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SHELL SHOCK
Published by the University of Manchester at
THE UNIVERSITY PRESS (H. M. MCKECHNIE, Secretary)
12, Lime Grove, Oxford Road, Manchester.
LONGMANS, GREEN & CO.
London: 39, Paternoster Row
New York: 443-449, Fourth Avenue and Thirtieth Street
Chicago: Prairie Avenue and Twenty-fifth Street
Bombay: Hornby Road
Calcutta: 6, Old Court House Street
Madras: 167, Mount Road
SHELL SHOCK
AND ITS LESSONS
BY
G. ELLIOT SMITH, M.A., M.D., F.R.C.P., F.R.S.
_Dean of the Faculty of Medicine and Professor of Anatomy_
AND
T. H. PEAR, B.Sc.
_Lecturer in Experimental Psychology_
MANCHESTER
AT THE UNIVERSITY PRESS
12, LIME GROVE, OXFORD ROAD
LONGMANS, GREEN & CO.
LONDON, NEW YORK, BOMBAY, ETC.
1917
PUBLICATIONS OF THE UNIVERSITY OF MANCHESTER
No. CXI.
To
MAJOR R. G. ROWS, M.D., R.A.M.C.
Contents.
_Page_
PREFACE vii
INTRODUCTION ix
CHAPTER I.
THE NATURE OF SHELL-SHOCK 1
CHAPTER II.
TREATMENT 27
CHAPTER III.
PSYCHOLOGICAL ANALYSIS AND RE-EDUCATION 53
CHAPTER IV.
SOME GENERAL CONSIDERATIONS 77
CHAPTER V.
SOME LESSONS OF THE WAR 105
INDEX 133
Preface.
Our reasons for writing this book will be explained by the book itself.
We desire here gratefully to acknowledge the help of several friends
who have considerably facilitated our task. Our thanks are due to Major
R. G. ROWS, M.D., R.A.M.C., for his unfailing interest, encouragement
and help; to Captains W. H. R. RIVERS, M.D., F.R.C.P., F.R.S., and
J. W. ASTLEY COOPER of the R.A.M.C., and Mr. E. GLEAVES, M.Sc., for
their valuable suggestions and assistance in the preparation of the
manuscript; to Captain W. E. SAWERS SCOTT, M.D., R.A.M.C., Dr. ALBERT
HOPKINSON and Mr. W. PERCY STOCKS, F.R.C.S., of Manchester, for help
in other ways; and to our colleague, Professor H. BOMPAS SMITH, for
reading the proofs and helping us to eliminate some of the more glaring
literary defects. To the Editor of the _Lancet_ we are indebted for
permission to use part of an article written by one of us. The stream
of requests for fuller information and explanation that poured in upon
the author of that article made the writing of this book an unavoidable
duty.
G. E. S.
T. H. P.
THE MEDICAL SCHOOL,
THE UNIVERSITY,
MANCHESTER.
_20th April, 1917._
Introduction.
Some account of the reasons for the appearance of this book is due to
the reader. During the last year we have been asked repeatedly, both by
members of the medical profession and the lay public, to write a simple
non-technical exposition of the ascertained facts of that malady, or
complex of maladies, for which we have adopted the official designation
“shell-shock.” Until recently such an attempt would have been premature
and largely speculative. But it is now possible to collate the medical
reports, not only from our own army, but also from those of France and
Russia. Valuable and suggestive data have, furthermore, been obtained
from such of the German medical journals as have reached us. The facts
described in the various accounts which we have seen are in close
agreement. The conclusions in this book, therefore, are not based upon
our experience alone.
Our object in thus publishing a brief and simple description of these
facts is twofold: first, to make them available to those who have
neither the time nor the special knowledge necessary for consultation
of the medical journals; secondly, to call attention to the obvious
significance of these truths for the future welfare and happiness of
the nation.
It might seem that to publish a book on this subject at such a time is
merely to irritate existing wounds. The topic is painful; perhaps one
of the saddest of the many grievous aspects of the war. But a condition
exists at present which is immeasurably more painful—the exaggerated
and often unnecessary distress of mind in many of the sufferers and
their friends, which arises from the manner in which we, as a nation,
have been accustomed to regard even the mildest forms of mental
abnormality. Of all varieties of fear, the fear of the unknown is one
of the greatest. Not the least of the successful work performed in the
special hospitals during the war has been the dispelling of this fear
by helping the sufferer to understand his strange symptoms (many of
which are merely unusual for the patient himself) and, in the light of
this new self-knowledge, to win his own way back to health.
It is because we believe that a similar probing of the _public_
wound—the British attitude towards the treatment of mental
disorder—though painful, is justifiable and necessary, that we have
written the concluding chapters of this book. For it cannot be too
strongly urged that the shifting and unstable blend of apathy,
superstition, helpless ignorance and fear with which our own country
has too long regarded these problems is rapidly becoming our exclusive
distinction. It must be realised that America, France, Germany, and
Switzerland have long ago faced the problem in the only practical
way—the scientific one. And to the long list of sciences which we all
agree must be cultivated more assiduously after the war should be
added—but not at, or even near, the end—psychiatry, the science of the
treatment of mental disorders.
