It is now possible to attempt a brief sketch of the typical conditions which give rise to some of the chief varieties of shell-shock. Let us take a common case; that of the patient who is returned to this country, figuring in the casualty lists under the terse and businesslike military formula, “shock, shell.”
For various reasons, which the reader will easily supply, we choose to present a composite picture of the history of such a soldier. Not all the conditions described here need necessarily have operated in any one case taken at random, but we shall err, if at all, on the side of understatement. The correctness of the description may be checked by a reference to the papers already mentioned.[5]
We must first try to conceive the experiences of the soldier before the occurrence of the knock-out blow, so far as they bear on his present condition. Let us suppose that his period of training has made him physically and mentally fitter than he had ever been before, that no military causes of anxiety or fear, such as the experience or the anticipation of being torpedoed on the outward voyage, have operated to any noteworthy extent in his case. He enters the trenches in first-class condition. The duration of his stay there, provided he is not wounded, or attacked by any bodily illness, will depend from that time forward upon the nature, duration, intensity and frequency of the emotion-exciting causes, and upon himself. By that all-inclusive word “himself” we mean to signify chiefly his temperament, disposition and character.[6]
It must be remembered that one of the greatest sources of breakdown under such circumstances is intense and frequently repeated emotion.[7] By this is meant not only experiences of fear or of sympathy with suffering comrades, in short, those conditions the manifestations of which might cause the man in the trenches to be spoken of as “emotional,” but also other mental states associated with general excitement, anxiety, remorse for major or minor errors, anger, elation, depression and that complex but very real state, the fear of being afraid. (The more definite terms of technical psychology are not used here, as it is considered wiser to employ popular language.)
The soldier may be subjected to intense emotional stimuli of this kind for days or weeks without relief. And whereas to the mental sufferer in civil life sleep often is vouchsafed, “setting him on his feet” to continue, more or less effectively, the struggle next day, to the soldier sleep may be impossible, not necessarily because of his excited mental state, but simply from the lack of opportunity or the disturbances going on about him. In course of time this loss of sleep from external causes may easily set up bodily and mental excitability, which in its turn acts as a further cause of insomnia. The usual mental conditions associated with loss of sleep then rapidly supervene: pains and unpleasant organic sensations, hyperæsthesia, irritability, emotional instability, inability to fix the attention successfully upon important matters for any length of time, loss of the power of inhibition and self-control.[8]
These symptoms, troublesome enough in civil life, become positively dangerous to the man in the trenches, especially if he is in a position of responsibility. In that case his standing as officer or N.C.O. merely adds to his mental distress. Bodily hardship, such as exposure to cold and wet, hunger, and the irritation from vermin, obviously aggravates the disorders we have described.
We must not suppose, however, that the man who is experiencing some or all of these mental and bodily conditions is at this period necessarily displaying any obvious outward signs of his trouble. There may be no tremor, no twitchings, no loss of control of the facial or vocal muscles which would indicate his state even to his neighbours. He may, for a long time, “consume his own smoke.” And during this process he may even appear to his comrades to be steadier and more contemptuous of danger than before. Dr. Forsyth[9] has cited some dramatic incidents, in which officers who imagined that their instinctive fear was becoming apparent to the men under their command took unnecessary risks in order to impress these men with the idea that they were not afraid.
It must be understood that this suppression of the external manifestations of an emotion such as fear is but a partial dominance of the bodily concomitants of that emotion. The only changes which can usually be controlled by the will are those of the voluntary or skeletal muscular system, not those of the involuntary or visceral mechanism. While no signs of fear can yet be detected in the face, the body, limbs or voice, these disturbances of the respiratory, circulatory, digestive and excretory systems may be present in a very unpleasant degree, probably even intensified because the nervous energy is denied other channels of outlet.[10]
The suppression of fear and other strong emotions is not demanded only of men in the trenches. It is constantly expected in ordinary society. But the experience of the war has brought two facts prominently before us. First, before this epoch of trench warfare very few people have been called upon to suppress fear continually for a very long period of time. Secondly, men feel fear in different ways and in very various degrees.
The first fact accounts for the collapse, under the long continued strain of trench warfare, of men who have shown themselves repeatedly to be brave and trustworthy. They may have felt intense emotions, obviously not of fear alone, for a long time without displaying any signs of them. But suppression of emotion is a very exhausting process. As Bacon says, “We know diseases of stoppings and suffocations are the most dangerous in the body; and it is not much otherwise in the mind.”