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The
UK as a
Medium
Maritime
Power in the
21st Century
LOGISTICS FOR INFLUENCE

CHRISTOPHER MARTIN
The UK as a Medium Maritime Power
in the 21st Century
 Christopher Martin

The UK as a Medium
Maritime Power in
the 21st Century
Logistics for Influence
Christopher Martin
School of Law and Politics
University of Hull Law and Politics
Hull, UK

ISBN 978-1-137-01236-4 ISBN 978-1-137-01237-1 (eBook)

DOI 10.1057/978-1-137-01237-1

Library of Congress Control Number: 2016958279

© The Editor(s) (if applicable) and The Author(s) 2016

The author(s) has/have asserted their right(s) to be identified as the author(s) of this work
in accordance with the Copyright, Designs and Patents Act 1988.
This work is subject to copyright. All rights are solely and exclusively licensed by the
Publisher, whether the whole or part of the material is concerned, specifically the rights of
translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other physical way, and transmission or information storage and retrieval,
electronic adaptation, computer software, or by similar or dissimilar methodology now
known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information
in this book are believed to be true and accurate at the date of publication. Neither the pub-
lisher nor the authors or the editors give a warranty, express or implied, with respect to the
material contained herein or for any errors or omissions that may have been made.

Cover illustration: © Jim Gibson / Alamy Stock Photo

Printed on acid-free paper

This Palgrave Macmillan imprint is published by Springer Nature

The registered company is Macmillan Publishers Ltd.
The registered company address is: The Campus, 4 Crinan Street, London, N1 9XW,
United Kingdom
 PREFACE

Less than a century ago there was huge public awareness of the impor-
tance of the Royal Navy. The navy was the first line of defence from inva-
sion and protected the empire and the trade upon which British wealth
and security depended. Children collected cards of naval heroes much
like children today collect stickers of football stars. The Royal Navy was,
then at least, synonymous in the public mind with defence and prosperity.
Today, despite the UK’s deep dependency upon the globalised maritime-
based trading system, the general public is almost completely ‘sea-blind’.
Few understand what the Royal Navy does. One might also ask if many
policy-makers really understand too.
From its days of naval supremacy, by 1990 the Royal Navy had been
reduced to little more than an anti-submarine warfare force. Following the
SDR98 the Royal Navy appeared to have been granted a new life and the
focus was shifted to power projection. Nevertheless, the numbers of ships
continued to dwindle with the Royal Navy obtaining ever fewer but more
expensive warships centred on its core power projection role. The massive
reduction in numbers from those planned under SDR98 and the ques-
tions that persisted about whether the Royal Navy would acquire two, one
or none of the Queen Elizabeth class aircraft carriers is a strong indicator
that the role of the Royal Navy post-Cold War is yet undecided, at least in
the minds of policy-makers.
In the public imagination, the focus is always upon warships and for
those who take an interest the dwindling numbers are a matter of concern.
However, a far more insidious attack on the capability of the Royal Navy
has been taking place and that is the precipitous reduction in the number

v
vi PREFACE

of Royal Fleet Auxiliary vessels that support the fleet. The effect of the
decline in the Royal Fleet Auxiliary is little understood and discussed. The
Royal Fleet Auxiliary hardly makes the headlines, except perhaps when
its ships are substituting for warships, which is an increasingly common
occurrence given the lack of warships. However, it is the Royal Fleet
Auxiliary that keeps the Royal Navy on station, and without a full afloat
support logistics capability, the ability of the Royal Navy to conduct opera-
tions autonomously, at distance for extended periods is severely curtailed.
This study will argue that the present structure of the Royal Navy is
unsuitable for the coming century. The Royal Navy is too small and too
focused on a warfighting capability and that the reduction in Royal Fleet
Auxiliary numbers and capability is a fundamentally flawed policy. It will
argue that the decisions that have led to this situation are because of a fun-
damental misunderstanding on the part of policy-makers of the relation-
ship between policy, strategy and logistics. It will argue that strategy and
logistics are directed to one objective, control: control of the opponent
and control of the situation. It will also argue that the theoretical premise
upon which naval operations at distance have been conceived, namely,
Boulding’s Loss of Strength Gradient, is flawed for naval operations and
instead postulates a new theoretical concept, a Loss of Time Gradient.
It is the Loss of Time Gradient that explains the crucial requirement for
both sufficiency in force size and afloat support logistics. It argues that
naval operations are not governed by factors of distance but by factors of
time. Only by understanding this concept can the fullest capability of naval
forces be attained.
For a state like the UK, naval forces of sufficient capability and scale
will be indispensable in the maritime twenty-first century should the UK
wish to have control over events that will affect its globalised economic
interests. Should the UK fail to meet this challenge then other states will
and this will leave the UK reliant on the beneficence of others. This is a
risk the UK cannot take.
 ACKNOWLEDGEMENTS

I should like to thank the following for their cooperation and assistance
in the completion of this monograph: Rear Admiral John Richard Hill,
Vice-Admiral Sir Jeremy K. Blackham KCB and Professor Eric Grove.
Most importantly, my wife Marie without whom none of this could have
happened.

vii
 CONTENTS

1 The United Kingdom: A Post-modern Maritime and

Globalised Nation 1

2 The Attributes and Roles of Naval Forces 21

3 The Fleet 39

4 Strategy: The Ability to Control Events 57

5 Logistics: The Arbiter of Opportunity 75

6 The Myth of the Loss of Strength Gradient 91

7 Naval Comparisons 109

8 Conclusion 133

Bibliography 137

Index 147

ix
 LIST OF ABBREVIATIONS/ACRONYMS

AAW Anti-Air Warfare

ASW Anti-Submarine Warfare
BMD4 British Maritime Doctrine, 4th Edition
Co Coastal/Patrol Craft
COMRFA Commodore Royal Fleet Auxiliary
CV Aircraft Carrier
CVH Helicopter Carrier
DD Destroyer
DSTL Defence Science Technology Laboratory
EEZ Exclusive Economic Zone
FF Frigate
FF2020 Future Force 2020
FLD Full Load Displacement
HK Hunter-Killer
IEA International Energy Agency
JMDF Japanese Maritime Defence Forces
LSG Loss of Strength Gradient
LST Loss of Time Gradient
MARS Programme Military Afloat Reach Sustainability Programme
MCM Mine Counter Measures
MOD UK Ministry of Defence
MSCC Marine Science Co-ordination Committee
MSO Maritime Stabilisation Operations
MW Mine Warfare
NATO North Atlantic Treaty Organisation
OECD Organisation for Economic Co-operation and
Development

xi
xii LIST OF ABBREVIATIONS/ACRONYMS

RAN Royal Australian Navy

RCN Royal Canadian Navy
RUSI Royal United Services Institution
SDR98 Strategic Defence Review 1998
SDSR10 Strategic Defence and Security Review 2010
SDSR15 Strategic Defence and Security Review 2015
SISR Strategic Intelligence, Surveillance and Reconnaissance
SOLAS Safety of Life at Sea
SS Diesel-electric submarine
SSBN Nuclear powered ballistic-missile carrying submarine
SSN Nuclear powered submarine
STUFT Ships Taken Up from Trade
TLAM Tomahawk Land Attack Missile
UNCTAD United Nations Conference on Trade and Development
USN United States Navy
UUI fishing Unreported, Unregulated, Illegal fishing
WTO World Trade Organisation
 LIST OF FIGURES

Fig. 2.1 The roles of naval forces 27

Fig. 5.1 Afloat-support logistics within the functions of navies 84
Fig. 5.2 Integration of logistic and strategic planning 86
Fig. 6.1 Representation of a Boulding LSG 92
Fig. 6.2 The loss of time gradient 100
Fig. 6.3 The effect of forward bases on the Boulding LSG 102
Fig. 6.4 The effect of forward bases on the LTG 103
Fig. 7.1 RN/RFA consumer and supply ship numbers 1980–2015 123
Fig. 7.2 RN/RFA supply tons to consumer tons ratio, 1980–2015 124

xiii
 LIST OF TABLES

Table 3.1 Fixed and variable factors determining naval forces 44

Table 7.1 Comparison of selected naval powers by consumer/supply
ratio (2015) 120
Table 7.2 Falklands War 1982: Consumer to supplier ships 127

xv
 CHAPTER 1

The United Kingdom: A Post-modern

Maritime and Globalised Nation

Before giving any consideration to what kind of navy the UK requires it

is important to first consider just what kind of country the UK actually is.
This is a complex question and there are various factors open to consid-
eration: these can include, aspirational, political, military and economic
factors as well as others.