Not patriotic motives alone urge this reform, but common sense and
common morality. For shell-shock has brought us no new symptoms. Its
sole ground of difference from other disordered states of mind lies
in its unusually intense and wide-spreading causes. The problems of
shell-shock are the every-day problems of “nervous breakdown.” They
existed before the war, and they will not disappear miraculously with
the coming of peace. The war has forced upon this country a rational
and humane method of caring for and treating mental disorder among
its soldiers. Are these signs of progress merely temporary? Are such
successful measures to be limited to the duration of the war, and to
be restricted to the army? Germany has applied them for years to the
alleviation of suffering among her civilian population, with a success
which has made her famous—outside England. Can we be content to treat
our sufferers with less sympathy, insight and common-sense than Germany?
It is at this time, while our country is anxiously considering how best
to learn the lessons of the war, that we wish to call attention to one
of these lessons which is in danger of being overlooked.
CHAPTER I.
The Nature of Shell-Shock.
A French doctor has said, “Il n’y a pas de maladies; il n’y a que des
malades.”[1] Whatever may be the general validity of this statement,
it is undoubtedly true of the nerve-stricken soldier. Every case is
a case by itself, and as such it must be considered by anyone, be he
layman or doctor, who is interested in its nature and treatment. For
the troubles displayed in the many disorders classed under the official
title shell-shock are extraordinarily numerous and different, and their
removal necessitates a similarly varied repertoire of “opening moves”
on the part of the physician.
Although the term shell-shock has been applied to a group of
affections, many of which cannot strictly be designated as “shock,” and
into the causation of which the effect of the explosion of shells is
merely one of many exciting factors, this term has now come to possess
a more or less definite significance in official documents and in
current conversation. It is for this reason that we have chosen to use
it rather than the more satisfactory, but less widely employed term,
“War-Strain.” The reader will, therefore, understand that whenever
the term shell-shock appears in these pages, it is to be understood
as a popular but inadequate title for all those mental effects of
war experience which are sufficient to incapacitate a man from the
performance of his military duties. The term is vague; perhaps its
use implies too much; but this is not altogether a disadvantage, for
never in the history of mankind have the stresses and strains laid
upon body and mind been so great or so numerous as in the present war.
We may therefore expect to find many cases which present not a single
disease, not even a mixture, but a chemical compound of diseases, so
to speak. In civil life, we often meet with cases of nervous breakdown
uncomplicated by any gross physical injury. We are scarcely likely, for
example, to meet it complicated by gas poisoning and a bullet wound.
Yet such combinations as these—or worse—are to be met with in the
hospitals every day.
This is perhaps an opportune place to point out a significant popular
misunderstanding concerning the nature of such maladies as we shall
discuss in this chapter. A common way of describing the condition
of a man sent back with “shock” is to say that he has “lost his
reason” or “lost his senses.” As a rule, this is a singularly inapt
description of such a condition. Whatever may be the state of mind
of the patient immediately after the mine explosion, the burial in
the dug-out, the sight and sound of his lacerated comrades, or other
appalling experiences which finally incapacitate him for service in the
firing line, it is true to say that by the time of his arrival in a
hospital in England his reason and his senses are usually not lost but
functioning with painful efficiency.
His reason tells him quite correctly, and far too often for his
personal comfort, that had he not given, or failed to carry out, a
particular order, certain disastrous and memory-haunting results
might not have happened. It tells him, quite convincingly, that in
his present state he is not as other men are. Again, the patient
reasons, quite logically, but often from false premises, that since
he is showing certain symptoms which he has always been taught to
associate with “madmen,” he is mad too, or on the way to insanity. If
nobody is available to receive this man’s confidence, to knock away
the false foundations of his belief, to bring the whole structure
of his nightmare clattering about his ears, and finally, to help
him to rebuild for himself (not merely to re-construct for him) a
new and enlightened outlook on his future—in short, if he is left
alone, told to “cheer up” or unwisely isolated, it may be his reason,
rather than the lack of it, which will prove to be his enemy. And
nobody who has observed the hyperæsthesia to noises and light in the
nerve-hospital, nobody who has seen the effects upon the patients of
a coal dropping unexpectedly out of the fire, will have much respect
for the phrase, “lost his senses.” There exist, of course, cases of
functional blindness, deafness, cutaneous anæsthesia and the rest, but
the majority of the nerve patients show none of these disorders and
recovery from them is often rapid.
In a word, it is not in the intellectual but in the _emotional_ sphere
that we must look for terms to describe these conditions. These
disturbances are characterised by instability and exaggeration of
emotion rather than by ineffective or impaired reason.[2] And as we
shall see later, in the re-education of the patient, the physician is
compelled continually to take this fact into account.
As we have pointed out, every nerve-stricken soldier presents a case
by itself. Slavish adherence by the physician to one of the classical
names or labels used in diagnosis usually spells failure. The patient
must be approached _without prejudice_, and the doctor who wishes to
be of real help to him must make up his mind to examine and ponder
over the sufferer’s mental wounds with as much, nay, even more—care and
expenditure of time than would be given to physical injuries. A mere
cursory inspection in the course of the formal ward visit is a solemn
farce, if it pretends to be a serious attempt to cure the mentally
afflicted.
A man standing at “attention” by the side of his bed, surrounded by
his comrades and faced by the medical officer, the military sister,
and perhaps even by other members of the staff may volunteer the
information that he is sleeping badly. But this imposing procession
and cloud of witnesses is scarcely conducive to the production of any
further evidence as to the cause of his insomnia. For of those causes
even pre-war experience makes it possible to assert that their name
is legion, and their character often of an exceedingly intimate and
private nature.
