The second fact mentioned above is of great importance in the consideration of our problem. There are undoubtedly men who seem to be immune to fear of the dangers of warfare. But to them we can scarcely apply the adjective “brave.” The brave man is one, who, feeling fear, either overcomes it or refuses to allow its effects to prevent the execution of his duty.
Other emotional states however, besides fear, arise and require suppression. The tendency to feel sympathetic pain or distress at harrowing sights and sounds, disgust or nausea at the happenings in the trenches, the “jumpy” tension in face of unknown dangers such as mines—all these, like fear, are or have been biologically useful under natural conditions and, like it, are deeply and innately rooted in man. But the unnatural conditions of modern warfare make it necessary that they shall be held in check for extraordinarily long periods of time.
The impossibility of regarding modern methods of warfare in the same light as natural and primitive means of fighting appears very clearly when we consider the instinctive and emotional factors involved in the two sets of circumstances. In natural fighting, face to face with his antagonist, and armed only with his hands or with some primitive weapon for close fighting, the uppermost instinct in a healthy man would naturally be that of pugnacity, with its accompanying emotion of anger. The effect of every blow would be visible, and the intense excitement aroused in the relatively short contest would tend to obliterate the action of other instincts such as that of flight, with its emotion of fear. But in trench warfare the conditions are different. A man has seldom a personal enemy whom he can see and upon whom he can observe the effects of his attacks. His anger cannot be directed intensely night and day against a trench full of unseen men in the same way in which it can be provoked by an attack upon him by an individual. And frequently the assaults made upon him nowadays are impersonal, undiscriminating and unpredictable, as in the case of heavy shelling. One natural way is forbidden him in which he might give vent to his pent-up emotion, by rushing out and charging the enemy. He is thus attacked from within and without. The noise of the bursting shells, the premonitory sounds of approaching missiles during exciting periods of waiting, and the sight of those injured in his vicinity whom he cannot help, all assail him, while at the same time he may be fighting desperately with himself. Finally, he may collapse when a shell bursts near him, though he need not necessarily have been injured by actual contact with particles of the bursting missile, earth thrown up by its impact, or gases emanating from its explosion. He may or may not be rendered unconscious at the time.[11] He is removed from the trenches with loss of consciousness or in a dazed or delirious condition with twitchings, tremblings or absence of muscular power.
Upon recovery of consciousness, which may take place after periods varying between a few minutes and a few weeks, the immediate disorders of sensation, emotion, intellect, and movement, are often very severe. It may be presumed that at the beginning of the war they must have appeared far more serious to most of the doctors who saw them in their early stages than they would now. This speculation is suggested by the evidence of the case-sheets sent with the men from France in the early period of the campaign. Such diagnoses as “delusional insanity,” and other similar terms taken from the current classifications of advanced conditions of insanity, appear very frequently as descriptions of cases which on arrival in England had almost entirely lost every sign of mental unusualness. In fact, one of the most cheering aspects of work amongst this type of case has been the rapidity with which men who have presented quite alarming symptoms have subsequently recovered.
It may seem almost unnecessary to enumerate the bizarre phenomena which constitute the immediate results of shell-shock, for our newspapers have naturally seized upon such unusual details and have made the most of their opportunities in this direction. But the reader will obtain a clearer idea of the facts if they are catalogued once more.
The most obvious phenomena are undoubtedly the disturbances of sensation and movement. A soldier may be struck blind, deaf or dumb by a bursting shell: in rare cases he may exhibit all three disorders simultaneously or even successively. It should be added that these troubles often vanish after a short space of time, as suddenly and dramatically as they appeared. Thus one of the blinded soldier survivors of the Hesperian recovered his sight on being thrown into the water. Other blind patients have had their sight restored under the action of hypnosis. Mutism is often conquered by the shock of a violent emotion, produced accidentally or purposely. Examples of such “shocking” events taken at random from our experience were the sight of another patient slipping from the arms of an orderly, the “going under” chloroform, the application of a faradic current to the neck, the announcement at a “picture house” of Rumania’s entry into the war (this cured two cases simultaneously), and the sight of the antics of our most popular film comedian. The latter agency cured a case of functional deaf-mutism, the patient’s first auditory sensations being the sound of his own laugh.
The muscular system may be affected in an equally striking manner. Contractures often occur in which a man’s fist may be immovably clenched for months; or his back may be bent almost at right angles to his lower limbs, there being in neither case any bodily change discoverable by the neurologist which can account for such a condition. These contractures, though curable, often prove very obstinate, and at present their nature remains somewhat of a mystery. Other distressing and long continued disturbances take the form of muscular twitchings and tremors or loss of power in the limbs.
Not every nerve-case, however, presents such striking and objective signs as those which we have just been describing. The subjective disturbances, which are apt to go undiscovered in a cursory examination of the patient, are frequently more serious than the objective,[12] and are experienced by thousands of patients who to the mere casual observer may present no more signs of abnormality than a slight tremor, a stammer, or a depressed or excited expression. These afflictions: loss of memory, insomnia, terrifying dreams, pains, emotional instability, diminution of self-confidence and self-control, attacks of unconsciousness or of changed consciousness sometimes accompanied by convulsive movements resembling those characteristic of epileptic fits, incapacity to understand any but the simplest matters, obsessive thoughts, usually of the gloomiest and most painful kind, even in some cases hallucinations and incipient delusions—make life for some of their victims a veritable hell. Such patients may have recovered from sensory or motor disturbances and yet may suffer from any or all of these afflictions as a residuum from the original “shock-complex;” they may suffer from them as a complication of the discomfort attending upon a wound or an illness, or, on the other hand, they may have no overt bodily disorder: their malady then being usually given the simple but all-inclusive (and blessed) description “neurasthenia.”
Now the happiness and welfare of such men obviously is bound up to no small extent with the character of the hospital or hospitals (for the plural number is commonly to be used in writing the history of these patients) to which they are sent. In the general military hospitals the medical officers have neither the time nor, in many cases, the special knowledge, necessary to deal with cases of this kind. Such patients may recover of themselves without any treatment, but a large number of them tend to get worse, and if they are left without attention their symptoms are apt to become stereotyped into definite delusions and hallucinations. Moreover, in a general ward such men may become a constant source of disturbance and annoyance to other patients and to the nurses. One of the symptoms of their illness is a morbid irritability; they tend to become upset and to take offence at the merest trifles[13]—and this leads to trouble with patients, nurses, and the medical officers responsible for discipline. But if special consideration is shown them by the nurses the other patients are apt to misunderstand it and even to complain of favouritism. In other words, when mixed with wound-cases in a general hospital, these nervous patients are apt to be regarded as a nuisance—which is bad for them and for the proper working of the hospital. Another consideration, too, is that the subjection of such men to irksome regulations of military discipline, and the usual penalties for infringing them, is often so potent a factor in producing disturbances as to be quite fatal to any hope of amelioration.
These considerations have led the military authorities to establish special hospitals for nerve-cases.[14] In such institutions the patients can be nursed and attended to by a staff which, being used to the idiosyncrasies of such illnesses can make conditions more suitable to them.