A POST-MODERN STATE?
“Our vision is for a secure and prosperous United Kingdom, with global
reach and influence.”1 Such ambition has not materialised from thin air;
it has been a constant theme of the UK’s foreign and defence policy.
The SDSR10 stated the UK, “has always had global responsibilities and
global ambitions. We have a proud history of standing up for the values
we believe in and we should have no less ambition for our country in
the decades to come.”2 The UK Foreign Secretary stated at a speech
at the Mansion House in March 2012: “Britain is a transatlantic nation
and a European nation. But our role and interests go beyond that to be
global.”3 On 15 September 2015 in the House of Lords, Earl Howe,
Minister of State for Defence stated: “The fact that we are one of four
countries in the world building aircraft carriers underscores our commit-
ment to remain engaged in the world. Taken alongside our upgraded
capabilities across all domains, it gives us a full-spectrum capability to be

© The Author(s) 2016 1

C. Martin, The UK as a Medium Maritime Power in the
21st Century, DOI 10.1057/978-1-137-01237-1_1
2 C. MARTIN

proud of.”4 On the face of it this all seems very well, but how can the
UK maintain influence in a complex and rapidly changing world where
the relative simplicity of the Cold War has given way to multipolarity,
regionalism and the growth of new centres of power? In this new world
order, according to the UK government: “The maintenance and expan-
sion of geopolitical influence will be an important consideration for all
powers, especially those with global or regional leadership aspirations.”5
And the UK has such aspirations as the Foreign Secretary stated: “The
National Security Council has reached a clear conclusion that Britain’s
national interest requires us to reject any notion of the shrinkage of our
influence.”6 This is a claim and ambition reaffirmed by Earl Howe in
2015: “We [the government] are clear that there will be no reduction in
Britain’s influence overseas.”7
Influence in global politics comes from a variety of factors, most of
which are fixed notwithstanding shifts in notions of power caused by
trends in globalisation. Power is important because “in international
politics, having power is having the ability to influence another to act in
ways in which that entity would not have acted otherwise.”8 This defini-
tion provides the widest understanding of power as it reflects the reality
that power encompasses a number of factors. In general it is sufficient
to note that in regard to concepts of power, Realist conceptions domi-
nate but there is certainly no proposal to enter into the long-standing
debate as to what constitutes power here.9 As regards economy, the World
Bank regards the UK as a “High Income OECD country”.10 UK’s GDP
amounted to $2.678 trillion dollars in 2013 and this placed the UK in
sixth place globally. The UK is a permanent member of the UN Security
Council, a leading member of the EU, at least for the present, and other
vitally important international organisations such as the Commonwealth.
Militarily the UK is a major player by normal (i.e. non-US) standards.
The UK is a leading member of NATO, the world’s most powerful and
long-standing military alliance, and is one of only seven declared nuclear-
armed states. In 2014 it spent $61.8 billion on defence, which placed
it fifth in the world in terms of largest defence spending.11 Although it
is almost certain that from 2016 the proportion of UK GDP dedicated
to defence will fall below the 2 % NATO minimum, whatever sleight-of-
hand perpetrated by government statisticians, the UK is one of a handful
of European members of NATO to have met this standard consistently
to date. There is no doubt that comparatively the UK retains many of
the ‘hard’ (Realist) determinants of power but it also has considerable
 THE UNITED KINGDOM: A POST-MODERN MARITIME AND GLOBALISED... 3

‘soft power’ features.12 According to the Institute for Government, the

UK ranks very highly in the soft power index (6.78) second only to the
USA (7.41).13 All these attributes of the UK have important implications
for the way the UK goes about its business in international politics. As
a prominent member of so many vital political, economic and military
organisations the UK has responsibilities to those organisations and their
member-states. It is also the case that other states look to the UK for lead-
ership in that the UK is expected to act in a particular way: power and the
ability to exercise power demands responsibility.14 Similarly, great wealth
brings with it responsibility and self-interest in maintaining the global
system; if the UK wants to sit at the top of the table it has to pay for the
privilege, financially and morally.
Since 2001 (Afghanistan) and especially 2003 (Iraq) UK governments
have been particularly wary of overseas commitments. There has been
an assumption, or a hope in some circles, that the UK public have had
enough of overseas adventures and that becoming a ‘normal’ European
country such as Ireland or Norway is the way for the UK to act. However,
if the UK government thinks it lacks the moral legitimacy that public sup-
port endows for playing a major role in world affairs it could not be more
wrong. A report published by Chatham House in 2015 on UK public
opinion stated that 63 % think the UK should aspire to be a ‘great power’;
42 % think the UK should pursue its interest at all times even if this is
done unethically; 69 % think the UK has a responsibility to maintain inter-
national security and 58 % think the UK should provide the UN with
peacekeeping troops (at which the UK has a poor record).15 In conclu-
sion the report stated: “Among the public and opinion-formers, a higher
number than ever say they want an ambitious UK that seeks to remain a
great power. Acceptance of what has been called the ‘Thesis of Decline’ is
at its lowest level since the survey began. Such a view may not result in a
sober reflection on Britain’s dwindling resources and reduced capabilities,
but it remains a testament to national ambition.”16 If there is a mismatch
between the UK’s capabilities and resources and public ambition for the
UK, then it is a result of successive governments’ parsimony, usually on
the basis that ‘there are no votes in defence’. The present spend on UK
defence expressed as a proportion of GDP is lower now than at any time
since the Second World War and should it fall below the NATO 2 % target
would send friends and enemies costly political signals. This has attracted
considerable criticism not the least from the USA. As Vice-Admiral Jeremy
Blackham explains, “there isn’t a natural law that says that the defence
4 C. MARTIN

budget has got to be at a certain level…but whatever it is it’s the smallest

proportion it has been for many, many, many decades…we have chosen
deliberately to spend a much smaller proportion of our national wealth
than we ever have in the past; much less than we can afford.”17 And
it is the fact that it is ‘much less than we can afford’ that is the critical
issue. The defence assumptions that underpin the ambition of the UK as
espoused by the government must be matched by financial commitment.
Unfortunately, in recent years defence has increasingly become a discre-
tionary spend to the extent that many of the defence assumptions under
plans under SDSR10 were potentially compromised. In that regard it is
worth quoting Air Chief Marshal Sir Jock Stirrup, former Chief of the
Defence Staff, who stated: “Ideas that do not have the adequate resource
put into them are not a strategy; they are a fantasy.”18
When the ‘thesis of decline’ is reconsidered and the basis of the UK’s
current power base is assessed, then, “compared to all other members of
today’s international society it is remarkable just how powerful the coun-
try remains.”19 If there is one aspect that must change however, it is the
persistent conceptualisation of the UK as a post-imperial power as this
perpetuates the notion of ‘decline’. Many labels are applied to describe
the UK today: ‘post-imperial’, ‘great power’, ‘major power’, ‘medium
power’ and ‘declining power’. Often, these labels are applied within the
context of what the UK was 70 years ago. The UK today is a very differ-
ent country from the one that began unravelling its imperial grandeur
in 1947. In the first place, the UK shares a space in international politics
with other Western states under the umbrella of what we can call ‘post-
modern’.20 Essentially there are three types of states in the modern world:
post-modern, modern and agrarian. Agrarian states are mainly, though
not exclusively, located in sub-Saharan Africa. They are poor, lack infra-
structure and governmental institutions and often lack legitimacy. Modern
states are industrial, jealous of absolute sovereignty, state-centred and
‘nationalistic’. Post-modern states are open, very advanced technologi-
cally, internationalised, wealthy and accepting that absolute sovereignty
is not ideal. They seek norm-based resolution of international issues and
recognise that working with others is the ideal means to operate within
international politics. These are the states that make the rules and so the
rules suit them. These are the states that gain the most from globalisation
and the have most to lose if it fails or if someone else is in a position to
change the rules. We must also recognise that the pillars that underpinned
the system for the past sixty or so years are shifting. The USA is focusing
 THE UNITED KINGDOM: A POST-MODERN MARITIME AND GLOBALISED... 5

on Asia-Pacific, power is shifting to East Asia, power will become more

diffuse and will be localised in regional blocs. And so, it is important to
reconceptualise the UK today, not within the context of what the UK was
but what the UK is, a post-modern power with global interests and with
a vital role to play in the international system that will change massively in
the next decades, requiring a navy suitable for the twenty-first century, not
an imperial or Cold War past.

A MARITIME GLOBALISED STATE

There are only 38 landlocked states in the world and even for these states
access to the sea is a vital development issue, the fact being that many
landlocked states are the least developed in the world.21 This simple fact
is in direct relationship to the importance of maritime-based trade in
human economic development and current economic well-being: mari-
time trading states have had the economic advantage over non-maritime
trading states for centuries. The crucial fact is that over 80 % of the world’s
human population lives within 200 miles of the sea, and the overwhelming
majority of the world’s greatest cities are ports. Trading by sea has always
been faster and cheaper than by land and—although it must be conceded
that some of the most valuable and time-sensitive freight goes by air—it
remains so today. The expansion of international trade at sea since the
end of the Second World War has been exponential: on average by 4.8 %
per annum.
Globalisation, so called, is not a modern phenomenon, but sea-borne
commerce has been at the heart of the process of globalization and has
accelerated the process over time, and although the Westline has shifted to
East Asia this has not diminished the UK’s dependence on the maritime
economy, quite the opposite. The UK today is more dependent on the
maritime trade system than at any time before.22 This has brought great
benefit for those states at the heart of the system; it has also brought the
UK considerable dependency and vulnerability, and the extent to which a
state is ‘maritime’ is really dependent upon its degree of dependence upon
the sea for resources, transportation and security: it is therefore relative.
It is well known that the UK had the greatest maritime-based empire the
world has seen with a navy to match. The question is: what existential
features does the UK have to suggest it remains a state with maritime
interests today?
6 C. MARTIN

AN ISLAND-STATE
Geography cannot be ignored. As an island archipelago the fact is that
what the UK cannot produce must in most cases come by sea and this is
also true of what the UK wishes to send abroad. The “UK’s coastline is
over 10,500 miles long and contains some 600 ports of various sizes.”23
The English Channel is the world’s second busiest international seaway.
UK ports move more than 500 million tons of freight annually including:
five million container units; seven million road goods vehicles; 240 mil-
lion tons of liquid bulk; seven million tons of Liquefied Natural Gas; 125
million tons of dry bulk and 25 million passengers: overall, 92 % of UK
international trade moves by sea as does 24 % of its internal trade.24

OVERSEAS TERRITORIES
Although the empire has gone, the UK maintains numerous overseas ter-
ritories. To these territories and their respective populations the UK has
legal and moral responsibilities. The territories are: Isle of Man; Channel
Islands; Anguilla; Bermuda; British Antarctic Territory; British Indian
Ocean Territory; British Virgin Islands; Cayman Islands; Falkland Islands;
Gibraltar; Montserrat; Pitcairn, Henderson, Ducie and Oeno Islands;
St Helena and dependencies (Ascension and Tristan da Cunha); South
Georgia and South Sandwich Islands; The Turks and Caicos Islands and
the sovereign base areas of Akrotiri and Dhekelia in Cyprus. These ter-
ritories are globally ranged, located in home waters, the North and South
Atlantic Ocean, Caribbean, Indian Ocean, Mediterranean, Antarctic and
Pacific Oceans. These territories taken together with the UK have a com-
bined EEZ of 2.5 million square miles, the fifth largest in the world.
In addition, it is estimated that about 10 % of the UK’s citizens live
overseas.25

SHIPBUILDING
Compared to only 50 years ago, UK’s shipbuilding is largely non-existent.
Save for specialised naval building and small leisure craft building, the
domestic mercantile marine shipbuilding industry has collapsed. This is
not unique to the UK however. According to the United Nations, in 2009
over 90 % of all shipbuilding occurred in just three countries: South Korea
(37.3 % of gross tonnage); China (28.6 %) and Japan (24.6 %) with the
 THE UNITED KINGDOM: A POST-MODERN MARITIME AND GLOBALISED... 7

rest of the world accounting for just 9.6 %.26 The reality is that mercantile
shipping construction, as well as much naval shipping construction, is a
globalised industry.