The formal visiting of patients in the wards, while adequate for the
care of physical injuries (which can be subsequently attended to by
trained nurses and sisters) and necessary for administrative and
disciplinary purposes, is insufficient for “mental cases.” It is with
this fact in mind that the military authorities have instituted special
hospitals in which more detailed attention may be given to the latter
class of patients. In these institutions the soldier may have private
interviews with his medical officer, and the history of the trouble
can be unravelled in conversation. _It is only in this way that any
scientific insight into a case of mental disorder can be obtained._
A short time spent in such interviews, or even the perusal, by the
uninitiated, of the papers already published in the _Lancet_, _British
Medical Journal_, and elsewhere[3], will convince one of the immense
complexity of these unusual mental conditions, and moreover, of the
absolute necessity of obtaining and understanding the patient’s past
history, before and during the war. A dozen cases sent back from
the front as shell-shock may prove to possess not a single feature
in common—except the fact of the shell explosion. And this, as has
been pointed out, may be but the “last straw.”[4] The patient often
discloses in the first interview the fact that he was displaying all
his present symptoms _before_ the arrival of the particular shell which
laid him out.
It is now possible to attempt a brief sketch of the typical conditions
which give rise to some of the chief varieties of shell-shock.
Let us take a common case; that of the patient who is returned to
this country, figuring in the casualty lists under the terse and
businesslike military formula, “shock, shell.”
For various reasons, which the reader will easily supply, we choose to
present a composite picture of the history of such a soldier. Not all
the conditions described here need necessarily have operated in any
one case taken at random, but we shall err, if at all, on the side of
understatement. The correctness of the description may be checked by a
reference to the papers already mentioned.[5]
We must first try to conceive the experiences of the soldier before the
occurrence of the knock-out blow, so far as they bear on his present
condition. Let us suppose that his period of training has made him
physically and mentally fitter than he had ever been before, that no
military causes of anxiety or fear, such as the experience or the
anticipation of being torpedoed on the outward voyage, have operated
to any noteworthy extent in his case. He enters the trenches in
first-class condition. The duration of his stay there, provided he is
not wounded, or attacked by any bodily illness, will depend from that
time forward upon the nature, duration, intensity and frequency of the
emotion-exciting causes, and upon himself. By that all-inclusive word
“himself” we mean to signify chiefly his temperament, disposition and
character.[6]
It must be remembered that one of the greatest sources of breakdown
under such circumstances is intense and frequently repeated emotion.[7]
By this is meant not only experiences of fear or of sympathy with
suffering comrades, in short, those conditions the manifestations
of which might cause the man in the trenches to be spoken of as
“emotional,” but also other mental states associated with general
excitement, anxiety, remorse for major or minor errors, anger, elation,
depression and that complex but very real state, the fear of being
afraid. (The more definite terms of technical psychology are not used
here, as it is considered wiser to employ popular language.)
The soldier may be subjected to intense emotional stimuli of this kind
for days or weeks without relief. And whereas to the mental sufferer
in civil life sleep often is vouchsafed, “setting him on his feet”
to continue, more or less effectively, the struggle next day, to
the soldier sleep may be impossible, not necessarily because of his
excited mental state, but simply from the lack of opportunity or the
disturbances going on about him. In course of time this loss of sleep
from external causes may easily set up bodily and mental excitability,
which in its turn acts as a further cause of insomnia. The usual mental
conditions associated with loss of sleep then rapidly supervene:
pains and unpleasant organic sensations, hyperæsthesia, irritability,
emotional instability, inability to fix the attention successfully
upon important matters for any length of time, loss of the power of
inhibition and self-control.[8]
These symptoms, troublesome enough in civil life, become positively
dangerous to the man in the trenches, especially if he is in a position
of responsibility. In that case his standing as officer or N.C.O.
merely adds to his mental distress. Bodily hardship, such as exposure
to cold and wet, hunger, and the irritation from vermin, obviously
aggravates the disorders we have described.
We must not suppose, however, that the man who is experiencing some or
all of these mental and bodily conditions is at this period necessarily
displaying any obvious _outward_ signs of his trouble. There may be
no tremor, no twitchings, no loss of control of the facial or vocal
muscles which would indicate his state even to his neighbours. He may,
for a long time, “consume his own smoke.” And during this process he
may even appear to his comrades to be steadier and more contemptuous
of danger than before. Dr. Forsyth[9] has cited some dramatic
incidents, in which officers who imagined that their instinctive fear
was becoming apparent to the men under their command took unnecessary
risks in order to impress these men with the idea that they were not
afraid.
It must be understood that this suppression of the external
manifestations of an emotion such as fear is but a partial dominance
of the bodily concomitants of that emotion. The only changes which
can usually be controlled by the will are those of the voluntary or
skeletal muscular system, not those of the involuntary or visceral
mechanism. While no signs of fear can yet be detected in the face,
the body, limbs or voice, these disturbances of the respiratory,
circulatory, digestive and excretory systems may be present in a very
unpleasant degree, probably even intensified because the nervous energy
is denied other channels of outlet.[10]
The suppression of fear and other strong emotions is not demanded only
of men in the trenches. It is constantly expected in ordinary society.
But the experience of the war has brought two facts prominently before
us. First, before this epoch of trench warfare very few people have
been called upon to suppress fear continually for a very long period
of time. Secondly, men feel fear in different ways and in very various
degrees.
