Shell shock and its lessons

by Grafton Elliot Smith; T. H. Pear

There are still not a few physicians who regard the group of functional troubles commonly labelled “hysteria” as something closely akin to malingering. If it would not be considered invidious we could quote the opinions of well-known physicians published within the last five years, suggesting that there is no real line of demarcation. (It is not uncommon to meet the expression “detecting,” instead of diagnosing hysteria.)

But even among those who regard these serious affections as something more than mere simulation there is a tendency to look upon any form of sympathy as a dangerous pandering to the patient’s lack of will power.[27]

This attitude often finds expression in leaving the patient alone to get better by his own efforts, or in suggesting to him that he is not so ill as he thinks he is, and that all he needs is some work to occupy his attention.

The attempt is often made to justify such methods by the plea that it is “bad for the patient to talk to him of his worries.” But how a physician is to rid a patient of the very root of all his trouble without first discovering and then discussing it with him is not apparent. Nor, again, is it any more rational merely to tell a man who is weighed down with some very real anxiety to “cheer up,” or to “work in the garden,” or “take a walking tour.”

We are not maintaining that such methods do not often meet with success in the case of many patients who are only mildly affected and earnestly want to get better. But experience shows that such advice is often fraught with danger, and, in severe cases of mental affection is worse than useless. The experience of those physicians who have been treating such patients with sympathetic insight during the last two years affords a striking condemnation of the theory that it is generally “bad to talk to them of their worries.” It has repeatedly happened that as soon as the patient was asked about his troubles he made a full statement of all that was troubling him and was obviously relieved to confess his worries to someone who took an intelligent interest in his welfare.

In many cases the mere unburdening of this weight of anxiety and the removal by the physician of quite trivial misunderstandings which were the original causes of it, were sufficient to cheer up the patient and to start him on the way to complete recovery. Yet many of these men had been inmates of a series of hospitals in which no attempt had been made to discover what was the real source of all the trouble. Thus to their other worries and anxieties was added the real additional grievance that they were being neglected and were of no account. In many cases this constituted a serious aggravation of the patient’s mental disturbance and encouraged him to believe that his state was already beyond help.

Those physicians who look upon such milder psychoses as varieties of simulation should be reminded that the methods we have just mentioned are not often likely to be effective in cases of real malingering.

In discussing the therapeutic use of “firmness” we have not thought it necessary to mention those applications of this method which at times are practised by combatant officers at the front. The use of military authority to suppress the minor manifestations of nervousness, or the resort to such expedients as unexpectedly firing off a gun alongside a man afflicted with functional deafness, are merely examples of the application of “suggestion.” They are akin to the use of “firmness” by the physician who has not investigated the cause of the patient’s trouble. The results of such expedients are as erratic in the one case as in the other. But there is no need for us to discuss this practice further, except to add that the knowledge that such “treatment by military authority” has been tried before, still further diminishes the justification for resorting to such measures when the patient reaches the home hospital.

Isolation. Many physicians regard isolation as an appropriate method of treatment for soldiers suffering from shock, and they urge in justification of such a procedure the success which often attends its use in civil cases. We do not deny the utility of isolation for suitable cases, and success has attended its use when the patient’s condition obviously required it. But the circumstances which were responsible for causing the mental disturbance in the soldier may be of a totally different nature from those which have upset the civilian; and therapeutic measures which may be appropriate in eliminating the civilian’s sources of irritation might be wholly unsuitable, if not positively harmful, in the case of soldiers.

It cannot be too strongly emphasised in connection with this subject that most of the theory and practice of treating hysteria by isolation has been developed in civil life, and in very many cases with reference to well-to-do women living in the lap of luxury. When such persons develop hysterical symptoms, some sources of irritation in the home or the social environment are often responsible. By isolation the patient is removed from the noxious influence of both domestic worries and mistaken sympathy; his or her whims and fancies are compulsorily subordinated by self-discipline and consideration for others. At home it is impossible satisfactorily to enforce such measures and the attempt to do so will almost inevitably fail, because sympathy, curiosity and anxiety on the part of various relatives hinder the attainment of these objects. By isolation the patient is removed from these unfavourable psychical influences. Through the freedom from such disturbing stimuli, the abnormally intense reaction of the mind is reduced. And in many patients of this class the desire to be cured or to be active, which is produced by the boredom of isolation, works favourably.[28]