Some Notes on Shell Shock

By Major P.R. Bolus, Royal Army Medical Corps
Canadian Defence Quarterly; Vol. XII, No. 3, April, 1935

The Mental Strain of War

The scientific critic might truly say that there is no such thing as shell-shock. The use of high explosives has caused no nervous disorder which was previously unknown, so no new word should be necessary. The man of logic may truly remark that many of the sufferers from shell-shock never saw a shell fired in anger or experienced a shock. The doctor may complain that the term is illegitimate, for it is due to the genius of an unknown soldier and was not fathered by any medical man. Nevertheless we face a very definite problem. War makes a searching test of human mentality. Some soldiers reach the uttermost limit of cold endurance or flaming courage. Many accomplish fine steady work, successfully facing strange new perils. But some find the mental stress so great that, in varying manner and degree. their minds give way beneath it. This last group forms the subject of these notes.

During the last great war, not less than a million soldiers suffered a nervous collapse. Physical injury to brain or body. though prominent in the stories told by patients, was but a rare complication. It is the mind swayed by gusts of strong emotion, which bends, twists or split: under the strain. Planned effort by combatant officers as well as military doctors is essential if such a serious loss of man power and morale is to be avoided in future wars.

Nomenclature

The word shell-shock originated during the great war. It was first spoken in 1914 and first printed in the following year. It is not to be found in the Oxford English dictionary, but was admitted to the supplement which was published at a later date. The soldiers' talent for inventing names is responsible also for the term "trench fever". as well as several finely descriptive names of shells such as "whizz-bang" and "crump".

The term "shell-shock" embraced within its ample borders a considerable variety of distinct diseases. The great majority of cases may be classified as neurosis or hysteria but the group includes many in whom temperamental nervous instability was the main factor. During the rush of hostilities, the label shell-shock was wrongly attached to some who were really suffering from epilepsy, mental deficiency, latent, insanity and other diseases. finally, there was a small but troublesome band of malingerers who remained in the throng until they came within reach of a capable neurologist.

In spite of its grave defects, the name shell-shock will endure, because it proves convenient to treat such cases as a group and to collect them in special hospitals under the care of specially trained medical officers. If there be any who retain affection for classical nomenclature, they may prefer the title "Psychopathia Martialis" which had a brief vogue but, like other minor horrors of war, is now forgotten.

History of Shell-Shock

Human nature and terrible wars are not recent inventions. It is certain that many cases of shell-shock occurred in every great war throughout the ages. Descriptions of individual instances remain, but the medical world treated them with amazing neglect until the twentieth century. It is difficult to explain this phenomenon, but I believe it was partly due to a misconception, widespread among doctors, that the victims of shell-shock are "poor stuff" unworthy of deep study. One medical officer with the rank of General declared that every such case should be shot as a warning to other shirkers and malingerers. In this connection, let me remind you that the man who recently exercised greater personal power than any other living human being, was once a typical case of shell-shock. Adolf Hitler was attacked by blindness While serving in the German front line in 1918, and he recovered his sight suddenly after being evacuated to the base. Concerning British patients, let us be guided by the soldiers' slogan, "No names, no pack-drill".

The great Roman General Germanieus, after a long and difficult campaign against the Teutons in the first century before Christ, suffered from hysterical shell-shock. The leading symptoms were hallucinations of sight and hearing, including the apparition of a gigantic Teuton goddess and agonized human meanings from the surrounding forest. The goddess suggests a parallel with the angels of Mons so frequently reported in 1914. As was recorded, the noises may have represented a distorted perception of the howling of wolves.

It is recorded that 10,000 sufferers from "nervous prostration" were pensioned after the American Civil War, but we have no statistical information of much value with regard to any war. It is safe to state that during the great war of 1914 to 1918, the British army had at least 100,000 cases of shell-shock and that the other armies involved in this struggle suffered proportionately.