The first fact accounts for the collapse, under the long continued
strain of trench warfare, of men who have shown themselves repeatedly
to be brave and trustworthy. They may have felt intense emotions,
obviously not of fear alone, for a long time without displaying any
signs of them. But suppression of emotion is a very exhausting process.
As Bacon says, “We know diseases of stoppings and suffocations are the
most dangerous in the body; and it is not much otherwise in the mind.”
The second fact mentioned above is of great importance in the
consideration of our problem. There are undoubtedly men who seem to be
immune to fear of the dangers of warfare. But to them we can scarcely
apply the adjective “brave.” The brave man is one, who, feeling fear,
either overcomes it or refuses to allow its effects to prevent the
execution of his duty.
Other emotional states however, besides fear, arise and require
suppression. The tendency to feel sympathetic pain or distress at
harrowing sights and sounds, disgust or nausea at the happenings in
the trenches, the “jumpy” tension in face of unknown dangers such as
mines—all these, like fear, are or have been biologically useful under
natural conditions and, like it, are deeply and innately rooted in man.
But the unnatural conditions of modern warfare make it necessary that
they shall be held in check for extraordinarily long periods of time.
The impossibility of regarding modern methods of warfare in the same
light as natural and primitive means of fighting appears very clearly
when we consider the instinctive and emotional factors involved in the
two sets of circumstances. In natural fighting, face to face with his
antagonist, and armed only with his hands or with some primitive weapon
for close fighting, the uppermost instinct in a healthy man would
naturally be that of pugnacity, with its accompanying emotion of anger.
The effect of every blow would be visible, and the intense excitement
aroused in the relatively short contest would tend to obliterate the
action of other instincts such as that of flight, with its emotion of
fear. But in trench warfare the conditions are different. A man has
seldom a personal enemy whom he can see and upon whom he can observe
the effects of his attacks. His anger cannot be directed intensely
night and day against a trench full of unseen men in the same way
in which it can be provoked by an attack upon him by an individual.
And frequently the assaults made upon him nowadays are impersonal,
undiscriminating and unpredictable, as in the case of heavy shelling.
One natural way is forbidden him in which he might give vent to his
pent-up emotion, by rushing out and charging the enemy. He is thus
attacked from within and without. The noise of the bursting shells,
the premonitory sounds of approaching missiles during exciting periods
of waiting, and the sight of those injured in his vicinity whom he
cannot help, all assail him, while at the same time he may be fighting
desperately with himself. Finally, he may collapse when a shell bursts
near him, though he need not necessarily have been injured by actual
contact with particles of the bursting missile, earth thrown up by its
impact, or gases emanating from its explosion. He may or may not be
rendered unconscious at the time.[11] He is removed from the trenches
with loss of consciousness or in a dazed or delirious condition with
twitchings, tremblings or absence of muscular power.
Upon recovery of consciousness, which may take place after periods
varying between a few minutes and a few weeks, the immediate disorders
of sensation, emotion, intellect, and movement, are often very severe.
It may be presumed that at the beginning of the war they must have
appeared far more serious to most of the doctors who saw them in their
early stages than they would now. This speculation is suggested by the
evidence of the case-sheets sent with the men from France in the early
period of the campaign. Such diagnoses as “delusional insanity,” and
other similar terms taken from the current classifications of advanced
conditions of insanity, appear very frequently as descriptions of cases
which on arrival in England had almost entirely lost every sign of
mental unusualness. In fact, one of the most cheering aspects of work
amongst this type of case has been the rapidity with which men who have
presented quite alarming symptoms have subsequently recovered.
It may seem almost unnecessary to enumerate the bizarre phenomena which
constitute the immediate results of shell-shock, for our newspapers
have naturally seized upon such unusual details and have made the most
of their opportunities in this direction. But the reader will obtain a
clearer idea of the facts if they are catalogued once more.
The most obvious phenomena are undoubtedly the disturbances of
sensation and movement. A soldier may be struck blind, deaf or dumb
by a bursting shell: in rare cases he may exhibit all three disorders
simultaneously or even successively. It should be added that these
troubles often vanish after a short space of time, as suddenly and
dramatically as they appeared. Thus one of the blinded soldier
survivors of the _Hesperian_ recovered his sight on being thrown into
the water. Other blind patients have had their sight restored under
the action of hypnosis. Mutism is often conquered by the shock of a
violent emotion, produced accidentally or purposely. Examples of such
“shocking” events taken at random from our experience were the sight
of another patient slipping from the arms of an orderly, the “going
under” chloroform, the application of a faradic current to the neck,
the announcement at a “picture house” of Rumania’s entry into the war
(this cured two cases simultaneously), and the sight of the antics
of our most popular film comedian. The latter agency cured a case of
functional deaf-mutism, the patient’s first auditory sensations being
the sound of his own laugh.
The muscular system may be affected in an equally striking manner.
Contractures often occur in which a man’s fist may be immovably
clenched for months; or his back may be bent almost at right angles
to his lower limbs, there being in neither case any bodily change
discoverable by the neurologist which can account for such a condition.
These contractures, though curable, often prove very obstinate, and at
present their nature remains somewhat of a mystery. Other distressing
and long continued disturbances take the form of muscular twitchings
and tremors or loss of power in the limbs.