DOMESTIC MERCANTILE MARINE

A century ago, the UK could boast that it owned 50 % of global mer-
chant shipping. Today UK merchant shipping ownership is much dimin-
ished. After decades of decline, by 1999 it was difficult to talk of a UK
merchant marine but, with the introduction of the Tonnage Tax in 2000
there has been a considerable revival in UK-owned merchant shipping.
The Tonnage Tax introduced fiscal policies that enabled UK firms to com-
pete on more equitable terms with foreign competitors in a very tough
environment. The resulting expansion of the UK maritime marine has
been considerable. Taking into consideration the ownership27 of larger
ships (over 1000 gross tonnes) the UK is fourth largest globally with 51m
DWT28 after: Japan (176m DWT); Greece (175m DWT); Germany (94m
DWT) and China (91m DWT).29 According to UNCTAD in 2010 the
UK-owned merchant fleet comprised 794 ships over 1000 GT and in total
1697 ships registered under the UK flag.30 The UK Chamber of Shipping
notes that this amounts to an increase in UK merchant shipping of 500 %
since 2000 and between 2008 and 2012 the UK-flagged merchant fleet
grew by an average of 8.5 % a year calculated by deadweight tonnage and
5.5 % a year in overall numbers of hulls.31 The mercantile marine also
makes a considerable contribution to UK GDP amounting to £5.6 bil-
lion in 2011 represented as value added contribution. The UK Exchequer
gained £581 million in various taxes. Indirectly UK shipping by virtue
of its reliance on UK industry and service suppliers is estimated to have
supported 287,000 jobs in 2011 and added £12.5 billion to GDP which
provided £2.8 billion in taxes.32

MARITIME LONDON AND THE MARITIME SERVICES SECTOR

Maritime London “is the world’s principal centre for a wide variety of
maritime industries. From the Baltic Exchange to marine insurance, mari-
time law, maritime banking, IT, classification and ship broking facilities.”33
Maritime London’s share of global maritime financial services in 2015 was
as follows: 9 % of ship finance; 21 % of insurance underwriting; 61 % of
Insurance (P & I) Clubs; 18 % of Lloyd’s register; 50 % of tanker charters;
8 C. MARTIN

35 % of dry bulk charters and 50 % of second-hand tonnage.34 The Baltic

Exchange is crucial to the maintenance and efficiency of the global mari-
time trading environment. It is, “the world’s only independent source of
maritime information for the trading and settlement of physical and deriv-
ative contracts. Its international community encompasses the majority of
the world shipping interests and its members are engaged in arranging the
ocean transportation of bulk cargoes such as oil, coal, grain and iron ore;
trading freight derivatives and buying and selling merchant vessels.”35 The
sector contributes £1 billion a year (2009) to the UK balance of payments
and employs 15,600 people.36 As a sector in totality the UK maritime
industry is one of the largest in the UK including ports, services, and ship-
ping services. In 2011–2012 the maritime sector, excluding oil, gas and
fisheries, created directly and indirectly 703,000 jobs and contributed a
value added £35 billion to the UK’s GDP with a contribution to the UK
Exchequer of £9.2 billion.37 London is also home to the International
Maritime Organisation (IMO) “the UN of the seas”, responsible for 70
% of the world’s surface and the monitoring and enforcement of the legal
governance agreements worldwide.

A MARITIME-DEPENDENT STATE
Could or should the UK limit its concern for maritime matters to those
coastal areas over which it has responsibility and rights under international
law? The definitive answer is no. What matters is the degree of depen-
dency a state has on the global maritime network, because dependency
equals vulnerability. The reality is that the UK would face critical problems
should the global trading environment suffer shocks and disruption. The
UK Chamber of Shipping is unequivocal in its assertion: “The UK, as an
island nation, remains totally dependent on seaborne trade for its prosper-
ity.”38 The UK’s vulnerability will only increase over time as it is estimated
that UK imports by sea will increase by 135 % by 2030.39 For the likes of
Corbett and Mahan writing a century ago, the direct relationship between
national naval strength and national merchant marine was fully recog-
nised: the latter being dependent on the former for protection. Today
the link is less obvious but what matters, for a state like the UK which is
dependent on ship-borne commerce, is the stability of the maritime-based
trading environment overall. As a globalised phenomenon, disruption in
one place has an immediate effect elsewhere: there are no ‘far off places’
in the globalised maritime economy. The global shipping trade operates
 THE UNITED KINGDOM: A POST-MODERN MARITIME AND GLOBALISED... 9

on a ‘just enough, just in time’ basis which leaves states with little reserves
of vital goods and materials in transit or in reserve. This has been com-
pounded by a decrease in the surplus of mercantile shipping available since
the 1980s. In 1986 there was an oversupply of shipping of 16.9 %, falling
to 0.7 % in 2005 increasing to 1 % in 2007. The recession which occurred
in the late 2010s will have increased this again but as the global economy
recovers, the surplus will again decline.40 Yet this decline in ‘spare capac-
ity’ is made all the more noteworthy by the fact that in the 30 years after
1980, the global shipping fleet increased as an expression of DWT by
almost 100 % meaning that the growth in global shipping capacity has just
kept pace with demand.41
For the UK it is the projected figures for vital raw materials such as
coal, oil and gas that cause the greatest concern. Over 90 % of UK energy
for light and heat comes from coal, gas and oil.42 As for coal, most of UK
domestic production was destroyed in the 1980s and consequently by
2006, 60 % of UK coal requirements came from overseas by ship. By 2020,
despite anticipated relative decline in coal use, the expectation is that the
UK will rely on overseas imported coal for over 75 % of its requirements.43
The UK has been fortunate in its oil and gas situation as a producer since
the 1960s. However, since 2006 the UK has been a net importer of oil.
The picture is complicated by the way the oil market, refining capacities
and products work. So for example in 2009 the UK imported 1.45 billion
barrels a day; exported 1.31 billion barrels a day; and consumed 1.62 bil-
lion barrels a day.44 Whatever energy measures are taken and whatever the
level of production of UK oil, it is expected that by 2020, 47 % of UK oil
consumption will be imported and, according to the IEA, “this will have
a significant impact on the United Kingdom’s oil security.”45 According
to the SDSR15, by 2030 the UK could import as much as 73 % of its
oil needs.46 The situation for gas is even worse. According to the IEA,
UK domestic production of gas will, “drop by more than 45 % over the
period to 2020, meaning that the United Kingdom’s import dependency
will rise sharply.”47 The same body reports that in 2009 imported gas
accounted for 31 % of the UK’s requirements and this could be as much
as 54 % by 2020.48 One assessment undertaken by the UK government is
even more pessimistic with a prediction that by 2020 the UK’s reliance on
imported gas could be as high as 80 %.49 Former First Sea Lord, Admiral
Sir Jonathan Band, speaking at RUSI in 2006 pointed out that, “Within
a few years, the UK will import a significant percentage of gas from the
Middle East—that means a gas carrying ship roughly every 300–400 miles
10 C. MARTIN

between the UK and the Gulf. With hardly any strategic reserve of gas in
the UK, it is clear that any interruption of that free supply of gas would
have very serious consequences for the UK’s economy.”50 Clearly, the UK
is a global player in the international trading environment. It is massively
dependent upon the security and stability of international trade, especially
for its energy security. Access to energy markets is absolutely crucial to the
well-being of the UK, as without this security of supply the UK way of
life would be crippled. Consequently, the issue is not just about shipping;
it is about the stability of UK interests globally. As the UK Chamber of
Shipping points out:

As an island nation, the UK has a vital strategic interest in the continued

security and freedom of navigation on the high seas to meet the needs
and aspirations of its citizens…the UK is a major player in the globalized
economy with a leading maritime role to fulfil. The stakeholders in global-
ized trade need to recognise that safeguarding UK trading interests extends
beyond just the protection of ships registered in the UK and to UK owned
ships, but also to UK owned and UK bound cargoes.51

The UK benefits from globalisation and the effective maintenance of the

international order is a vital interest of the UK. Making a major contri-
bution to maintaining this system is the price of living in an advanced
civilized economy. As British Maritime Doctrine explains most succinctly,
“The UK is a maritime nation whose prosperity, stability and security
depend upon the vital access provided by the sea and the maintenance of
an international system of law and free trade.”52