Disappointed in the doctors, we can gain much information by studying the poets. One cannot read Dante's Inferno without realizing that he understood very perfectly the effects of fear on human nature. One passage reads, "The remembrance of any terror bathes me still in sweat and conquers all my senses." Milton knew the psychology of horror, but the most masterly and complete description of a typical case of shell-shock is to he found in Shakespeare's tragedy of Henry IV. I know of no medical case-taking earlier than the nineteenth century which can compare with this. The patient is Henry Percy, son of the Earl of Northumberland who was commonly known as Harry Hotspur. He had been waging prolonged warfare, combined with worries about his loyalty to the King.

Hotspur's wife speaks to him:—

"For what offence have I this fortnight been
A banish'd woman from my Harry's bed?
Tell me, sweet Lord, what is it takes from thee
Thy stomach, pleasure, and thy golden sleep?
Why dost thou bend thine eyes upon the earth
And start so often when thou sitt'st alone?
Why hast thou lost the fresh blood in thy cheeks
And given my treasures and my rights of thee
To thick-eyed musing and cursed melancholy?
In thy faint slumbers I by thee have watched
And heard thee murmur tales of iron wars."

Such symptoms as irritability, tremors and excessive sweating are mentioned in other parts of the play but, in the passage quoted, you will observe that besides depression, dyspepsia (centuries later, Pavlov showed that fear caused change of gastric juice in dogs) broken sleep and war dreams, Shakespeare did not fail to observe the pallor (the shell-shocked in the early stages are pale though their blood shows no real anaemia) and the partial loss of sexual power which characterize the disease. Among the poets of today, Graves and Sasson show particularly keen understanding of shell-shock.

Perhaps a future historian will remark that the chief benefit derived from the great war was the impetus which it gave to the study of psychological medicine. The spate of books on shell-shock published during the past twenty years is more notable for quantity than for quality, but man has come to know his own mind a little better and much knowledge has been gained of the nervous conditions which lie between insanity and mental health.

Description of Cases

A brief account will now be given of three typical cases of shell-shock as seen in their first stage by a regimental medical officer.

Private A. is found in a bewildered condition, having thrown himself down in the deepest corner of a dugout. He is trembling, rigid and unresponsive. His face is drawn and haggard. His eyes stare forward but give the impression of seeing nothing. The breathing is laboured and he moans occasionally. When questioned, he makes no reply, and has the appearance of not understanding. He resembles a man struck by a sudden horror, with the important difference that the terrified aspect is persistent instead of being transitory. There has been shell fire but Private A has not been particularly close to danger. When examined, he pays no attention to what is being done. The pupils are small and react normally. The pulse is rapid and strong. The tendon reflexes are neither excessive nor diminished. Any attempt at treatment is useless at this stage, and the soldier should be quietly transferred to the field ambulance as soon as an opportunity occurs. The regimental medical officer may describe the case as "acute anxiety state" of "fear neurosis" and he should report on the field medical card the extent to which the soldier has been exposed to fire.

Captain B. has done prolonged and strenuous war service. His record is a fine one. but a newcomer would not guess this. During the past few weeks he has complained of sleeplessness, lack of appetite and dyspeptic symptoms. The Captain drinks much more whiskey than he used to take. He has shown obvious deterioration of temper and he has lost his former keen interest in his company. His face looks drawn and there has been some loss of weight. Captain B. has had his fill of fighting. In soldierly slang he is "fed up" with the "poor bloody infantry". That excellent play. "Journey's End", pictures the condition to perfection. Matters come to a head when Captain B. completely loses his temper with a superior officer and omits essential orders to his company. In the line he is now almost useless and in the mess he is a storm centre. He must be evacuated to a rest station or a convalescent camp. The regimental medical officer, if he dislikes the term shell-shock, may describe the case as neurasthenia, and he should record that the disease arose from the strain of prolonged active service.

