Shell-Shock
- Author:
Earl Sullenger,
University of Oklahoma.
The great conflict from which the civilized world is just emerging has brought us face to face with problems very new and of great importance both from a medical and a military standpoint. Of all these problems there is one of importance to which the leading psychologists, psycho-neurotics and neurologists of the world are directing their attention?namely, the shell-shocked soldier.
The term “shell-shocked” has been adopted officially as a diagnostic term to cover all neuroses arising among officers and soldiers of the army. This term has an advantage in its picturesqueness that has helped to stimulate popular as well as professional interest. But it is a term which can be defined with difficulty from a purely medical or psychological standpoint. There are two main reasons for this difficulty. In the first place it implies a single etiology?the physical effects of high explosive shells on those subjected to bombardments who suffer no external physical injury. Secondly, the clinical types covered by this diagnostic term are too numerous to mention and to be safely gathered under one heading. When these cases were first brought to notice various ideas and opinions were formulated. Those who had had little sympathy with the neurotic looked upon these victims of war as mere malingerers and advised treatment by a firing squad. Those who had been previously interested in hereditary defects asserted that these new patients were practically all inferior or degenerate individuals. This second statement can easily be disproved. As yet no definite accepted conclusion has been reached by the psychologists or medical men, but I have found in my psycho-analysis of the patients, after having closely observed many of them several months, that the central nervous system is the seat of affliction and that the condition is also the product of some reaction to abnormal conditions. These patients whom I have had under my care and observation have recently been transferred from base hospitals in France, and I have carefully mentioned a few typical examples from among them. My conclusions, however, are drawn from the results of observation of many patients as well as the few special cases given in this paper. If my readers could see what I have seen these many months, they would agree with me that this topic is a painful one; perhaps one of the saddest of the many grievous aspects of the war.
The main symptom of shell-shock is prolonged nervousness? unconsciousness from either a common shock which is a climax or an unusual incident. This may last for hours and even days. Lumbar punctures at this time may, according to reports, show blood in cerebro-spinal fluid. It has also been determined that there are minute hemorrhages throughout the brain in some cases that have been killed instantly by shell-shock or concussion, and it also is suggested by the fact that retinal hemorrhages may frequently be observed. When consciousness is recovered it does not remain immediately and permanently clear as the patient is apt to go through a period of hours or days in which he is constantly drifting off into unconsciousness or sleep. A soldier told me a few days ago that since he received his shock he would become unconscious almost any time if excited and remain that way for as long as two hours. This patient was a discharged soldier and supposed to have been cured.
Consciousness may be retained longer when patient’s attention is continually stimulated. Retention of urine or incontinence of both urine and feces is common during this stage. I had two patients in which this was very common when passing through this subconscious stage. Many patients on coming clear are very indifferent. A period of delirium is apt to ensue during which patient may imagine himself fighting again. He is in a period of great fatigue and poor mental tension (the last demonstrated by a difficulty in collecting his thoughts) defective orientation, poor memory for remote past and practically no memory at all for immediate past. All his mental operations are preformed with great difficulty and as a rule inaccurately, which can easily be tested when given some simple calculation. The voice is peculiar, if not entirely gone, for a period of time, being often pitched somewhat higher than is usual for the patient, monotonous and frequently glow, words being separated by a pause of one or two seconds. The patient begins with a greater or less speed, according to the severity of injury, to recover his memory of remote past and can often reconstruct period immediately preceding his injury, particularly if some hints are given him. (See case five for a good example of this.) In milder cases the patient feels as well as he ever did after a few weeks of rest. Occasionally a patient may retain delusions for months that originated in his actual delirium.
Another very prominent symptom is their terrified expression. They crouch, start and stare wildly when spoken to. One such man in my ward would awake from his sleep at night and recite in a one-sided conversation his experiences at the front. I have seen them in the stage in which there was a continuous shaking of the entire body accompanied by various pains and usually severe headaches. In some cases this shaking has been observed to last several days and even weeks, although in most instances its duration is only a few hours. During the time that they are passing through this period or stage of terrified expressions, the soldiers give the impression that they are again living through the experiences which caused the condition in which they are now placed.
A temporary loss of memory is common with those who have been through extremely trying periods. In such cases the recovery of memory is as sudden as its loss. Many have told me that they could remember nothing that happened to them for some period of time, then they would suddenly return to their normal state, but they could recall nothing of their previous experience. Some patients pass through what is known as the stuporous stage. Daring this state the patient may suffer from hallucinations concerning which he is confused later. It is only the more severe cases, of course, which show marked or prolonged symptoms of stupor. In others the hallucinations pass over into somewhat similar visions which are now accompanied by fear. The patient sees soldiers of the enemy advancing against him with fixed bayonets, throwing bombs at him, feels mines exploding beneath his feet, or he hears shells come shrieking toward him. Any sudden sound, such as a door slamming, is interpreted as the explosion of a shell with consequent terror. The patient jumps with fright although he usually realizes very quickly the real nature of the sound. A frequent complication is depression. This seems to be a very common symptom of shell-shock. It is being used as a basis upon which to work in treating the disease. Sometimes the depression is the accompaniment of obsessing thoughts about the horrors that the patient has seen and about the horrors of war in general. I have known of cases in which the patients would have certain things on their minds which were troubling them. They would brood over these things most of the time. (See cases two, five and eight.) Very often the patient is depressed because he feels that he is not well treated. This is very common in the government hospitals. He is prone to dwell on the sacrifice he has made and the obligations of the nation to him. Such patients are therefore morbidly interested in having attention paid to them. If the patient is left in this condition, the depression becomes more intense. He needs some one to help him to rebuild for himself a new enlightened outlook on his future? in short, if he is left alone and told to “Cheer up,” or isolated, his troubles only increase. His troubles are yearning for expression. 1 have had them come to me and talk for hours, telling me their troubles and crying at the same time. Thus we see that the emotional sphere is one in which we may look for terms to describe in a small way this awful condition.