ECONOMIC WELL-BEING
There is considerable danger in simply reiterating the points above with-
out reflecting on what the real situation is for a globalised state such as the
UK. It is worth noting that many of the points made above are repeated
ad nauseam by those who wish to state the case for naval power. Indeed
they are used so often that, notwithstanding their truth, the impact of
these points is often lost through overfamiliarity. All the points can be
and are well made, but do they reflect accurately the economic situa-
tion the UK finds itself in today? At the 2011 International Seapower
Symposium, Mr Stephen Carmel53 made a powerful speech in which he
pointed out a number of important realities for the maritime sector.54 The
 THE UNITED KINGDOM: A POST-MODERN MARITIME AND GLOBALISED... 11

most important point that Carmel made was that the commonly held view
of globalisation is erroneous. Commentators, argued Carmel, often focus
upon ‘interdependence’ with their meaning explicitly being embedded
in Ricardian concepts of comparative advantage. According to Carmel,
“this is, however, a strikingly narrow view of globalisation, and in truth
it is a definition more fitting of the last age of globalisation [which ended
in 1914] than the current one.”55 Nations do not manufacture in order
to trade as they did before, rather, according to Carmel, “We no longer
simply trade what we make for what we do not make but need. We now
trade in order to get what we need to make what we make. Before we
were self-sufficient in some, but not all of what we needed, and we could
trade the excess to fill the gaps. Now we are self sufficient in nothing
but make everything.”56 But what does this mean in practice? Consider
the following well-known trademark seen on the back of Apple products.
“Designed by Apple in California. Assembled in China.” The important
word here is “assembled”. Years ago it would have been common to see
‘made in’, but Apple products are not ‘made in’ China nor indeed are they
‘made’ anywhere else. Consider the following observation from the New
York Times, “Though components differ between versions, all iPhones
contain hundreds of parts, an estimated 90 % of which are manufactured
abroad. Advanced semiconductors have come from Germany and Taiwan,
memory from Korea and Japan, display panels and circuitry from Korea
and Taiwan, chipsets from Europe and rare metals from Africa and Asia.
And all of it is put together in China.”57 This is not just true of this one
product; in today’s international system this is typical. Products are not
‘made’, they are assembled: their original components, the raw materials
and the initial composite stage components shipped, transhipped, assem-
bled, shipped again for the next stage in the ‘assembly’ process. Products
thus assembled originate in dozens or more countries. They move many
times in various stages of completion before final assembly and sale, and
these movements, except in rare cases, are by sea. A 2014 report by
Standard Chartered Bank explained: “Trade is increasingly ‘unbundled’
with countries no longer trading in goods so much as in ‘tasks’, such as
design or assembly. Goods are ‘made in the world’, with components and
partial assemblies frequently traded several times across borders before the
final product reaches consumers.”58 This report notes that this trend will
continue:
12 C. MARTIN

The difference between the traditional supply chain model and today’s more
complex supply chains lies in the fact that trade is now not so much in goods
but in tasks, a reflection of growing specialisation that allows the same prod-
uct to be both imported and exported by the same country…this difference
is highlighted by the rise in the import content of exports, now estimated to
be around 40 %, compared to 20 % in the 1990s according to the WTO…
data from the OECD confirms this trend…the WTO expects it to rise to
60 % by the 2030s…rapid advances in communication and technology are
lowering barriers to unbundling tasks further, allowing for integration of
newer, low-cost, more distant geographies in the global supply chain.59

In other words this complexity and multilayering will deepen. Furthermore

there is a hugely important trade in services: finance, construction, insur-
ance, communications, computers and IT, licence fees, royalties, legal ser-
vices, personal services, culture and recreation. According to the same
Standard Chartered report, measured conventionally this amounts to 20
% in value of total global trade; it is estimated however that this could be
as much as 40 % when more accurately calculated.60 Not only is this of
immense monetary value, but without these services the global maritime-
based movement of goods would not occur. Additionally, the EU is the
largest global exporter of services with more than a 50 % share and within
the EU the UK is the largest individual exporter of services.61 And for
the UK, in terms of value added, services account for 50 % of exports
and London, as we noted before, is at the centre of this global services
phenomenon that underpins the globalised trade network.62 The fullness
of this complexity is impossible to unravel; it would be easier to unpick a
spider’s web, such that when disturbances to the web occur they are felt
everywhere, and the closer to the epicentre an economy is by measure of
globalisation, the greater the effect is felt to the extent that, “Disruptions
to supply chains no longer mean just not having your favourite brand on
the shelf; they now mean closed factories, unemployment, and social stress
in areas far removed from the initial disruption.”63
The end of the ‘made in’ label perhaps helps partly explains the death
of ‘national’ merchant marines. If states no longer ‘make’ and export
products as before, the requirement for a national merchant marine is less
pressing as there is little need to transport ‘domestic’ manufactures, but
this does not lessen the importance of the globalised merchant marine; far
from it, it means all have a stake in ensuring its protection and the system
that underpins it. The UK National Strategy for Maritime Security identi-
 THE UNITED KINGDOM: A POST-MODERN MARITIME AND GLOBALISED... 13

fies British-flagged cargo ships for protection, but, given the complexity
described, just what constitutes a ‘British cargo’ under modern conditions?
Of particular concern is the very complexity of this system. It is just pos-
sible that it is so complex that we lack the ability to diagnose problems
and find fixes. Efforts to deconstruct the globalised trading system into
neat maritime and non-maritime silos are doomed to failure owing to the
overwhelming complexity of the system to the degree that it is erroneous
and misleading to try to disaggregate the system and isolate ‘maritime’
as though it were independent of all other system parts.64 Additionally, it
is nonsensical, according to Carmel, to see system vulnerability as simple
threats to isolated nodes; it is far more complex than that. “Vulnerability
is not about the physical ease or difficulty of attack on any particular node
or vector in the supply chain. It is not—instead, vulnerability is a matter
of how the system behaves, how it fails, and how quickly it can be made
to recover once a particular node or vector has been disrupted.”65 What
we are considering is a global system of astonishing complexity and, whilst
it certainly is maritime-based, it is far more than that. Almost all west-
ern navies discuss interconnectivity and make sweeping claims about the
rationale for navies within the context of globalised interconnectedness
but do they fully comprehend the meaning of it? “Consider that in 2010,
according to the WTO, there was $18.8 trillion in total world trade, of
which $3.7 trillion, or about 19.5 % was in services…this trade moves on
fibre-optic backbones, not ships—and in fact…goods can no longer move
on ships without a robust and parallel flow in information. This means that
cyber warriors are doing every bit as much to ensure the smooth flow of
trade as are those standing watches on the bridges of ships in the Strait of
Hormuz.”66
The UK’s maritime interests go much further than trade and services.
The MSCC points out that as well as the standard areas of activity (resource
exploitation, services, trade) the UK maritime sector includes: academia;
scientific research; manufacture of specialised marine equipment; mechan-
ical, chemical, electrical and civil engineering; marine archaeology; earth
sciences; climate research; socio-economics and aquaculture. This wide,
and not exhaustive, list of activities brings together what is now referred
to as the Blue Economy. The Blue Economy is a key programme of invest-
ment and development for the wider EU area incorporating: aquaculture,
coastal tourism, marine biotechnology, ocean energy and seabed mining.
The UK is a key partner in this EU-wide policy and, as the UK has one of
the largest EEZs, has much to gain. The Blue Economy in the EU area is
14 C. MARTIN

responsible for generating 5.4 million jobs across Europe and €500 billion
annually.67 Technology has made the marine environment far more impor-
tant today for human economic development and well-being.

THE FUTURE OF THE GLOBAL MARITIME ENVIRONMENT?

The UK government in its Strategy for Maritime Security states unequiv-
ocally: “national prosperity is often dependent on distant resource, and
the government is clear on the importance of the international system to
our national interests: the UK depends on open trade routes and a stable
global market for the critical supply of energy, raw materials, food and
manufactured goods.”68 Futurism is a dangerous game as the future is
seldom how we expect it. Nevertheless we can make use of studies that
examine potential trends over the next decades and consider trends over
previous ones. Today, the UK stands 19th in the world as to its degree
of ‘globalisation’ measured by various economic, social and political fac-
tors with an index score of 82.96.69 What is noteworthy is the deepening
process of globalisation of the UK since 1970 (oldest data). In 1970, the
UK’s overall globalisation index was 59.6 (82.96 in 2015). In 1970 the
UK’s economic globalisation index was 42.9 (70.53 in 2015). The com-
pilation of this data is complex, and although the UK stands 19th overall,
when particular anomalies are considered (e.g. Singapore is 100 % urban)
and other factors are stripped out, for example countries with low popula-
tions, the UK rises to the 3rd most globalised state overall.70
Much has been made of the factors of shipping and trade today in
this chapter. The report Global Marine Trends 2030 has conducted trend
assessments from 2010 to 2030 under three potential scenarios: Status
Quo (SQ)—that will see long-term growth, an increase in challenges,
some friction but development of normative values and acceptance that
inwardness is detrimental. Global Commons (GC)—a huge explosion of
trade, norms, cooperation and mutual recognition of benefits, harmonisa-
tion and collective action. Competing Nations (CN)—a retreat of globali-
sation, localism, insularity and protectionism resulting in a contraction of
trade. Global Marine Trends considered these scenarios in application to
trade and shipping and concluded that under SQ conditions trade moving
by sea will increase from 9000 million tonnes in 2010 to 22,000 million
tonnes by 2030, in other words an expansion of 2.5 times in 20 years.71
Regardless of the scenario, this represents an astonishing expansion in
global shipping, and at a time when the number of warships, particularly
 THE UNITED KINGDOM: A POST-MODERN MARITIME AND GLOBALISED... 15