Gunner C. was sent with a message from a forward observation post to battery position because the telephone wires were broken. He came through heavy shell-fire and the journey took three hours instead of the usual half hour. On one occasion he was partially buried in earth. On arrival, Gunner C. was pale, voiceless and very shaky. In an agitated whisper he complained of pains in the head and back. He appeared confused and his memory was obviously defective. He murmured about increasing pain and tenderness of the spine but before the medical officer arrives he has become quite mute. On examination, the doctor found no physical sign of injury but both legs showed complete paralysis and the lower spine was tender. There was complete loss of speech and functional paraplegia. Such a case must be sent down the line as shell-shock or hysteria.

These three cases are selected in order to show typical modes of origin. When seen at a later stage, the shell-shock cases show more uniformity. Anxiety dominates everything else in the physical and mental condition. The power of attention (mother of all the faculties) is deficient because its entire field is occupied by the emotional incident or by the effects of fear. For a time, the patient is so obsessed by his memories that he pays little heed to his surroundings and he is unresponsive when questioned. He looks pale, agitated and fatigued. The pulse rate is usually rapid and he sleeps more by day than by night.

Eventually, most of the severe shell-shock cases subside into a chronic state marked by general nervousness, headache, lack of confidence and depression. Tremor, excessive sweating, palpitation of the heart and terrifying war-dreams are other symptoms of very frequent occurrence. In some cases the leading complaint may be fear of meeting strangers, indigestion, lack of concentration, fear of traffic, mental confusion or attacks of dizziness. Almost all the patients are introspective and apprehensive.

Complications of Shell-Shock

In addition to the general symptoms which I have just mentioned, or in lieu of them, the hysterical cases show some conversion phenomenon such as fits, dumbness, deafness, paralysis of an arm or leg, blindness, or a muscular contracture.

This list of symptoms relates only to those of common occurrence for a large volume would be required to record the amazing variety of complaints attributed to shell-shock. Every bodily system may figure as the centre of disorder, every conceivable symptom, however bizarre may appear, and the clinical picture may resemble any one of a thousand diseases. Weird changes of type occur with kaleidoscopic abruptness. After months of persistent vomiting, a patient's complaint may alter to stammering or asthma. I recall one soldier who could read but could not write, whereas in the following week he could write but could not read.

Shell-shock is notably rare among soldiers who are seriously wounded, but is common in those who have received slight wounds. It is very exceptional among prisoners of war. Out of 20,000 French prisoners captured at Verdun, after heavy bombardment, the Germans found only five such cases. Shell-shock occurs among the insane, but is not itself a cause of insanity; in fact, the great war did not lead to an increase over the anticipated incidence of insanity, based on population.

Many shell-shocked patients allege that they suffered true concussion through a shell exploding close by, although they were not actually hit. They claim to belong to a group "wounded without wounds." It is true that minute haemorrhages of brain and spinal cord can be caused by pressure changes arising from a nearby explosion. Nevertheless, it was found that shell-shock did not, in fact, arise in that way. In most cases it appeared that they made a very modest under-estimate of the proximity of the offending shell. Anyhow, I have not personally seen a single instance of the "shell commotion" which was once thought to be the most common cause of shell-shock.

Characteristic of all cases of shell-shock is their liability to recurrence though this tendency fades with the passing years. In 1919 or 1920 a storm or a fire alarm would send many a shell-shock case into hysterical convulsions. Examination by a medical board on the anniversary of a fright frequently brought about the revival of severe symptoms. The main point of interest is that a small part of a complex stimulus may evoke a recurrence of the entire emotional reaction. Shell-shock may be a response to an extremely complicated stimulus including drill, weapons explosions, ghastly sights, flame, discipline and restriction of liberty. The whole fright reaction may be re-enacted owing to nothing more than an unexpected shout or a peal of thunder or the sight of a military parade. Thus we see the reverse of the process called redintegration, which was frequently used to encourage enlistment in 1914. Patriotism is an emotional reaction to a complex stimulus including racial inheritance. Surroundings and national achievements, yet the whole thrill of patriotism was easily aroused by a flag, a few selected words or a short passage of music.

