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. 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 prescribing such costly measures.[29]
Déjerine and Gauckler[30] 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 are 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 Déjerine and Gauckler proceed to define the different degrees in which the method of isolation may be practised; viz.: (1) 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 Salpêtrière. 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.”[31]
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.