in the west, is to continue to decline.72 This decline has to be of concern

given that the future security environment is likely to be less than benign.
Globalisation will no doubt continue but it is uneven, unequal, not
welcomed by all and does not promise to solve the world’s problems. Nor
should we assume that the future would be any less violent than the past;
indeed human history should be more of a guide to the twenty-first cen-
tury than we allow it and, based on that history, we should expect it to be
violent.73 This is reflected by a study of conflict trends to 2040 produced
by the UK MOD.74 Global Strategic Trends determined that there would
be constant tension between states and that the global distribution of
power would continue to shift to Asia. It also concluded that there would
be periods of very intense competition between states and great instabil-
ity in international politics.75 Rather pessimistically it noted that, “there
are few convincing reasons to suggest that the world will become more
peaceful.”76 Importantly, the benefits of globalisation will also be a source
of tension and conflict as more and more states rely on the globalised
system of distribution, and this will require the use of force to protect the
system.77 In the matter of energy, an area where as we have noted the UK
is particularly vulnerable, there is particular concern as the report makes
the point: “The issue of energy security is one in which governments, and
defence organisations, will increasingly have to be engaged if states are to
maintain their standards of living, and to ensure adequate supplies of natu-
ral resources at reasonable prices.”78 Failure to do so will undermine the
very fabric of western democracy, consumerism and welfare. Governments
will be thrown out if they do not maintain and improve the high standard
of living westerners enjoy at the expense of everyone else, and it will be the
ability to access these resources that will be of central significance as well as
being able to position the country at the heart of power and influence over
events that may affect access to them. As the report states clearly: “The
maintenance and expansion of geopolitical influence will be an impor-
tant consideration for all powers, especially those with global and regional
leadership aspirations.”79 And if we are to believe the UK government, the
UK is a state with global and regional aspirations to leadership and influ-
ence and so the means to influence should be a priority issue.
In conclusion we return to the question, ‘what kind of country is the
UK?’ The aspiration of the UK government is to maintain its global status
and to have influence over the events that affect it. It is a wealthy state and
politically is a leading member of all the major international organisations
and is held in high regard by other actors. Militarily it is one of the world’s
16 C. MARTIN

major defence spenders and has technologically advanced, though small,

modern forces. The UK takes its responsibilities to the global community
of states seriously. It has a high degree of globalisation expressed as a cal-
culation of its social, economic and political integration. It recognises it
has common interests along with like-minded states and seeks collective
rather than unilateral action as a means to maintain the globalised eco-
nomic system upon which it depends absolutely and through which it also
has great vulnerabilities. Consequently we can say that the UK today and
for the coming century is a major post-modern globalised maritime state.
It is important, and the point was made above, to reconceptualise the UK
today as, not a post-imperial power desperate to retain some semblance
of glory and status based on its past, but as a post-modern power with a
vital role to play in an international system that will change massively in
the next decades, with a navy suitable for the twenty-first century. Global
Marine Trends states the following important fact. “The marine world in
2030 will be almost unrecognisable owing to the rise of emerging coun-
tries, new consumer classes and resource demand.”80 Consequently, it is
imperative that the UK is ready for these huge upheavals most especially
to protect the wealth that underpins the consumer- and benefits-based
society the general population have come to regard as their ‘human right’.
The maritime environment will be the new frontier in the twenty-first
century for humanity’s economic, social and political development; the
twenty-first century will be the maritime century. The UK must be at the
forefront of this new maritime century.

NOTES
1. National Security Strategy and Strategic Defence and Security
Review 2015: A secure and prosperous United Kingdom, (hereinaf-
ter SDSR15), Cm9161, (London, HMSO, November 2015), p. 9,
para 1.1, (Bold in original).
2. Securing Britain in an Age of Uncertainty: Strategic Defence and
Security Review 2010, (hereinafter SDSR10), Cm7948, (London,
HMSO, October 2010), p. 3.
3. FCO, Foreign Secretary’s Speech to the Lord Mayor’s Banquet, 29
March 2012, online at: www.fco.gov.uk/news/en/news/latest-
news/?view=Speech&id=747730582 (accessed on 30 November
2012).
 THE UNITED KINGDOM: A POST-MODERN MARITIME AND GLOBALISED... 17

4. Lords Hansard, Tuesday 15 September 2015, Column GC 206,

Earl Howe, Grand Committee, ‘The Role and Capabilities of the
UK Armed Forces, in the Light of Global and Domestic Threats to
Stability and Security’.
5. DCDC, Global Strategic Trends Out to 2040, (Shrivenham, January
2010), p. 44.
6. A Strong Britain in an Age of Uncertainty: The National Security
Strategy, Cm 7953, (2010), pp. 9–10.
7. Lords Hansard, 15 September 2015, Col. GC 252.
8. E. Wilson, “Hard Power, Soft Power, Smart Power”, The Annals
of The American Academy of Political Science, 616, March 2008,
p. 114.
9. S. M. Walt, “International Relations: One World, Many Theories”,
Foreign Policy. No. 110, Spring 1998, pp. 29–46.
10. www.data.worldbank.org/country/united-kingdom (accessed 30
June 2015).
11. The Military Balance 2015, (London, International Institute for
Strategic Studies), p. 21.
12. J. S. Nye Jr., ‘Soft Power’, Foreign Policy, No. 80, Twentieth
Anniversary, 1990, pp. 153–171.
13. Jonathan McLory, The New Persuaders II, (London, Institute for
Government, 2011), p. 15. The calculation included: business and
innovation; government; culture; diplomacy and education. It is
interesting to note that the UK was second in all categories but the
first two in which it was not in the top ten for either.
14. Justin Morris, ‘How Great is Britain? Power, Responsibility and
Britain’s Future Global Role,’ The British Journal of Politics and
International Relations, 2011, Vol. 13, pp. 326–347.
15. Internationalism or Isolationism? The Chatham House-You Gov
Survey. British Attitudes Towards the UK’s International Priorities,
(Royal Institute of International Affairs, Chatham House, London,
January 2015).
16. Internationalism or Isolationism, p. 12.
17. Interview with Vice-Admiral Jeremy Blackham (2012).
18. Evidence of Air Chief Marshal Sir Jock Stirrup, Who Does UK
National Strategy? Public Administration Select Committee, HC
435, 18 October 2010, Q. 294, Ev 51, col. 1.
19. Morris, ‘How Great is Britain?’, p. 341.
Another random document with
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but when relieved or cured of this, suddenly a new manifestation
occurs. A new figure appears upon the scene, or perhaps I might
better say a new actor treads the boards. Even in these cases,
however, it would be difficult to say that the phenomena are really
simulated. They are rather induced, and get partly beyond the
patient's will.

A remarkable case of this kind is well known at the Philadelphia

Polyclinic and College for Graduates in Medicine. She is sometimes
facetiously spoken of as the “Polyclinic Case,” because she has
done duty at almost every clinical service connected with the
institution. The case has been reported several times: the fullest
report is that given by Harlan.100 The patient was taken sick in
September with sore throat, and was confined to the house for about
two weeks. She was attended by S. Solis Cohen. There was
difficulty in swallowing, and some regurgitation of food. At the same
time she had weakness of sight in the right eye. Later, huskiness of
voice came on, and soon complete aphonia. Her voice recovered,
and she then had what appeared to be pleuro-pneumonia. During
the attack her arms became partially paralyzed. She complained of
numbness down her legs and in her feet.
100 Transactions of the Amer. Ophthalmological Soc., 20th annual meeting, 1884,
649.

Before these symptoms had disappeared twitchings of the muscles

of the face set in, most marked on the right side. The face improved,
but in two days she had complete spasmodic torticollis of the left
side. One pole of a magnet was placed in front of the ear, and the
other along the face; and under this treatment in a week the spasm
ceased entirely.

In a short time she complained of various troubles of vision and a

fixed dilatation of the pupil. Homonymous diplopia appeared.
Reading power of the right eye was soon lost. The pupil was slightly
dilated, and reacted imperfectly to light. She had distressing
blepharospasm on the right side and slight twitchings on the left. Two
months later a central scotoma appeared, and eventually her right
eye became entirely blind except to light. The pupil was widely
dilated and fixed, and the spasm became more violent and extended
to the face and neck. The sight was tested by Harlan by placing a
weak convex lens in front of the blind eye, and one too strong to
read through in front of the sound eye, when it was found that she
read without any difficulty. The use of the magnet was continued by
Cohen. Blepharospasm and dilatation of the pupil improved. She,
however, had an attack of conjunctivitis in the left eye, and again got
worse in all her eye symptoms. A perfect imitation of the magnet was
made of wood with iron tips. Under this imitation magnet the pupil
recovered its size and twitching of the face and eyelids ceased.

The next campaign was precipitated by a fall. She claimed that she
had dislocated her elbow-joint; she was treated for dislocation by a
physician, and discharged with an arm stiff at the elbow. A wooden
magnet was applied to the arm, the spasm relaxed, and the
dislocation disappeared.

This ends Harlan's report of the case, and I had thought that this
patient's Iliad of woes was also ended; but I have just been informed
by J. Solis Cohen and his brother that she has again come under
their care. The latter was sent for, and found the patient seemingly
choking to death. The right chest was fixed; there was marked
dyspnœa; respiration 76 per minute; her expectoration was profuse;
she had hyperresonance of the apex, and loud mucous râles were
heard. At last accounts she was again recovering.

This patient's train of symptoms began with what appeared to be

diphtheria. The fact that she had some real regurgitation would seem
to be strong evidence that she had some form of throat paralysis
following diphtheria. She was of neurotic temperament. From the
age of seven until ten years she had had fits of some kind about
every four weeks. Because of her sore throat and subsequent real or
seeming paralytic condition she came to the Polyclinic, where she
was an object of interest and considerable attention, having been
talked about and lectured upon to the classes in attendance.
Whether her first symptoms were or were not hysterical, those which
succeeded were demonstrably of this character. Frequently some
real disease is the starting-point of a train of hysterical disorders.

DURATION AND COURSE.—Hysteria is pre-eminently a chronic disease;

in the majority of cases it lasts at least for years. Its symptoms may
be prolonged in various ways. Sometimes one grave hysterical
disorder, as hysterical paralysis, persists for years. In other cases
one set of symptoms will be supplanted by others, and these by still
others, and so on until the whole round of hysterical phenomena
appears in succession.

Deceptive remissions in hysterical symptoms often mislead the

unwary practitioner. Cures are sometimes claimed where simply a
change in the character of the phenomena has taken place. Without
doubt, some cases of hysteria are curable; equally, without doubt,
many cases are not permanently cured. It is a disease in which it is
unsafe to claim a conquest too soon. In uncomplicated cases of
hysteria the disorder often abates slowly but surely as age
advances. As a rule, the longevity of hysterical patients is not much
affected by the disorder.