Not every nerve-case, however, presents such striking and objective
signs as those which we have just been describing. The _subjective_
disturbances, which are apt to go undiscovered in a cursory examination
of the patient, are frequently more serious than the objective,[12]
and are experienced by thousands of patients who to the mere casual
observer may present no more signs of abnormality than a slight tremor,
a stammer, or a depressed or excited expression. These afflictions:
loss of memory, insomnia, terrifying dreams, pains, emotional
instability, diminution of self-confidence and self-control, attacks
of unconsciousness or of changed consciousness sometimes accompanied
by convulsive movements resembling those characteristic of epileptic
fits, incapacity to understand any but the simplest matters, obsessive
thoughts, usually of the gloomiest and most painful kind, even in some
cases hallucinations and incipient delusions—make life for some of
their victims a veritable hell. Such patients may have recovered from
sensory or motor disturbances and yet may suffer from any or all of
these afflictions as a residuum from the original “shock-complex;” they
may suffer from them as a complication of the discomfort attending upon
a wound or an illness, or, on the other hand, they may have no overt
bodily disorder: their malady then being usually given the simple but
all-inclusive (and blessed) description “neurasthenia.”
Now the happiness and welfare of such men obviously is bound up to no
small extent with the character of the hospital or hospitals (for the
plural number is commonly to be used in writing the history of these
patients) to which they are sent. In the general military hospitals the
medical officers have neither the time nor, in many cases, the special
knowledge, necessary to deal with cases of this kind. Such patients
may recover of themselves without any treatment, but a large number
of them tend to get worse, and if they are left without attention
their symptoms are apt to become stereotyped into definite delusions
and hallucinations. Moreover, in a general ward such men may become
a constant source of disturbance and annoyance to other patients
and to the nurses. One of the symptoms of their illness is a morbid
irritability; they tend to become upset and to take offence at the
merest trifles[13]—and this leads to trouble with patients, nurses,
and the medical officers responsible for discipline. But if special
consideration is shown them by the nurses the other patients are apt to
misunderstand it and even to complain of favouritism. In other words,
when mixed with wound-cases in a general hospital, these nervous
patients are apt to be regarded as a nuisance—which is bad for them and
for the proper working of the hospital. Another consideration, too,
is that the subjection of such men to irksome regulations of military
discipline, and the usual penalties for infringing them, is often so
potent a factor in producing disturbances as to be quite fatal to any
hope of amelioration.
These considerations have led the military authorities to establish
special hospitals for nerve-cases.[14] In such institutions the
patients can be nursed and attended to by a staff which, being used to
the idiosyncrasies of such illnesses can make conditions more suitable
to them.
A man’s particular nervous malady is likely to be of common occurrence
in the nerve-hospital; it does not render him conspicuous, and
therefore an object of fussy solicitude, galling pity, or suspicious
contempt, as is too often the case in other institutions. If unwounded,
he need not suffer the taunt of “having nothing to show” as his reason
for staying in hospital. Further, while in the special hospital,
more importance is attached to some of the patient’s symptoms, less
disturbance is produced by others. The occurrence of a “fit” is
viewed by the rest of the men in this class of hospital in a truer
perspective, and the patient does not find himself a nine-days’
wonder, as he so easily may do in a small auxiliary hospital full of
straightforward wound cases.
Up to this point we have discussed the various troubles subsumed under
the term shell-shock in what may be termed its initial and middle
stages. In the middle stage, the patient having recovered from the
severe and acute symptoms constituting the former phase, is left with
a motley residuum of troubles, the chief of which we have enumerated
on pages 12, 13. In distinguishing between this middle stage and
that which follows it, we may perhaps ask the reader to assist us by
recalling the difference between a mechanical mixture and a chemical
compound. In the former the ingredients of the mixture remain unaltered
and unaffected by the proximity of other substances, as for example
when sugar is mixed with sand. In the compound, on the other hand,
chemical action and reaction occur between the components so that not
one of the substances is immediately recognisable in the complex, as
for example when carbon, hydrogen and oxygen combine to form alcohol,
which resembles none of them.
Now it would be distorting the facts of mind to suggest that while the
third stage of shell-shock is a compound (as it undoubtedly is) the
middle stage is a mixture. For the very essence of mind is its compound
nature. But what we wish to point out is that in this middle stage the
abnormalities have had very little time to react upon each other, with
the result that there is some resemblance to a state of mixture, the
phenomena existing temporarily side by side, so to speak. In this stage
a patient may be troubled simultaneously by several unusual mental
occurrences, such as terrifying dreams during very light sleep, loss
of memory for certain periods of his past, and inability to understand
or to carry out complex orders. For a short time in his “bowled-over”
state he may be worried by the separate attacks, of these various
troubles at different periods of the day and he may be too overwhelmed
to try to understand or to attempt to see relations between them. This
state of mind, in which the patient is still his “old self,” though
a somewhat overturned self, resembles the mechanical mixture in our
illustration. The reader may obtain some idea of this condition if he
recalls any one day in his own experience when “everything seemed to go
wrong”; when at one moment he was turning to face this difficulty, at
another, that, but still retained to a great extent his usual attitude
towards the world.
As has been pointed out, however, the state of “mechanical mixture” is
utterly alien to the normal mind, which tends rapidly to interpret, in
the light of its own experience, and to integrate as far as possible,
its events, however incongruous they may be. The mind cannot, for any
length of time, allow a new experience to remain strange or undigested.
It must gather in and assimilate that event to the systematised complex
which we call its own past experience. It follows that the ultimate
result upon any particular mind of a new experience, if it be of a
personally significant nature, will depend almost entirely upon the
past history of that mind.
