect of havingto give up his employment.Upon investigation it was found that he was not suited

to the work of controlling others. There were severalwomen clerks in the office whose complaints disturbed himconstantly. They were inclined to take advantage of hislack of knowledge of the world. One incident that occurredwas the loss to the firm of ;500 as the result of a mistakeby one of the clerks, and the patient was conscientiousenough to be seriously disturbed by the occurrence,although he had not been in a position to prevent it inany way.

These circumstances were apparently sufficient toproduce a subconscious wish to get away from his work,although this was so contrary to his common sense. Inthis case the symptom was recent, and was, therefore,easily removed. The mechanism of the mind was explainedto him and he was advised to explain his difficulties to hisemployer. At this interview he was assured that his workwas in every way satisfactory. The conditions of his workwere altered to make them less irksome, and the symptomsdisappeared within a few days.The treatment of these cases is extremely simple.

It is naturally easier to remove the symptoms whenthey are of recent occurrence, and the difficulty ofdealing with them when they are of long standingis made greater by the fact that the patient hasorganised his life around the symptom and hasusually given up all hope of recovery, so that hemust be taught to make the effort to get well.This sometimes makes a long re-education processnecessary. In many of the long-standing casesthe original cause has disappeared, while the habitof illness remains, and it is in such cases that theso-called "miracle cures" occur. The removalof the symptom may be brought about by thelaying on of hands, a pilgrimage to Lourdes, orthrough the attentions of some kind of faith healer.Any method will suffice to bring about this resultthat conveys the right suggestion to the patient.

It is more effective if the element of mystery isintroduced into the method, or if the correct stateof mind for cure is aroused by religious fervour orby some similar effect. Such patients can beactually cured because the symptom is no longerrequired, owing to the disappearance of the originalmotive which called the symptom into being.

It should be remembered that the patient doesnot give in, in the first place, without a struggle,that before the symptom is produced there hasgone on in the mind a very definite conflict and astruggle against ill-health which is greater or lessaccording to the training and mental strength ofthe patient in whom the conversion neurosis occurs.Once this step is taken and the patient has developedthe symptom his position is no longer the same.A breach has been made in his defences. The samepath can be travelled again and a subsequent mentalconflict or disturbance is likely to be expressedmuch more readily than the first one and alongthe old path, this path being used again and again,more and more readily as the habit of using it grows,until finally the patient responds to the simplestdifficulties by the production of the symptom.

This is illustrated by the case of a girl of 21, who learntto fall asleep in any circumstances if a difficulty arosein her life. She was in domestic service, and if she wasscolded for any fault she was quite likely to go to sleepstanding up and leaning against the table. Going to newsituations always produced a strain and she usually sleptheavily at intervals during the first day in a new placein all kinds of curious circumstances. Occasionally, thissymptom gave rise to amusing incidents. Her mistressfor the time being was invariably alarmed at this occurrenceand sent for the local doctor who always used every artto remove the symptom, measures which rather tendedto keep the patient more definitely asleep. She was onrone occasion sent into hospital by a doctor who diagnosedencephalitis lethargica.

If the cause of the disturbance of mind persiststhe removal of the symptom is' as difficult as inthe other type of case it is easy. The symptom isof value to the patient; it satisfies the subconsciousneed of the patient, and he will submit to almostany torture to retain it.

It is of very little use to demonstrate thefunctional nature of the condition to the patient,because he will refuse to understand you. Should'his life be made so absolutely unendurable that theretention of the symptom is associated with reallysevere pain, the original symptom will be givenup and a new symptom will arise to take its place,usually more difficult to explain and very muchmore difficult to remove than the first. Forexample, a series of cases of mutism during thewar were treated by a strong faradic currentapplied to the larynx. This was so painful thatthe patients screamed with agony, but it apparentlyproduced a dramatic cure. Practically every one,of these cases developed a severe and persistentstammer.