COMPLICATIONS.—We should not treat a nervous case occurring in a

woman or a man as hysterical simply because it is obscure and
mysterious. Unless, after the most careful examination, we are able
by exclusion or by the presence of certain positive symptoms to
arrive at the diagnosis of hysteria, it is far better to withhold an
opinion or to continue probing for organic disease. I can recall five
cases in which the diagnosis of hysteria was made, and in which
death resulted in a short time. One of these was a case of uræmia
with convulsions, two were cases of acute mania, another proved to
be a brain abscess, and the fifth a brain tumor. Hughes Bennett101
has reported a case of cerebral tumor with symptoms simulating
hysteria in which the diagnosis of the true nature of the disease was
not made out during life. The patient was a young lady of sixteen at
the time of her death. Her family history was decidedly neurotic. She
was precocious both mentally and physically, was mischievous and
destructive, sentimental and romantic; she had abnormal sexual
passions. She had a sudden attack of total blindness, with equally
sudden recovery of sight some ten days afterward. Sudden loss of
sight occurred a second time, and deafness with restoration of
hearing, loss of power in her lower limbs, and total blindness,
deafness, and paraplegia. Severe constant headaches were absent,
as were also ptosis, diplopia, facial or lingual paralysis, convulsions
with unconsciousness, vomiting, wasting, and abnormal
ophthalmoscopic appearances. She had attacks of laughing, crying,
and throwing herself about. Her appearance and character were
eminently suggestive of hysteria. The patient died, and on post-
mortem examination a tumor about the size and shape of a hen's
egg was found in the medullary substance of the middle lobe of the
right hemisphere.
101 Brain, April, 1878.

The association of hysteria with real and very severe spinal

traumatism partially misled me in the case of a middle-aged man
who had been injured in a runaway accident, and who sustained a
fracture of one of the upper dorsal vertebræ, probably of the spines
or posterior arch. This was followed by paralysis, atrophy of the
muscles, contractures, changed reactions, bladder symptoms, bed-
sores, and anæsthesia. The upper extremities were also affected.
Marked mental changes were present, the man being almost
insanely hysterical. The diagnosis was fracture, followed by
compression myelitis, with descending motor and ascending sensory
degeneration. An unfavorable prognosis was given. He left the
hospital and went to another, and finally went home, where he was
treated with a faradic battery. He gradually improved, and is now on
his feet, although not well. In this case there was organic disease
and also much hysteria.

Seguin102 holds that (1) many hysterical symptoms may occur in

diseases of the spinal cord and brain; (2) in diseases of the spinal
cord these diseases appear merely as a matter of coincidence; (3) in
cases of cerebral disease the hysterical symptoms have a deeper
significance, being in relation to the hemisphere injured. He collects,
as illustrative of the propositions that hysterical symptoms will
present themselves in persons suffering from organic disease of the
nervous system, the following cases of organic spinal disease: One
case of left hemiplegia with paresis of the right limbs, which proved
after death to be extensive central myelitis, with formation of cavities
in the cord; two cases of posterior spinal sclerosis, two of
disseminated sclerosis, and one of sclerosis of the lateral column. In
some of these cases the organic disease was wholly overlooked.
Sixteen cases of organic disease of the brain accompanied by
marked hysterical manifestations are also given: 9 of left hemiplegia;
2 of right hemiplegia with aphasia; 1 of left alternating with right
hemiplegia; 1 of hemichorea with paresis; 1 of double hemiplegia;
and 2 of general paresis. It is remarkable and of interest, in
connection with other unilateral phenomena of hysteria, that
emotional symptoms were present in 14 cases of left hemiplegia and
in only 2 of right.
102 Op. cit.

Among the important conclusions of this paper are the following: “1.
In typical hysteria the emotional symptoms are the most prominent,
and according to many authors the most characteristic. In all the
cases of cerebral disease related there were undue emotional
manifestations or emotional movements not duly controlled. 2. In
typical hysteria many of the objective phenomena are almost always
shown on the left side of the body, and we may consequently feel
sure that in these cases the right hemisphere is disordered. In nearly
all of the above sixteen cases the right hemisphere was the seat of
organic disease, and the symptoms were on the left side of the
body.”

The possibility of the occurrence of hysteria in the course of acute

diseases, particularly fevers, is often overlooked. Its occurrence
sometimes misleads the doctor with reference to prognosis. Such
manifestations are particularly apt to occur in emotional children. A
young girl suffering from a moderately severe attack of follicular
tonsillitis, with high fever, suddenly awoke during the night and
passed into an hysterical convulsion which greatly alarmed her
parents. Her fingers, hands, and arms twitched and worked
convulsively. She had fits of laughing and shouting, and was for a
short time in a state of ecstasy or trance. Once before this she had
had a similar but slighter seizure, during the course of an ephemeral
fever.

Among other complications of hysteria which have been noted by

different observers are apoplexy, disease of the spleen, mania-a-
potu, heart disease, and spinal caries, and among affections alluded
to by competent observers as simulated by hysteria are secondary
syphilis, phthisis, tetanus, strychnia-poisoning, peritonitis, angina
pectoris, and cardiac dyspnœa.

DIAGNOSIS.—Buzzard103 significantly remarks that you cannot cure a

case of hysteria as long as you have any serious doubt about its
nature; and, on the other hand, if you are able to be quite sure on
this point, and are prepared to act with sufficient energy, there are
few cases that will not yield to treatment. The importance of a correct
diagnosis is a trite topic, but in no affection is it of more consequence
than in hysteria, that disorder which, although itself curable, may, as
has been abundantly shown, imitate the most incurable and fatal of
diseases.
103 Clinical Lectures on Diseases of the Nervous System, by Thomas Buzzard, M.D.,
Philada., 1882.

A few remarks with reference to the methods of examining hysterical

patients will be here in place. Success on the part of the physician
will often depend upon his quickness of perception and ability to
seize passing symptoms. It is often extremely difficult to determine
whether hysterical patients are or are not shamming or how far they
are shamming. The shrewdness and watchfulness which such
patients sometimes exercise in resisting the physician's attempts to
arrive at a diagnosis should be borne in mind. A consistent method
of procedure, one which never betrays any lack of confidence,
should be adopted. “Trifles light as air” will sometimes decide, a
single expression or a trivial sign clinching the diagnosis. On the
other hand, the most elaborate and painstaking investigation will be
frequently required.

The physician should carefully guard against making a diagnosis

according to preconceived views. On the whole, the general
practitioner is more likely to err on the side of diagnosticating organic
disease where it does not exist; the specialist in too quickly
assigning hysteria where organic disease is present, or in failing to
determine the association of hysteria and organic disease in the
same case.

Special expedients may sometimes be resorted to in the course of

an examination. Not a few hysterical symptoms require for their
continuance that the patient's mind shall be centred on the
manifestations. If, therefore, the attention can, without arousing
suspicions, be directed to something else during the examination,
the disappearance of the particular hysterical symptom may clear
away all obscurity. In a case reported by Seguin,104 in which
staggering was a prominent symptom, the patient was placed in the
middle of the room and directed to look at the ceiling to see if he
could make out certain fine marks; he stood perfectly well without
any unsteadiness. In the case of a boy eleven years old whose chief
symptoms were hysterical paralysis with contracture of the lower
extremities, great hyperæsthesia of the feet, and a tremor involving
both the upper and lower extremities, and sometimes the head, I
directed him, as if to bring out some point, to hold one arm above his
head and at the same time fix his attention on the foot of the
opposite side. The tremor in the upper extremities, which had been
most marked, entirely disappeared. This experiment was varied, the
result being the same.
104 Op. cit.

The method adopted in the cases supposed to be phthisis, but which

proved to be hysterical, which has already been alluded to under the
head of hysterical or nervous breathing, is worthy of note. The
patients, it will be recalled, could not be induced to draw a long
breath until the plan was adopted of having them count twenty
without stopping, when the lungs expanded and the diagnosis was
clear.

It is important to know whether or not children are of this hysterical

tendency or are likely, sooner or later in life, to develop some forms
of this disorder. In children as well as in adults the hysterical
diathesis will be indicated by that peculiar mobility of the nervous
system, which has been referred to under Etiology. It is chiefly by
psychical manifestations that the determination will be made. These
are often of mild degree and of irregular appearance. Undue
emotionality under slight exciting cause, a tendency to simulation
and to exaggeration of real conditions, inconsistency in likes and
dislikes, and great sensibility to passing impressions, are among
these indications. Children of hysterical diathesis are sometimes,
although by no means always, precocious mentally, but not a few
cases of apparent precocity are rather examples of an effort to
attract attention, which is always present in individuals of this
temperament.

It is also important, as urged by Allbutt,105 to make a distinction

between hysterical patients and neurotic subjects, often incorrectly
classed as hysterical. Many cases of genuine malady and suffering
are contemptuously thrown aside as hysteric. Allbutt regards some
of these neurotic patients as almost the best people in this wicked
world. Although, however, this author's righteous wrath against the
too frequent diagnosis of hysteria, hysterical pain, hysterical spine,
etc. is entirely justifiable, he errs a little on the other side.
105 On Visceral Neuroses, being the Gulstonian Lectures on Neuralgia of the
Stomach and Allied Disorders, delivered at Royal College of Physicians, March, 1884,
by T. Clifford Allbutt, M.A., M.D. Cantab., F. R. S., Philada., 1884.

