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.