Treatment of Shell Shock

At the close of the great war many thousands of soldiers remained totally incapacitated by shell-shock. In most cases their condition was not improving, so their treatment presented a large and urgent problem. In the United Kingdom the best available neurological specialists were sought and some doctors were specially trained, while sundry infirmaries and private mansions were secured in which to hospitalize the worse cases. Milder cases were treated at out-patient clinics. To a large extent the British Ministry of Pensions permitted the doctors to carry out treatment according to the method which most appealed to them.

Thus arose a highly diversified and diverting picture. At one hospital psycho-analysis formed the back-bone of treatment amid an atmosphere filled with dreams, word-associations and Freudian episodes of childhood. Meanwhile, in another institution, where the main emphasis was laid on physical defects and infection, tonsils, teeth and appendices were sacrificed wholesale, movable kidneys were brought to rest and pounds of miscellaneous drugs were swallowed. At more than one of the smaller hospitals the doctors maintained the old civilian view that shell-shock patients are wilfully perverse and, in effect, their only specific treatment consisted of commands such as "control yourself more" or "don't worry"! Extra verbiage, however, was employed and. many tricky methods of persuasion were invented. For example, one doctor treated a case of hysterical loss of voice by allowing the patient to overhear him instructing the nurse that, "This man must be kept on milk diet, but when he can ask loudly for it, he may have a bottle of beer and a steak." Another group of neurologists was chiefly influenced by the view that shell-shock represents a form of nervous exhaustion calling for recuperative measures. Rest in bed, therefore, with isolation and systematic over-feeding were the chief forms of treatment, as in the method once made fashionable by Dr. Weir Mitchell.

Many other methods of treatment were freely used. At one establishment hypnotism was much practised. Hypnosis offers a ready means of making the patient re-enact the emotional reaction which initiated his attack of shell-shock. It was thought that by re-experiencing his emotion the patient would be purged of its disease-producing material. At least it was dramatic to see a man with hair on end, pale sweating countenance and horror-stricken eyes, attempting to tear his way out of a dugout in which be imagined himself to be bombarded. A second reason for the use of hypnotism was that shell-shock patients usually obeyed implicitly any suggestion put to them during hypnosis. For instance, in a case whose leading symptom was headache, one could suggest, during a morning hypnosis, that, the pain would disappear at 3 o'clock, with the utmost confidence that this would occur. In another hospital, stress was laid on "miracle cures" and the development of an atmosphere of optimism. By means of gross masterful suggestion, sometimes assisted by an electric brush or an anaesthetic, the blind were made to see, the paralyzed to walk and the deaf to hear after a single short session of treatment.

Finally there was a school of physicians psycho-therapists who depended on discovering by careful questioning some painful incident or emotion which had been repressed by the patient and then revealing to him the way in which his symptoms arose. The patient is taught not to banish unpleasant memories but to transform them into tolerable companions. A simple example may be given. Private D. had been batman to an officer whom he held in high esteem. When this officer received a head wound, Private D. got him on to a stretcher and attended him while he had convulsions and died. Afterwards, whenever faced with a difficult situation, the soldier suffered from hysterical convulsions. After therapeutic conversations, based on the discovery of this incident, cure was effected.

The most curious feature that first developed from a study of these varied forms of treatment was that rather good results were reported by all of them. After a time, however, it was observed that the early degree of success was not maintained. It appears that the basis for this observation was that "cures" could readily be effected so long as the doctor retained complete faith in his method, but when further experience showed him that he had not wholly solved the riddle, the doctor's own confidence was shaken and the response of patients to his suggestions decreased accordingly.

