Shell Shock and Its Lessons

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.

The Nature of Shell-Shock.

A French doctor has said, “Il n’y a pas de maladies; il n’y a que des malades.” 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.

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