Thus for example the question whether the patient can or cannot
satisfactorily stand up to his new troubles will be determined not only
by his disposition, temperament and character, but also by his previous
personal experience.
It is thus obvious to anyone who gives the matter any serious
consideration, that the manifestation of a severe psychical shock must
necessarily be determined in a large measure by the nature of the mind
upon which the injury falls. It would be idle to pretend therefore,
that, in diagnosis, the story of the patient’s past experience can be
left out of account, for the manifestation of the injury will obviously
depend largely upon the individual patient’s “mental make-up.”
Faced by the existence of a number of unusual mental phenomena the
patient will inevitably succeed in time in inventing for himself,
explanations of their co-existence. This “rationalisation,”[15] as it
is called, is a perfectly normal process which is constantly going on
in every individual, yet it plays a great part in complicating the
mental disorders of the middle stage, and thereby intensifying the
patient’s ultimate distress. For instance, he may not be more than
temporarily disturbed by the unusual experiences we have mentioned[16]
if they assail him separately. But, given time, he will soon begin
to connect their appearances, and will argue to himself that these
phenomena can have only one meaning: that he is mad or rapidly becoming
so. And in this completely erroneous procedure he will be aided and
abetted, not only by his own ignorance of the relation of mental
normality to abnormality, but also by the general tendency of the
uneducated to class everything unusual in the mental sphere as “mad.”
Once he is convinced that he is in this state he may easily lose all
hope of getting better, thereby increasing enormously the gravity
of his case. Completely illogical, but to him entirely satisfactory
explanations of his condition will then multiply.
As we have mentioned, this rationalisation is no unusual phenomenon
in ordinary life. It will be clear to anyone who gives the question
a moment’s thought that few of the non-scientific[17] beliefs held
by even a highly educated person have ever been logically reasoned
out from fundamental principles. In fact such principles frequently
cannot be reached, for the very good reason that they have never been
consciously conceived by the individual. One’s views on religion,
politics, or the relations and rights of the sexes may exhibit in their
outer casings a semblance of rational structure: their core, however,
is not reason but emotion. As James expresses it:—
“In its inner nature, belief or the sense of reality is a sort of
feeling more allied to the emotions than to anything else ... reality
means simply relation to our emotional and active life. This is the
only sense which the word ever has in the mouths of practical men....
Whenever an object so appeals to us that we turn to it, accept it,
fill our mind with it, or practically take account of it, so far it is
real for us and we believe it. Whenever, on the contrary, we ignore
it, fail to consider it or act upon it, despise it, reject it, forget
it, so far it is unreal for us and is disbelieved.... Whatever things
have intimate and continuous connection with my life are things whose
reality I cannot doubt.”[18]
Few people, however, realise this truth so clearly, or express it so
lucidly, as Professor James. Often we believe that we are logically
convinced when in reality we have been convinced first, and have
invented reasons for our conviction afterwards. But many of our beliefs
and attitudes have been implanted in us in childhood or early youth
by processes which could not by the wildest stretch of imagination be
called logical. And not the least important of those beliefs are those
held by the average Briton with regard to insanity.[19]
For the patient, then, his mental troubles, having intimate and
continuous connection with his life, become very real indeed. But the
longer he is left alone to “cheer up,” the longer he broods over his
troubles in isolation, the longer he is allowed to build theories
upon his inadequate and inaccurate data, the more intimately and
continuously connected with his life will the abnormalities become.
They may come to be so integrated with each other that his very
personality becomes tinged. Then he is no longer a normal person
battling with his separate enemies, but one who has made terms, and
those often disastrous ones, with his closely allied foes. An attempt
to cure him at this stage will then necessitate the analysis of a
highly complex compound, while in the early and middle stages merely
the attack upon separated elements is necessary.
We are concerned at present with the facts of shell-shock, but this
is perhaps a suitable place in which to deal with an opinion about
this set of phenomena, which is not uncommon, especially perhaps in
people above military age. That judgment, expressed sometimes bluntly,
but oftener in a more subtle fashion, is that shock or neurasthenia
are polite names for nothing else but “funk.” It is not easy to take
a dispassionate view of this question, but to persons holding this
opinion the following points are worthy of consideration.
First, the most severe and distressing symptoms occur to a surprising
extent in the case of those patients whose past history shows that,
far from possessing even the normal quota of timidity, they had been
noted for their “dare-devilry” and had been specially chosen as
despatch-riders, snipers and stretcher-bearers in the firing line.
Secondly, it is not uncommon for patients to ask to be sent back to
duty because they feel that they have been too long with nothing to
do, while it is quite obvious to the doctor that they are as yet unfit
to bear any great strain. Thirdly, the seasoned regular, officer or
N.C.O.,[20] as well as the young soldier of only a few months’ service
may display precisely the same symptoms as those we have described.
Such men have frequently been in the army for many years, and have
fought on previous occasions with great success. Their strength of
mind and body has been demonstrated over and over again, yet at last
they have broken down. And they manifest the greatest concern at their
unusual symptoms.