TEE CONVERSION SYMPTOM.The main object of treatment is the discovery

of the conditions in the patient's life which gave

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44 POST-GRADUATE WORK IN VIENNA.

rise to the mental conflict, a process which involvesnot only a general understanding of the mentalprocesses involved, but a capacity on the part ofthe physician of seeing himself in the situation thatthe patient describes in order that he may under-stand what the particular elements are which makethe appearance of the conversion symptom neces-sary. The patient will hide the cause even if heis aware of it. He will discuss his whole life for.an hour and, perhaps, give you a hint of the realtrouble just before the end of the interview. Itis often these hints which are of the greatest valueto the psychologist. They may be mentioned quitecasually or they may be associated with restlessmovements and uneasiness in the patient's demean-our or they may be accompanied by an outburstof weeping. It is my practice to follow theseindications quietly and, if necessary, to prolongthe interview so as to take full advantage of thecommunicative state to which the patient hasarrived. Once the patient feels that the attitudeof the physician is sympathetic, no difficulty willbe experienced at subsequent interviews in obtain-ing a full account of the whole condition.The patient is usually well aware of the disturb-

ance of mind from which he has suffered or issuffering and recognises that the conditions arecausing unhappiness or dread or some other painfulemotion, but such is the nature of these cases, thathe does not associate cause and symptom and will.often resist the idea. In practice this makes nodifference to treatment.Any difficult conditions in the patient's life must

be investigated and brought fully into the patient's-consciousness. They must then be dealt with eitherby the removal of the condition, if that is possible,-or by a conscious acquiescence and a correct mentaladjustment to the difficulty. The symptom shouldbe retained until this process is complete. It is ofvalue as an indicator to show whether or not thework has been completed. Sometimes, when thepatient's mind is at rest, the symptom will disappearspontaneously, but it most frequently happens, ashas been previously mentioned,thatsomething moreis needed to remove the symptom, and if the methodcan be made rather dramatic it helps the patientto give up a symptom and at the same time toretain his self regard. He is bound to feel rathera fool if he is cured by cold logical common sense.Full advantage is taken of this by the practitionersof the unqualified type in treating these patientsand, because of the failure of ordinary medicineto deal correctly with these conditions, these casestend to fall into the hands of those practitionerswho have been taught along less orthodox lines.It should never happen that the regular practi-tioners of medicine fail to cure them.

Suggestion, with or without hypnosis, electricaltreatments, sudden shock, or any similar methodwill serve to remove the symptom, but the realwork of cure is effected when the psychologicalinvestigation, the explanation of the condition,and the re-education of the patient are complete.

NOTES ON

POST-GRADUATE WORK INVIENNA.

J. L. MEAGHER, M.D., B.S. nMELB., L.M. COOMBE.

THESE notes on post-graduate opportunities aremainly personal impressions, and are the result ofexperience during six months' study in Vienna.Three main facts emerge:-

1. The effectiveness of the teaching organisationand the excellence of the teaching.

2. The great range and quantity of the clinicalmaterial and its availabilitv for the purposes ofthe post-graduate student.

3. The cordial spirit of the teachers toward thepost-graduates and the disinterestedness of the.teachers. THE UNIVERSITY.

These, apart from the romance inseparable fromthe city and the medical side of its artistic life, arethe chief impressions. The success of post-graduateteaching in Vienna is a consequence of and a tributeto the excellent organisation of the UJniversityauthorities, for it continues in spite of the absenceof elementary provision for the comfort of thelarge body of post-graduates in the city. Theirnumbers are difficult to estimate. They include afew Englishmen, some from the Dominions, manyAmericans, Continentals from every quarter, andmen from South America, Egypt, and Asia. Themajority appear to be American, but a great manystudents not from English-speaking countries arescattered in various parts of the city. The numberof women post-graduates from the English-speakingcountries is small. The American Medical Asso-ciation provides the only club purely for medicalpost-graduates. As a club it was, in 1924, in thecommon opinion of members, very much less thansatisfactory. But in spite of this handicap insocial life-Vienna at the time, be it remembered,was a desperately poor city-the universal feelingof the post-graduates respecting the work in themedical schools which they were able to do, wasof enthusiastic appreciation.The post-graduate teaching in Vienna so far as

regards the majority of English-speaking studentsthere to-day is the outcome of an arrangementbetween the American Medical Association andthe Medical Faculty. The Association is a verysuccessful body, possessing a surplus of funds,founded some 30 years ago for the organisationof medical post-graduate work, and the promotionof the social side of life among its members.The conditions of post-graduate study are laid

down by the Faculty.TEACHERS AND COURSES.

Part of the duties of the professors in the variousbranches of medicine is to teach in the hospitals.

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