A common history in these cases was that the man became ‘unconscious’ after a shell explosion, and on returning to consciousness found himself mute, shaky, or paralysed. These facts led to the belief that the condition was actually due to the physical effect of an explosion, ‘shell-shock’ and ‘concussion’ being regarded as almost synonymous. But the same symptoms occurred when there was no question of concussion, whilst the recoveries, often sensationally reported in the press, after accidental or deliberate stimuli of various kinds were on all fours with the cures wrought by Christian Science or the pilgrimage to Lourdes. Hence the hysterical nature of the symptoms became evident and the concussion theory faded away.
When one of these patients is encouraged to talk he often tells how he had felt himself overpowered by the horrors of his surroundings and forced to make increased efforts to keep going and avoid showing his condition to his fellows–in other words, to repress his emotions. The strain continuing, the shell-burst proved the last straw, and his repressed feelings broke into consciousness and took possession of it; this is what the man called being ‘unconscious’, but the condition is really an abrupt dissociation. In course of time–hours, days, or even weeks–he comes to himself again, and once more his feelings are buried; but now he is a hysteric, and his buried feelings–his dissociated stream–produce and maintain his symptoms.
In whatever way the hysteria arises the developed symptoms are the result of a mental activity which is powerful enough to overcome for a long time the desire for recovery. There are two streams of thought–the one desirous of cure and the other engaged in keeping up the symptoms–and we recognise an extreme example of continuous dissociation, in which the main stream is not only unaware of the existence of the other and unable to control it, but in which the results produced by the dissociated stream are antagonistic to the desires of the main personality.
This conception accords fairly well with Janet’s definition as given above, but though it gives us a description of the disease and indicates its relation to other phenomena we have yet to understand why the dissociation occurs. This is a difficult problem, and one to which several answers can be given. I have suggested one above, and Freud supplies another, which he applies not only to hysteria but to allied nervous conditions. What follows is not an exposition of his ideas, but rather my interpretation of such as are acceptable and useful to me. A complex, which according to Freud usually centres around an infantile sexual desire, is repugnant to the consciousness and becomes repressed as a result of conflict in just the same way as a memory is repressed. The complex is kept thrust down in the unconscious, but always tends to produce effects; it may do so in dreams or may obtain symbolic representation in the form of a neurosis, especially in times of stress. Besides the primary aim of expressing repression by a symbolic representation, Freud admits a ‘secondary function’ of the neurosis by which the patient may derive some advantage from the disease.
Here is a case capable of explanation by the Freudian hypothesis: A man said he had fallen on to the blade of an aeroplane propeller and bruised his neck; he complained of severe pain in one side of his neck, with twitching of the arm on the same side, which continued for months. It was found that the patient, who was apprenticed to engineering, had such a deep-seated fear of making mistakes that he had sometimes stayed at the workshop for hours after the day’s work was over in order to familiarise himself with the use of tools; but in spite of this his fear increased, until the handling of a file or spanner produced feelings of anxiety. Then he joined the army. Being put to work at aeroplanes he tried to do his duty and succeeded so far as to be made a corporal, saying never a word about his fears and banishing them as far as possible from his thoughts. At last the repression broke forth and took symbolic form in pain, the expression of his fear of the machinery which was blamed as its material cause. No account can picture the emotion produced by the recall of this complex, and it was evident that his feelings were intense and of more importance to him than one unfamiliar with such cases would suppose. His pains ceased when the cause had been revealed, and, what is very important, when he was told that he could not be expected to work at machinery. It must be added that the out-and-out Freudian would not be satisfied with this explanation; he would trace the cause of the original fear of making mistakes, and would expect to find it in some repression of infantile desires or fears. Certainly I have a feeling that the case had only been half investigated, but it will serve as a simple example of symbolic representation.