It will be readily granted, of course, that there exist among the nerve
patients returned from the front cases in which there is genuine fear
of the war, arising from memories of the experiences which they have
undergone. Even this state of mind, however, is usually expressed by
the patient in some such phrase as “I don’t want to go back, but I’ll
go quite willingly if I’m ordered to.” It should not be forgotten,
moreover, that not a small number of instances are known in which these
men prove to have made repeated attempts at enlistment after having
been rejected several times, or even discharged from the army, changing
their medical examiner until they have succeeded. One case, presenting
a great number of the symptoms of shell-shock in a very intense form,
including, beside the ordinary neurasthenic troubles, blindness,
deafness, and mutism at successive times, was that of a man who had
been discharged from the army as medically unfit and had re-enlisted.
Two cases may be quoted here in illustration of some of these
assertions:
The first is that of a non-commissioned officer who went through the
initial eleven months of the war in France and Flanders, was subjected
to every kind of strain, physical, mental and moral, which that
stricken field provided; and in addition was wounded twice, gassed
twice, and buried under a house, on all five occasions being treated
in the field ambulance and then returning to the trenches. After all
this experience he had not qualified for sick leave, but was granted
five days ordinary leave to return home, apparently in a good state of
health. After reaching England and while waiting for a train in the
railway station, he suddenly collapsed, became unconscious, and for
months afterwards was the subject of severe neurasthenia. Apparently at
the front the excitement, the sense of responsibility and especially
the example that he felt he should set his men, seem to have kept him
right. These stimuli removed, he broke down. The whole of his trouble
seemed to be due to the dread lest on his return to the front, the
added responsibilities which would fall upon his shoulders (because
most of his own officers had been killed and there would be new men
to replace them) might be too much for him. His intelligence seemed
(to himself) to have become numbed by his experiences, and he became
conscious of the unreliability of his memory and of his inability
to understand not only complex orders, but, as he put it, “even
the newspapers.” It was this that excited in him the dread lest he
should be incompetent to discharge adequately the duties which would
fall upon him. There was nothing of malingering or shirking in his
case. There was no fear of physical injuries or of returning to the
front; on the contrary, he was anxious to go back. His fear lest the
possibility of his failure would be bad for his platoon was wholly due
to that admirable sentiment of regimental loyalty, which comes out so
strikingly in the nervous troubles of the non-commissioned officer.
This class of case demands a great deal of patient and sympathetic
attention before the real cause of the trouble is elicited, and then
months of re-education may be required to build up anew the man’s
confidence in himself.
The second case is that of a soldier who had suffered from severe shock
symptoms and had recovered. In conversation with the medical officer
the soldier expressed his willingness, and even his desire, to return
to the front, in full knowledge of the fact that the officer’s report
in that sense would lead to his being sent back to fight. That night
the patient was awakened by a terrifying dream, the true significance
of which was certainly not adequately appreciated by him. Although
he dreamt that he was afraid to go back to the front, apparently he
did not realise that he was actually afraid—_i.e._, that the dream
had any meaning. On examination it proved to be a detailed forecast
of the imaginary incidents of his return to his regiment, and of his
attempt to commit suicide when ordered to go to France. Here was a
man who of his own initiative had asked his doctor to certify him as
ready to go back, yet in his sleep the train of thought, started by the
discussion of the possibility of his return, working subconsciously,
had stirred up images of what this implied, and reinstated emotions of
so terrifying a nature that in his dream he preferred suicide to facing
the ordeal again.
It may perhaps be allowable to quote in this connection the view of a
German neurologist, Prof. Gaupp, on the “shock-cases” which have been
sent back from the German front.[21] At the same time it is important
to remind our readers that Gaupp is writing of a conscript army,
the authorities in which are certainly not notorious for lenity to
the individual; further, that up to the time of writing the present
chapter, all the “shock” patients in Great Britain have been men who
voluntarily elected to serve their country, the majority of them
having enlisted in the earliest stages of the war.
In discussing cases where nervous trouble, uncontrollable in nature and
intensity, had led to the patients being kept in German hospitals for
months, it was sometimes found that the mental foundation which was a
causal factor of these troubles was a more or less conscious anxiety
concerning the possibility of a return to the front.
“There is no justification,” says Gaupp, “for calling every instance
of this a case of malingering or simulation. There are quite capable
men of irreproachable character whose nervous system is positively
unfitted for the hardships and horrors of war. They have enthusiasm
and the best of intentions but these cease to inspire them when the
horrors and terrors come. Their inner strength rapidly decreases,
and it only requires an acute storm to break upon the nervous system
(such as the explosion of a shell or the death of comrades) for their
self-control to vanish completely. Then automatically their condition
changes into what is popularly called ‘hysteria.’ The exhausted mind
then feels that it is no longer master of the situation, and therefore
‘takes refuge in disease.’ At first, as a rule, obvious signs of
terror and anxiety (trembling, twitching, etc.) manifest themselves;
if these are cured there still remain chronic symptoms of hypochondria
and despondency. Time, however, has its effect in many of these
cases.”[22]
If a patient comes into the hands of a physician before the processes
of rationalisation and systematisation have become established, the
medical officer should be able to meet his difficulties, and help him
correctly to interpret his unusual experiences by explaining to him
their origin and nature.
“The application of discreet sympathy and tact by a physician who
endeavours to discover something of the man’s past mental history may
be able to reassure a patient upon his particular trouble with the
happiest of results. To a man quite unacquainted with text-books or
speculation on psychology there can be no darker mystery than the
working of other people’s minds. To such a man the natural conclusion
is that his own mental processes are universal and normal. But if,
as a result of some nerve-shattering experience of warfare his mind
suddenly develops a trick which was quite unknown to him before,
though this development may be far from abnormal, to the troubled
patient it may seem to be an unquestionable symptom of madness.”[23]
Many of the cases in which a patient has merely needed reassuring
have been of this type. A short and very simple explanation of some
elementary facts of psychology is often sufficient to bring about an
immense change in the man’s condition, which has led to his curing
himself. And this is the ideal method of cure.