Hysteria and neurasthenia are often confounded, and, while both

conditions may exist in the same case, just as certainly one may be
present without the other. The points of differential diagnosis as
given by Beard106 are sufficient for practical purposes. They are the
following: In neurasthenia convulsions or paroxysms are absent; in
hysteria they are among the most common features. In neurasthenia
globus hystericus and anæsthesia of the epiglottis are absent,
ovarian tenderness is not common, and attacks of anæsthesia are
not frequent and have little permanency; in hysteria globus
hystericus, anæsthesia of the epiglottis, ovarian tenderness, and
attacks of general or local anæsthesia are all marked phenomena.
The symptoms of neurasthenia are moderate, quiet, subdued,
passive; those of hysteria are acute, intense, violent, positive.
Neurasthenia may occur in well-balanced intellectual organizations;
hysteria is usually associated with great emotional activity and
unbalanced mental organization. Neurasthenia is common in males,
although more common in females; hysteria is rare in males.
Neurasthenia is always associated with physical debility; hysteria in
the mental or psychical form occurs in those who are in perfect
physical health. Neurasthenia never recovers suddenly, but always
gradually and under the combined influences of hygiene and
objective treatment; hysteria may recover suddenly and under purely
emotional treatment.
106 Op. cit.

An affection termed general nervousness has been described by

Mitchell. It does not seem to be strictly a neurasthenia, nor does it
always occur in hysterical individuals. These cases are sometimes
“more or less neurasthenic people, easily tired in brain or body; but
others are merely tremulous, nervous folks, easily agitated, over-
sensitive, emotional, and timid.” It is sometimes an inheritance;
sometimes it results from the misuse of alcohol, tobacco, tea or
coffee. Usually, it is developed slowly; occasionally, however, it
arises in a moment. Thus, Mitchell mentions the case of a healthy
girl who fell suddenly into a state of general nervousness owing to
the fall of a house-wall. General nervousness is to be distinguished
from hysteria, into which it sometimes merges, only by the absence
of the mental perversions and the special motor, sensory, vaso-
motor, and visceral disorders peculiar to the latter.

The differential diagnosis of hysteria and hypochondria, or what is

better termed hypochondriacal melancholia, is often, apparently at
least, somewhat difficult. Formerly, it was somewhat the fashion to
regard hysteria in the male as hypochondria; but this view has
nothing to support it. Hypochondria and hysteria, as neurasthenia
and hysteria, are sometimes united in the same subject; one
sometimes begets the other, but they have certain points of
distinction. Hypochondria more frequently passes into real organic
disease than does hysteria; it is more frequently associated with
organic disease than is hysteria. Hypochondria is in the majority of
cases a true insanity, while hysteria can only be regarded as such in
the special instances which have been discussed. In hypochondria
the individual's thoughts are centred upon some supposed disease
until a true delusional condition is developed; this does not often
occur in hysteria. Hypochondria is seen with as great a frequency in
the male as in the female, while hysteria prevails much more largely
in the female sex. In typical hypochondria more readily than in
hysteria the patient may be led from one set of symptoms to another,
the particulars of which he will detail in obedience to questions that
are put to him, these symptoms not unusually partaking of the
absurd and impossible. In hypochondria are absent those distinctive
symptoms which in nearly all cases of hysteria appear in greater or
less number, such as convulsions, paralysis, contracture, aphonia,
hysterical joints, and the like. In hypochondria is present the
groundless fear of disease without these outward manifestations of
disease. The symptoms of hypochondria, as a rule, but not
invariably, are less likely to change or abate than those of hysteria.

It is often of moment to be able to distinguish between two such well-

marked affections as common acute mania and hysterical mania. In
acute mania the disorder usually comes on gradually; in hysterical
mania the outbreak of excitement is generally sudden, although
prodromic manifestations are sometimes present. This point of
difference is not one to be absolutely depended upon. In acute
mania incoherence and delusions or delusional states are genuine
phenomena; in hysterical mania delusional conditions, often of an
hallucinatory character, may be present, but they are likely to be of a
peculiar character. Frequently, for instance, such patients see, or say
that they see, rats, toads, spiders, and strange beasts. These
delusions have the appearance of being affected in many cases;
very often they are fantastical, and sometimes at least they are
spurious or simulated. In hysterical mania such phenomena as
obstinate mutism, aphonia, pseudo-coma, ecstasy, catalepsy, and
trance often occur, but they are usually absent in the history of cases
of acute mania. In acute mania under the influence of excitement or
delusion the patients may take their own lives: they may starve or kill
themselves violently; in hysterical mania suicide will be threatened or
apparently attempted, but the attempts are not genuine as a rule;
they are rather acts of deception. In acute mania the patients often
become much reduced and emaciated; in hysterical mania in
general, considering the amount of mental and motor excitement
through which the individuals pass, their nutrition remains good. In
acute mania sleeplessness is common, persistent, and depressing;
in hysterical mania usually a fair amount of sleep will be obtained in
twenty-four hours. In many cases of hysterical mania the patients
have their worst attacks early in the morning after a good night's
rest. Acute mania under judicious treatment and management may
gradually recover; sometimes, however, it ends fatally: this is
especially likely to occur if the physician supposes the case to be
simply hysterical and acts accordingly. Hysterical mania seldom has
a serious termination unless through accident or complication.

In order to make the diagnosis of purposive hysterical attacks

watchfulness on the part of the physician will often suffice. Such
patients can frequently be detected slyly watching the physician or
others. Threats or the actual use of harsh measures will sometimes
serve for diagnostic ends, although the greatest care should be
exercised in using such methods in order that injustice be not done.

In uræmia, as in true epilepsy, the convulsion is marked and the

condition of unconsciousness is usually profound. An examination of
the urine for albumen, and the presence of symptoms, such as
dropsical effusion, which point to disorder of the kidneys, will also
assist.
Hysterical paralysis in the form of monoplegia or hemiplegia must
sometimes be distinguished from such organic conditions as
cerebral hemorrhage, embolism or thrombosis, tumor, abscess, or
meningitis (cerebral syphilis).
When the question is between hysteria and paralysis from coarse
brain disease, as hemorrhage, embolism, etc., the history is of great
importance. The hysterical case usually has had previous special
hysterical manifestations. The palsy may be the last of several
attacks, the patient having entirely recovered from other attacks. In
an organic case, if previously attacked, the patient has usually made
an incomplete recovery; the history is of a succession of attacks,
each of which leaves the patient worse. In cerebral syphilis it
happens sometimes that coming and going paralyses occur; but the
improvement in these cases is generally directly traceable to specific
treatment. Partial recoveries take place in embolism, thrombosis,
hemorrhage, etc. when the lesion has been of a limited character,
but the improvement is scarcely ever sufficient to enable the patient
to be classed as recovered. The exciting cause of hysterical and
organic cases of paralysis is different. While in hysterical paralysis
sudden fright, anxiety, anger, or great emotion is frequently the
exciting cause, such psychical cause is most commonly not to be
traced as the factor immediately concerned in the production of the
organic paralysis. In the organic paralysis an apoplectic or
apoplectiform attack of a peculiar kind has usually occurred. In
cerebral hemorrhage or embolism the patient suddenly loses
consciousness, and certain peculiar pulse, temperature, and
respiration phenomena occur. The patient usually remains in a state
of complete unconsciousness for a greater or less period. In hysteria
the conditions are different. A state of pseudo-coma may sometimes
be present, but the temperature, pulse, and respiration will not be
affected as in the organic case.

Hysterical monoplegia or hemiplegia, as a rule, is not as complete as

that of organic origin, and is nearly always accompanied by some
loss of sensation. The face usually escapes entirely. In organic palsy
the face is generally less severely and less permanently affected
than the limbs, but paresis is commonly present in some degree.
Hysterical palsies are more likely to occur upon the left than upon
the right side. Embolism is well known to occur most frequently in the
left middle cerebral artery, thus giving the palsies upon the right. In
hemorrhage and thrombosis the tendency is perhaps almost equal
for the two sides. Some of these and other points of distinction
between organic and hysterical palsies have been given incidentally
under Symptomatology.

In organic hemiplegia aphasia is more likely to occur than in

hysterical cases; and acute bed-sores and wasting of the limbs, with
contractures, are conditions frequently present as distressing
sequelæ. Such is not the rule in hysterical cases, for while there may
be wasting of the limbs from disuse and hysterical contractures, bed-
sores are seldom present, and the wasting and contractures do not
appear so insidiously, nor progressively advance to painful
permanent conditions, as in the organic cases. Mitchell mentions the
fact that in palsies from nerve wounds feeling is apt to come back
first, motion last; while in the hysterical the gain in the power of
motion may go on to full recovery, while the sense of feeling remains
as it was at the beginning of treatment. This point of course would
help only in cases where both sensory and motor loss are present.

The examination of an hysterically palsied limb, if conducted with

care, may often bring out the suppressed power of the patient.
Practising the duplicated, active Swedish movements on such a limb
will sometimes coax resistance from the patient. As already stated,
electro-contractility is retained in hysterical cases.

The disorders from which it may be necessary to diagnosticate

hysterical paraplegia are spinal congestion, subacute generalized
myelitis of the anterior horns (chronic atrophic spinal paralysis of
Duchenne), diffused myelitis, acute ascending paralysis, spinal
hemorrhage, spinal tumor, posterior spinal sclerosis or locomotor
ataxy, lateral sclerosis or spasmodic tabes, multiple cerebro-spinal
sclerosis, and spinal caries.

In spinal congestion the patients come with a history that after

exposure they have lost the use of their lower limbs, and sometimes
of the upper. Heaviness and pain in the back are complained of, and
also more or less pain from lying on the back. Numbness in the legs
and other disturbances of sensation are also present. The paralysis
may be almost altogether complete. Such patients exhibit evidences
of the involvement of the whole cord, but not a complete destructive
involvement. A colored woman, age unknown, had been in her
ordinary health until Nov. 24, 1884. At this time, while washing, she
noticed swelling of the feet, which soon became painful, and finally
associated with loss of power. She had also a girdling sensation
about the abdomen and pain in the back. She was admitted to the
hospital one week later, at which time there was retention of the
urine and feces. She had some soreness and tenderness of the
epigastrium. She complained of dyspnœa, which was apparently
independent of any pulmonary trouble. It was necessary to use the
catheter for one week, by which time control of the bladder had been
regained. The bowels were regulated by purgatives. She was given
large doses of ergot and bromide and iodide of potassium, and
slowly improved, and after a time was able to get out of bed and
walk with the aid of a chair. An examination at the time showed that
the girdling pain had disappeared. There was distinct loss of
sensation. Testing the farado-contractility, it was found that in the
right leg the flexors only responded to the slowly-interrupted current,
while in the left both flexors and extensors responded to the
interrupted current. In both limbs with the galvanic current the flexors
responded to twenty cells, while the extensors responded to fifty
cells. She gradually improved, and was able to leave after having
been in the hospital three months.

