Shell shock and its lessons

by Grafton Elliot Smith; T. H. Pear

For the patient, then, his mental troubles, having intimate and continuous connection with his life, become very real indeed. But the longer he is left alone to “cheer up,” the longer he broods over his troubles in isolation, the longer he is allowed to build theories upon his inadequate and inaccurate data, the more intimately and continuously connected with his life will the abnormalities become. They may come to be so integrated with each other that his very personality becomes tinged. Then he is no longer a normal person battling with his separate enemies, but one who has made terms, and those often disastrous ones, with his closely allied foes. An attempt to cure him at this stage will then necessitate the analysis of a highly complex compound, while in the early and middle stages merely the attack upon separated elements is necessary.

We are concerned at present with the facts of shell-shock, but this is perhaps a suitable place in which to deal with an opinion about this set of phenomena, which is not uncommon, especially perhaps in people above military age. That judgment, expressed sometimes bluntly, but oftener in a more subtle fashion, is that shock or neurasthenia are polite names for nothing else but “funk.” It is not easy to take a dispassionate view of this question, but to persons holding this opinion the following points are worthy of consideration.

First, the most severe and distressing symptoms occur to a surprising extent in the case of those patients whose past history shows that, far from possessing even the normal quota of timidity, they had been noted for their “dare-devilry” and had been specially chosen as despatch-riders, snipers and stretcher-bearers in the firing line. Secondly, it is not uncommon for patients to ask to be sent back to duty because they feel that they have been too long with nothing to do, while it is quite obvious to the doctor that they are as yet unfit to bear any great strain. Thirdly, the seasoned regular, officer or N.C.O.,[20] as well as the young soldier of only a few months’ service may display precisely the same symptoms as those we have described. Such men have frequently been in the army for many years, and have fought on previous occasions with great success. Their strength of mind and body has been demonstrated over and over again, yet at last they have broken down. And they manifest the greatest concern at their unusual symptoms.

It will be readily granted, of course, that there exist among the nerve patients returned from the front cases in which there is genuine fear of the war, arising from memories of the experiences which they have undergone. Even this state of mind, however, is usually expressed by the patient in some such phrase as “I don’t want to go back, but I’ll go quite willingly if I’m ordered to.” It should not be forgotten, moreover, that not a small number of instances are known in which these men prove to have made repeated attempts at enlistment after having been rejected several times, or even discharged from the army, changing their medical examiner until they have succeeded. One case, presenting a great number of the symptoms of shell-shock in a very intense form, including, beside the ordinary neurasthenic troubles, blindness, deafness, and mutism at successive times, was that of a man who had been discharged from the army as medically unfit and had re-enlisted.

Two cases may be quoted here in illustration of some of these assertions:

The first is that of a non-commissioned officer who went through the initial eleven months of the war in France and Flanders, was subjected to every kind of strain, physical, mental and moral, which that stricken field provided; and in addition was wounded twice, gassed twice, and buried under a house, on all five occasions being treated in the field ambulance and then returning to the trenches. After all this experience he had not qualified for sick leave, but was granted five days ordinary leave to return home, apparently in a good state of health. After reaching England and while waiting for a train in the railway station, he suddenly collapsed, became unconscious, and for months afterwards was the subject of severe neurasthenia. Apparently at the front the excitement, the sense of responsibility and especially the example that he felt he should set his men, seem to have kept him right. These stimuli removed, he broke down. The whole of his trouble seemed to be due to the dread lest on his return to the front, the added responsibilities which would fall upon his shoulders (because most of his own officers had been killed and there would be new men to replace them) might be too much for him. His intelligence seemed (to himself) to have become numbed by his experiences, and he became conscious of the unreliability of his memory and of his inability to understand not only complex orders, but, as he put it, “even the newspapers.” It was this that excited in him the dread lest he should be incompetent to discharge adequately the duties which would fall upon him. There was nothing of malingering or shirking in his case. There was no fear of physical injuries or of returning to the front; on the contrary, he was anxious to go back. His fear lest the possibility of his failure would be bad for his platoon was wholly due to that admirable sentiment of regimental loyalty, which comes out so strikingly in the nervous troubles of the non-commissioned officer.

This class of case demands a great deal of patient and sympathetic attention before the real cause of the trouble is elicited, and then months of re-education may be required to build up anew the man’s confidence in himself.

The second case is that of a soldier who had suffered from severe shock symptoms and had recovered. In conversation with the medical officer the soldier expressed his willingness, and even his desire, to return to the front, in full knowledge of the fact that the officer’s report in that sense would lead to his being sent back to fight. That night the patient was awakened by a terrifying dream, the true significance of which was certainly not adequately appreciated by him. Although he dreamt that he was afraid to go back to the front, apparently he did not realise that he was actually afraid—i.e., that the dream had any meaning. On examination it proved to be a detailed forecast of the imaginary incidents of his return to his regiment, and of his attempt to commit suicide when ordered to go to France. Here was a man who of his own initiative had asked his doctor to certify him as ready to go back, yet in his sleep the train of thought, started by the discussion of the possibility of his return, working subconsciously, had stirred up images of what this implied, and reinstated emotions of so terrifying a nature that in his dream he preferred suicide to facing the ordeal again.

It may perhaps be allowable to quote in this connection the view of a German neurologist, Prof. Gaupp, on the “shock-cases” which have been sent back from the German front.[21] At the same time it is important to remind our readers that Gaupp is writing of a conscript army, the authorities in which are certainly not notorious for lenity to the individual; further, that up to the time of writing the present chapter, all the “shock” patients in Great Britain have been men who voluntarily elected to serve their country, the majority of them having enlisted in the earliest stages of the war.

In discussing cases where nervous trouble, uncontrollable in nature and intensity, had led to the patients being kept in German hospitals for months, it was sometimes found that the mental foundation which was a causal factor of these troubles was a more or less conscious anxiety concerning the possibility of a return to the front.