We soon learned many other lessons from this noble experiment in psychological medicine. Notwithstanding much success, most forms of treatment showed grave defects. Treatment by the "don't worry" school was wholly rejected. The patient is only too willing to obey such injunctions but he cannot do so, and he is not helped by gross suggestions based on ignorance. It was found that no medicines have any value for the shell-shocked except as a clumsy form of suggestion and that little is gained by the treatment of intercurrent physical disorders. Hypnotism was dropped because it is unnecessary as a vehicle for curative suggestions and also because it increased the instability of neurotic subjects. In France, treatment by hypnotism was officially forbidden.

Complete psycho-analysis on the lines of Freud is absolutely impracticable. Each case would require from 25 to 500 hours of attention by a trained physician. Moreover, Freudian psycho-analysis lay special stress on sexual matters whereas self preservation was a more central feature of war experiences. The cure of hysterical phenomena may be achieved by suggestion in a few minutes, but this may mean only that symptoms have been altered while an underlying emotional conflict, still continues to rage within the depths of the patients mind and his lost courage has not been restored. Analytical methods alone have shed light on the underlying cause of shell-shock and on the true nature of its symptoms.

The general conclusion is that a considerable proportion of shell-shock cases may be cured by the lapse, of time or by the use of suggestion in any form which carries conviction. The physician should be a man of wide experience, richly endowed with patience, sympathy and imagination. His manner should be authoritative and free from any sign of doubt or hesitation. Some knowledge of psychology is essential. There remains a number of cases for which deliberate scientific treatment is necessary.

For reasons which lack of time prevents me from stating, most neurologists are now convinced that the cause of shell-shock is the banishment to the sub-conscious mind of an emotionally toned group of ideas which is alien to the main body of the personality. The only logical method of treatment consists in tracing this occurrence and restoring the banished complex to consciousness so that it may be recognized by the patient and assimilated by him as part of his personality. Such mental analysis and restoration can be easily achieved in some cases, while in others considerable time and thought are required. The unconscious conflict often results to the patient's advantage in that, he gains sympathy. leisure and maintenance. Treatment is then handicapped. Any sympathetic attitude toward the continuance of such benefits must be carefully avoided.

The limitations of treatment must not be forgotten. Among the shell-shocked there are a great many men of constitutionally poor mental fibre, who never could face strain or stress without showing nervous symptoms. We should be able to cure these men insofar as the effects of war service are concerned, but there is no known method of making them normal.

Shell-Shock in Times of Peace

Shell-shock may be acquired in the battles of life as well as in the combats of war. Earthquakes, fires and accidents cause many cases of nervous collapse, which are in every way similar to those seen during warfare. We have learned to control our reactions to fear, but we have not learned our lesson thoroughly. Control fails either when moderate stress attacks men who are by temperament predisposed to excessive anxiety. or when men normally poised are exposed to excessive strain. Susceptible individuals may show the same response to domestic or financial troubles.

Perhaps the economic depression of the last five years has caused the whole modern world to suffer from a mild degree of shell-shock. In 1934, H.G. Wells wrote, "The truth remains today that nothing prevents the attainment of universal freedom and abundance but mental tangles, egocentric preoccupations, obsessions, bad habits of thought, subconscious fears and dreads and plain dishonesty in people's minds."

It is inevitable that multitudinous cases of shell-shock will occur in the next great war unless strong measures of prevention are adopted. In ancient times, war mainly involved hand-to-hand fighting by professed soldiers. Two mighty changes have entirely altered the picture, first came the adoption of long distance fighting, which took origin when four cannons were used at the battle of Crecy in 1346. This introduced unseen and fatal dangers to greater numbers than in the combats of olden time. Obviously, long range methods of warfare have now become dominant and shell-shock is specially liable to occur among men who face unknown perils or execute orders which they do not understand. The second great change arose with the introduction of conscription by Napoleon in 1798. Instead of professional soldiers, the personnel of armies came to consist of ordinary citizens. Many of these, though quite fit to face the vicissitudes of ordinary life, do not possess sufficient nervous stability to withstand the additional shocks of battle.

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