The diagnosis of subacute myelitis of the anterior horns from

hysterical paraplegia is often of vital importance. “A young woman,”
says Bennett,107 “suddenly or gradually becomes paralyzed in the
lower extremities. This may in a few days, weeks, or months become
complete or may remain partial. There is no loss of sensation, no
muscular rigidity, no cerebral disturbances, nor any general affection
of the bladder or rectum. The patient's general health may be robust
or it may be delicate. She may be of emotional and hysterical
temperament, or, on the contrary, of a calm and well-balanced
disposition. At first there is no muscular wasting, but as the disease
becomes chronic the limbs may or may not diminish in size. The
entire extremity may be affected or only certain groups of muscles.
Finally, the disease may partially or entirely recover, or remain
almost unchanged for years.” This is a fair general picture of either
disease.
107 Lancet, vol. ii. p. 842, November, 1882.

Two facts are often overlooked in this connection: first, that

poliomyelitis is just as liable to occur in the hysterical as in the other
class; and, secondly, that the symptoms of hysterical paraplegia and
poliomyelitis may go hand in hand.

The history is different in the two affections. Frequent attacks of

paralysis in connection with hysterical symptoms are very
suggestive, although not always positive. In poliomyelitis the disease
may come on with diarrhœa and fever; often it comes on with
vomiting and pain. The patellar reflex is retained, often exaggerated,
and rarely lost, in hysteria, while it is usually lost in poliomyelitis.
Electro-muscular contractility is often normal in hysterical paralysis,
although it is sometimes slightly diminished quantitatively to both
faradism and galvanism: the various muscles of one limb respond
about equally to electricity: there are no reactions of degeneration in
hysterical paralysis as in poliomyelitis. In poliomyelitis reactions of
degeneration are one of the most striking features. The cutaneous
plantar reflex is impaired in hysterical paraplegia; bed-sores are
usually absent, as are also acute trophic eschars and the nail-
markings present both in generalized subacute myelitis and diffused
myelitis. True muscular atrophy is also wanting in hysterical
paraplegia, although the limbs may be lean and wasted from the
original thinness of the patient or from disuse. The temperature of
the limbs is usually good. There is no blueness nor redness of the
limbs, nor are the bowels or bladder uncomfortably affected.

Buzzard108 gives two diagrams (Figs. 16 and 17), which I have

reproduced. They are drawn from photographs. They show two pairs
of feet, which have a certain superficial resemblance. In each the
inner border is drawn up into the position of a not severe varus. They
are the feet of two young women who were in the hospital at the
same time. A (Fig. 16), really a case of acute myelitis, had been
treated as a case of hysteria; and B (Fig. 17), really a case of
hysteria, came in as a paralytic. In these cases the results of
examination into the state of the electrical response and of the
patellar-tendon reflex was sufficient to make a diagnosis clear. In the
organic case the electrical reactions were abnormal and the patellar-
tendon reflex was abolished. These conditions were not present in
the hysterical case.

FIG. 16. FIG. 17.

108 Clin. Lectures on Diseases of the Nervous System, London, 1882.

The diagnosis of hysterical paraplegia from diffused myelitis is

governed practically by the same rules which serve in subacute
myelitis of the anterior horns, with some additional points. In diffused
myelitis, in addition to the motor, trophic, vaso-motor, electrical, and
reflex disorders of myelitis of the anterior horns, affections of
sensibility from involvement of the sensory regions of the cord will
also be present. Anæsthesia and paræsthesia will be present.

Acute ascending paralysis, the so-called Landry's paralysis,

particularly when it runs a variable course, might be mistaken
sometimes for hysterical paralysis. In one instance I saw a fatal case
of Landry's paralysis which had been supposed to be hysterical until
a few hours before death. In Landry's paralysis, however, the swiftly
ascending character of the disorder is usually so well marked as to
lead easily to the diagnosis. In Landry's paralysis the loss of power
begins first in the legs, but soon becomes more pronounced, and
passes to the arms, and in the worst cases swallowing and
respiration become affected.

Spinal hemorrhage and spinal tumors, giving rise to paralysis, may

be mistaken for hysterical paralysis, partly because of the
contractures. Reactions of degenerations are usually features of this
form of organic paralysis. The contractures of hysterical paralysis
can be promptly relieved by deep, strong pressure along supplying
nerve-trunks; this cannot be accomplished in the organic cases.
Severe localized pains in the limbs, sometimes radiating from the
spinal column, are present in the organic cases. Pain may be
complained of by the hysterical patient, but close examination will
show that it is not of the same character, either as regards severity
or duration.

Hysterical locomotor ataxy is usually readily distinguished from

posterior spinal sclerosis, although the phenomena are apparently
more marked and more peculiar than those exhibited as the result of
organic changes. Hysterical ataxic patients often show an
extraordinary inability to balance their movements, this want of co-
ordinating power being observed even in the neck and trunk, as well
as the limbs. In hysterical cases a certain amount of palsy, often of
an irregular type, is more likely to be associated with the ataxia than
in the structural cases. The knee-jerk, so commonly absent in true
posterior spinal sclerosis that its absence has come to be regarded
as almost a pathognomonic symptom of this affection, in hysterical
motor ataxy is present and exaggerated. In hysterical locomotor
ataxy other well-marked symptoms of general hysteria, such as
hysterical convulsions, aphonia, etc., are present.

In the diagnosis of spastic spinal paralysis from hysterical paraplegia

great difficulties will sometimes arise. A complete history of the case
is of the utmost importance in coming to a conclusion. If the case be
hysterical, usually some account of decided hysterical manifestation,
such as aphonia, sudden loss and return of sight, hysterical
seizures, etc., can be had. Althaus holds that a dynamometer which
he has had constructed for measuring the force of the lower
extremities will, at least in a certain number of cases, enable us to
distinguish between the functional and spinal form of spastic
paralysis. In the former, although the patient may be unable to walk,
the dynamometer often exhibits a considerable degree of muscular
power; while in the latter, more especially where the disease is
somewhat advanced, the index of the instrument will only indicate
20° or 30° in place of 140° or 160°, and occasionally will make no
excursion at all.

The diagnosis of multiple cerebro-spinal sclerosis from hysteria

occasionally offers some difficulties. Jolly goes so far as to say that it
can only with certainty be diagnosticated in some cases in its later
stages and by the final issue—cases in which the paralytic
phenomena frequently alter their position, in which paroxysmal
exacerbations and as sudden ameliorations take place, and
convulsive attacks and disturbances of consciousness of a like
complicated nature as in hysteria are met with. Disorders of
deglutition and articulation, also characteristic of multiple cerebro-
spinal sclerosis, are now and again observed in the hysterical.
Recently, through the kindness of J. Solis Cohen, I saw at the
German Hospital in Philadelphia a patient about whom there was for
a time some doubt as to whether the peculiar tremor from which he
suffered was hysterical or sclerotic. At rest and unobserved, he was
usually quiet, but as soon as attention was directed to him the tremor
would begin, at first in the limbs, but soon also in the head and trunk.
If while under observation he attempted any movement with his
hands or feet, the tremor would become violent, and if the effort was
persisted in it would become convulsive in character. The effort to
take a glass of water threw him into such violent spasms as to cause
the water to be splashed in all directions. The fact that this patient
was a quiet, phlegmatic man of middle age, that his troubles had
come on slowly and had progressively increased, that tremor of the
head and trunk was present, that cramps or tonic spasms of the
limbs came and went, indicated the existence of disseminated
sclerosis. The knee-jerk was much exaggerated, taps upon the
patellar tendon causing decided movement; when continued, the leg
would be thrown into violent spasm.

Spondylitis, or caries of the vertebræ, is sometimes difficult to

distinguish from hysterical paraplegia or hysterical paraplegia from it,
or both may be present in the same case. Likewise, painful
paraplegia from cancer or sarcoma of the vertebræ may offer some
difficulties. A woman aged forty-four when two years old had a fall,
which was followed by disease of the spine, and has resulted in the
characteristic deformity of Pott's disease. She was apparently well,
able to do ordinary work, until about five years before she came
under observation, when her legs began to feel heavy and numb,
and with this were some pain and slight loss of power. These
symptoms increased, and in three months were followed by a total
loss of power in the lower extremity. She was admitted to the
hospital, and for about three years was unable to move the legs. She
went round the wards in a wheeled chair. The diagnosis was made
of spondylitis, curvature, and paralysis and sensory disorders
depending on compression myelitis, and it was supposed she was
beyond the reach of remedies. One day one of the resident
physicians gave her a simple digestant or carminative, soon after
which she got up and walked, and has been walking ever since. She
attributes her cure entirely to this medicine.

What is the lesson to be learned from this case? It is, in the first
place, not to consider a patient doomed until you have made a
careful examination. There can be much incurvation of the spine
without sufficient compression to cause complete paralysis. In this
patient organic disease was associated with an hysterical or
neuromimetic condition. This woman had disease of the vertebræ,
the active symptoms of which had subsided. The vertebral column
had assumed a certain shape, and the cord had adjusted itself to this
new position, yet for a long time she was considered incurable from
the fact that the conjunction of a real and a mimetic disorder was
overlooked.