It may seem that an inordinate amount of space has been devoted to the
demonstration of a simple truth, that mental, like bodily disorder,
should be treated early, or complications may ensue. But there are
reasons for giving so much prominence to this aspect of the subject.
The chief is that in our own country, mental disorder is seldom treated
in its early stages. Nearly all our elaborate public machinery for
dealing with this distressing form of illness is devised, and in
practice is available, only for the advanced cases. This war has shown
clearly a truth which, of course, was already known before to many
doctors, but never adequately appreciated by the general public, that
a case of advanced mental disorder may pass not only through various
milder stages on its way, but that if intercepted at these earlier
stages, it may frequently be cured with ease.
Another point which should be emphasised is this: shell-shock involves
no _new_ symptoms or disorders. Every one was known beforehand in
civil life. If by any stretch of the imagination we could speak of a
specific variety of disease called shell-shock, it would be new only
in its unusually great number of ingredients. And the most gratifying
truth of all is that even this hydra-headed monster, if caught young,
can be destroyed.
From the fact that shell-shock includes no new disorders the important
inference may be drawn that the medical lessons taught by the war must
not be forgotten when peace comes. The civilian should be offered
the facilities for cure which have proved such a blessing to the
war-stricken soldier.
FOOTNOTES:
[1] There are no sicknesses, there are only sick people.
[2] This subject has been lucidly discussed by C. Burt, “Psychology and
the Emotions,” _School Hygiene_, May, 1916.
[3] Such as for instance, D. Forsyth, _Lancet_, Dec. 25th, 1915, p.
1399; C. S. Myers, _Lancet_, Mar. 18th, p. 608; R. G. Rows, _Brit. Med.
Jour._, Mar. 25th, 1916, p. 441; G. Elliot Smith, _Lancet_, April 15th
and 22nd, 1916; H. Wiltshire, _Lancet_, June 17th, 1916.
[4] Wiltshire, _op. cit._, p. 1210.
[5] On pp. 4, 5.
[6] The reader who is interested in these important distinctions should
consult McDougall, _Social Psychology_, London, 1915, p. 116.
[7] _Cf._ the statements of two experienced neurologists:—Déjerine and
Gauckler (written before the war), “Overwork and fatigue are no more a
cause of neurasthenia than they are of tuberculosis. Without emotion
there are no psychoneuroses.”
(_The Psychoneuroses and their Treatment by Psychotherapy_, Jelliffe’s
translation, 1913, p. 232.)
[8] An experimental investigation of the mental effects of loss
of sleep has been carried out by Miss May Smith of the Oxford
Psychological Laboratory. A short account of these experiments
and their results is given in “Some Experimental Investigations
of Fatigue,” by T. H. Pear, _Proceedings of London County Council
Conference of Teachers_, 1914.
[9] _Op. cit._, p. 1402.
[10] In his book, “Bodily Changes produced by Fear, Pain, Hunger and
Rage,” Professor Cannon has given a striking demonstration of the
importance of emotion in producing such bodily disturbances.
[11] Capt. Wiltshire, as a result of recent experience near the firing
line in France thinks that the men’s accounts of the duration of
unconsciousness are often exaggerated, owing to their faulty memory of
the time at which it occurred. He also says that in his opinion the
actual individual shell-shock which prostrates the man is but the final
precipitating cause. (_Op. cit._, p. 1207.)
[12] This fact is in danger of being overlooked by members of the
public whose knowledge of “shock” is obtained from the newspaper
reports.
[13] R. G. Rows, _op. cit._, p. 441.
[14] For particulars of these hospitals, see W. Aldren Turner’s
Report, _Lancet_, May 27th, 1916, p. 1073. The reports published in
the special war numbers of the _Revue Neurologique_ (and especially
Nos. 23, 24, November and December, 1915) bear ample testimony to the
magnificent work being done by the French in this direction. Not only
has special provision been made in each military district for dealing
with neurological and mental cases, but also admirable accounts of the
work are being published, and those responsible for the care of such
patients have been afforded many opportunities for discussing their
difficulties and learning from each other.
[15] Or “seeking conscious and rational grounds for actions”
(and beliefs) “whose motives are largely unconscious and perhaps
irrational.” (A description borrowed from Burt’s article, _q. v._)
[16] On pp. 12, 13.
[17] (and, obviously, the same may be said of not a few ‘scientific’
beliefs.)
[18] _Principles of Psychology_, II., 283-324.
[19] The opinions of Dr. Bedford Pierce upon this matter are highly
important. _British Medical Journal_, January 8th, 1916, p. 4.
[20] Our personal experience has been of privates and non-commissioned
officers only, but there is no _a priori_ reason for supposing that
these remarks do not apply to the commissioned ranks. It has been found
that in the French Army the cases of neurasthenia amongst officers have
been very numerous.
[21] “Hysterie und Kriegsdienst” (Hysteria and War Service), _Münchener
Medizinische Wochenschrift_, March 16th, 1915.
[22] The translation is very free, but it fairly represents the sense
of the German original.
[23] From a leading article on “War-Shock and its Treatment,” in the
_Manchester Guardian_.