Shell shock and its lessons

by Grafton Elliot Smith; T. H. Pear

The methods of treatment which have been described in the foregoing pages: sympathy, firmness, isolation, suggestion in its various forms, and hypnosis; while all useful in their proper place, often prove to be of no avail in cases of psychoneurosis. Where the distressing symptoms lie on the surface so that both they and their causes are easily discoverable by the physician—if, indeed, they have not been known from the beginning, to the patient himself—it is sometimes possible to bring about a complete cure without any very penetrating analysis by the doctor of the mental antecedents of the patient’s present condition. Thus, for example, a courageous and keen soldier who, suffering from loss of sleep and from the harassing experiences of the battlefield, eventually breaks down, the precipitating cause perhaps being shell-shock, may need little more to set him on his legs than the comfort, assiduous attention, and pleasant distractions of a Red Cross hospital. For the civilian whose chief trouble is the irritability caused by a multiplicity of minor business worries, or family jars, a few days of isolation, giving perhaps, among the other benefits which we have mentioned, the opportunity to think things out, may have excellent results. The beneficent action of hypnosis in removing the acute disturbances caused by shell-shock has already been illustrated. But a large number of cases fall into none of these categories. Sympathy merely annoys them, isolation tortures them, for besides letting them think—usually in a very unwise way—it helps to confirm their impression that they are seriously ill, just because it involves the treatment of them as special cases. Suggestive measures may be to them like water on a duck’s back, and hypnosis may prove of no avail. Firmness may have merely the effect of proving to the doctor that there exist patients firmer than himself. But, fortunately, psychical methods are not exhausted. There still remains at least one—that of psychological analysis and re-education.

The employment of psychological analysis in medicine means the resolution of the patient’s mental condition into its essential elements, just as by chemical analysis it is possible to determine that water, for example, is composed of certain definite proportions of oxygen and hydrogen combined in a particular way. Re-education is the helping of the patient, by means of the new knowledge gained by analysis, to face life’s difficulties anew.

It is sometimes urged that if this be all that is meant by psychological analysis, alienists have been doing this ever since insanity was first treated, nay, further, doctors have been practising it since the time of Hippocrates. It is pointed out that when a patient is first interviewed by the physician, an inquiry is always made into his mental state and behaviour, and into the presence of delusions and hallucinations or other unusual mental phenomena. His relatives are questioned concerning the relation of his recent behaviour to that at the time when he was considered normal. Now the answer to this assertion is that such an investigation is useful, indispensable in fact, but it cannot be called psychological analysis.

The point may become clearer to the untechnical reader if he will imagine for a moment that a carver, skilled in separating the legs and wings from the body of a bird, should claim to be practising anatomy. The anatomist would at once object that while such separation of limbs from trunk is a small detail which sometimes forms part of the anatomist’s task, it can scarcely be called more than a preliminary to his study. For first of all, while to a carver a leg is an ultimate unit, to the anatomist it is, for the naked eye, a collection of bones, muscles, tendons, skin, nerves, veins, arteries, nails and the rest, and, seen through the microscope, a tremendous organisation of infinitely more complex structures. Furthermore, it might be pointed out that merely to separate these more minute structures into their constituent parts and to name them, by no means constitutes the whole of the work of the intelligent anatomist. He wishes to study the inter-relations of these parts, the way in which they work together for the common good of the leg. And lastly, the leg must not be studied only in separation from the trunk, for its functions are subordinate to the requirements of the body as a whole.

So, in the same way, to record that a man is suffering from a delusion of persecution or an unreasonable fear of open spaces is merely to “carve up” the condition of his mind. First of all it must be ascertained how far that delusion has interpenetrated with the rest of his mental life; whether, for example, his false belief is restricted to a specific kind of persecution from a particular person, or is a general delusion that everybody and everything in the world is against him. And again, if the delusion is strictly specific, it is important to know whether it has been the cause of secondary false beliefs, produced by rationalisation, to buttress the primary delusion against the inevitable contradiction from facts which it would otherwise suffer.

Further, the nature of the delusion must be analysed. Why is it of this and not of that persecution? Why is this particular person feared or hated? Is it a constant factor in the patient’s existence, or does it break out at certain times? If so, the patient’s life at these critical periods must be carefully examined. The doctor must discover where the patient was at the time, what he was doing and thinking, who were his companions, and so on.

Next comes the important inquiry into the history of the delusion. And here, just as the anatomist is able nowadays to mobilise for service all his knowledge of comparative anatomy and evolution, so if the physician has really scientific knowledge, not only of the delusions in other patients, but also of the development of ordinary beliefs in sane people,[37] he will be immensely helped in his search, and may be enabled thereby to make many short cuts to the essential facts. He will endeavour to date the important stages of development of the delusion; to find a time when, so far as the patient knows, his mind was free from it.

Thus we may say that a psychological investigation of a case of mental disorder dissects its normal as well as its abnormal phenomena into their functional elements. Compared with the procedure which merely records such gross units as delusions or hallucinations, it is as anatomy to mere carving, however skilful the latter may be.

But the psychological investigation is not merely comparable to anatomical dissection. We have also compared the mind to a chemical compound, rather than a mechanical mixture. Especially is this true not only of the normal but also of the abnormal mind, when the latter has had time to settle down into its new position of relative equilibrium and integration; when, for example, a delusion has become so fixed that the patient’s life is entirely ordered in obedience to it, and he has ceased to have any doubts as to its reality or to struggle against its domination.[38] It is only when the warring elements in the mind are relatively independent, and before they have succeeded in “making terms” with each other, that the mind even remotely resembles a mechanical mixture. It follows, therefore, that psychological analysis of a case of mental disorder is usually comparable to chemical analysis as well as to anatomical dissection.

Now the most striking result of chemical analysis is to show that the appearance and general properties of the elements composing a compound are different from the appearance and properties of the compound itself. This is exactly the case, too, with mental analysis. A mere dissection of an abnormal condition is sometimes sufficient in the milder cases to serve as the basis for curative measures,[39] but in more advanced cases, or those of longer standing, real analysis is necessary in order to get at the unknown factors.