Shell shock and its lessons

by Grafton Elliot Smith; T. H. Pear

The case was one of violent spasmodic tremor in the right arm of a soldier. When in a state of convalescence from a wound and shell-shock he suddenly encountered his company officer, to whom he was greatly attached. This officer had lost his right arm since he was last seen in France by the patient. The shock of suddenly meeting the officer in this condition set up the man’s tremor. The case came under psychotherapeutic treatment some weeks later, when the patient, who was an extremely emotional individual, had lost all hope of recovery. Any attempt at purposive movements of the right hand and arm threw all the muscles of the right side of the body into a violent state of jerky tremor.

Long continued treatment by persuasion failed to effect any improvement whatsoever. The medical officer in charge of the case therefore decided to try hypnotic suggestion. This was easily carried out; the hypnotic state being moderately deep, though the patient was still in touch with his environment. Hope, courage and assurance of recovery following his own effort, together with determination to make every endeavour, were suggested to him. The patient was assured at each sitting that his nerves and muscles would every day respond more and more to his efforts at self-control. After a very few short sittings the man’s hopeless attitude became changed to one of hope, effort and attention in the waking stage, and there was a slight but decided improvement in his voluntary power. Hypnotic suggestion was then given up, and the treatment was continued by means of encouragement, exercises and explanation of his trouble, with the result that two months later he was fit for discharge from the hospital.

It may reasonably be doubted whether methods of persuasion alone would have cured this man. In any case, it is clear that it would have taken a very long time. It is also probable that hypnotic suggestion alone, if continued, would very quickly have removed the symptoms. It may be doubted, however, whether it would have effected a permanent cure in a person so open to auto-suggestion. It seems, therefore, that a judicious combination of methods was advisable.

We are of the opinion that hypnotic treatment, when used with skill, discretion, and discrimination, has its place in the treatment of shell-shock and similar conditions, both in the acute and chronic stages.

In the majority of cases of some considerable duration, however, and in practically all those in which the trouble is due to some ante-war worry or emotion, it may be regarded as provable that hypnosis alone will be of relatively slight use and in many cases may be positively harmful, for under such circumstances, even with the most favourable conditions, it would result merely in the removal of symptoms; and the removal of one may be followed by the appearance of another, which may even be induced by the process of hypnosis. Moreover, in cases where there is a tendency to the development of a double personality hypnosis may have the effect of increasing the risk. Further, if the patient has sufficient of his own will-power to enable the process of re-education to be carried out, it is clearly undesirable, both on psychological and ethical grounds, for the doctor to impress his influence from without.

In considering the possibility of the usefulness of hypnotic suggestion it is important to bear in mind that various factors may come into play in impressing an event upon the patient’s memory, or in determining the effect of the shock from which he is suffering when he arrives in hospital. In the first place there is the vividness or intensity of the stimulus; in the second, the degree of recency; in the third, the frequency of the stimulus; and in the fourth its relevancy. By the latter is meant the extent to which a given event appeals to the individual’s past experience, and becomes integrated into his personality.

A patient who has recently received a severe shock, the effects of which alone represent the real trouble, without the disturbance of any antecedent experience, might quite well be relieved by hypnotic suggestion from sleeplessness, pain, or amnesia; and in some cases this removal of the acute symptoms which determine the persistence of the shock effects may lead to complete recovery. A single and sudden wholly irrelevant experience, such as the bursting of a shell, which has no relationship whatever to the patient’s past experience, and produces effects by its vividness and its recency, might quite well be neutralised by another kind of wholly irrelevant intrusion, such as hypnotic suggestion. This argument may perhaps be made more intelligible by a homely analogy. A temperate man walking along the street might be thrown temporarily into a condition of faintness or collapse by seeing some ghastly accident, but by taking a “brandy and soda,” which to such a man would be a wholly irrelevant experience, the physiological expressions of his emotions might be controlled and he might be able to proceed on his way, and to overcome completely the effects of the transitory occurrence. But in the case of a man who, for example, had been greatly worried by monetary troubles for a number of years, the “brandy and soda” would not produce anything more than a temporary alleviation of his troubles. The latter illustration represents the chronic psychosis which, as Déjerine has so admirably explained, is quite unsuitable for hypnotic treatment. But the distinguished French neurologist’s statements do not seem to apply to the former type of case, due to a vivid recent shock, in the symptomatology of which troubles before the shock play no part. In such cases the results of hypnotic suggestion are often brilliant, if erratic, as is the “brandy and soda cure” for the man who is overcome by a sudden terrible experience in the street.

There are, however, patients who have not sufficient will-power or intelligence to be properly re-educated, to whom a certain amount of suggestion may be of some use.

Those who have used hypnosis in civil practice are aware that in certain individual cases of long-standing trouble, such, for example, as chronic alcoholism, hypnotic treatment is of unquestionable value. Among soldiers suffering from the long-standing effects of shell-shock, hypnosis may be able in some cases to help in the restoration of health with an effectiveness that no other method can rival.

Both the danger and the possible usefulness of hypnotism may be illustrated by an actual case. It is that of a man all of whose companions were destroyed by the bursting of a shell, and who suffered for months afterwards from complete loss of memory. A medical man hypnotised him, and perhaps with undue tactlessness, brought back the memory of the critical incident at the front, stripped of all the episodes which led up to or followed it. This excited in him the most violent emotions, and he became sick with terror; for the revived incident seemed perfectly real to him, or, as he described it afterwards, “it jumped up against him,” and for weeks he was so utterly terrified that he would not go near the doctor. Even though he could not retain the memory of any other recent events the horror of that experience seemed to have made him remember his dread of a particular medical man. But by making use of the information gained during that revival under hypnosis of an incident unknown to anyone but the patient, which his amnesia up till then had kept sealed up, it became possible for another medical officer to bridge the gap between his memory of previous events and the experiences which the patient was known to have had in the military hospitals.