One of the greatest sources of breakdown under such circumstances is intense and frequently repeated emotion. By this is meant not only expression of fear or sympathy with suffering comrades, but also other mental states associated with general excitement, anxiety, remorse, anger, elation, depression and that complex but very real state, the fear of being afraid. The soldier suffers some time before his comrades know of it. He keeps it to himself as long as possible. It would be a gross misrepresentation of the facts to label all soldiers who suffer these mental troubles and general nervousness as weaklings. The strongest man when exposed to sufficiently intense and frequent stimuli may become subject to mental derangement. It is quite common to find among patients suffering from shell-shock officers of high rank and those who have been in the service many years.
The afflictions through which the shell-shocked soldier goes, such as loss of memory, insomnia, terrifying dreams, pains, emotional instability, diminution of self-confidence and self-control, attacks of unconsciousness or of changed consciousness, incapacity to understand any but the simplest matters, obsessive thoughts, usually of the gloomiest and most painful kind, even in some cases hallucinations and delusions, make life for some of these victims a veritable hell.
The root of all the trouble seems to be a mental conflict, the complete details of which can seldom be found on the surface of the complex symptoms.
The treatment of the shell-shocked patients is still in its experimental stage. At first, the patient is removed from war environment when he is first shocked to such a degree that he can withstand the strain no longer. They have found that a frequent change from one hospital to another has been beneficial in that it kept the surroundings and general environment from becoming monotonous. At first every patient suffers more or less from fatigue, and little is gained by psychological treatment on one who is suffering from such a definitely physical disability as severe fatigue. The first effort, therefore, is to give the patient absolute rest and good normal sleep. At first this is produced by means of some drug to quiet his nerves. It has been found that in order to treat the case from a medical or psychological standpoint some idea of the individual must be gained at once. Each nerve-stricken soldier presents a case of itself. A dozen cases sent back from the front as shell-shocked may prove to possess not a single feature in common except the fact of the shell explosion. But when the patient is first brought to the base hospital the same treatment is administered. When the patient is brought to this, the St. Elizabeth Hospital, a good cleansing bath and a dose of epsom salts are given him. The douche bath is given daily for several days. The patient must be given confidence in himself and thus allow himself to forget his former environment. Active effort must be made to detract his mind. His environment must be made as nearly civilian as possible and practicable, but he should not be confined with civilian patients who are suffering from other mental troubles. It worries and irritates him. He must not abandon his uniform as they always want to wear them and most of my patients wished a nice, neat uniform.
In England they are making some successful experiments. One in particular is being conducted by Mr. Prosser, a color specialist in Miss McCall’s Hospital, London. Mr. Prosser says, “Shell-shcok is a disease of the tissues of the brain and I hold that the right vibration of colour will help to build them up. I do away with the sense of four walls which so affect the nerves, by introducing the colour vibrations of outdoors. I open the ceiling up to the sky by decorating it in the colours of the firmament blue. The walls are thrown open by being the colour of the sun, light lemon yellow. I shall use green of buds just bursting, for it is that light the nerve patient needs, and I shall have violet rays which have already been proved useful to the nerves. I shall have only one picture of spring in a lemon yellow frame which will be part of the room. The effect will be harmony. The curtains will be on brackets so that a patient who needs a violet light will have that coloured curtain and one who needs sunlight a yellow curtain. Presently, they will be able to stand stronger vibrations, such as orange.”
The therapeutic value of color is now becoming recognized. Different colors emanate different forms of vibration. These vibrations react on the brain and nervous system in a remarkable and very real manner, especially in case of a very sensitive person. This color scheme is still experimental, but I found in my study of conditions at Walter Reed Hospital, Washington, D. C., that our government is trying on a very small scale the “color cure” for our shellshocked soldiers, and it is proving to be a success. The authorities told me that it had the desired mental effect.
Another remedy or treatment which has been found beneficial and advantageous in many cases is hypnosis. It helps in more quickly breaking down resistance which occurs in patients who will not easily give up to treatment. By hypnotizing the patient they seem to place him nearer his normal condition for a short time. Thus assistance may be sought without in any way interfering with subsequent treatment of patient by psycho-analysis and re-education. In treating shell-shock by means of hypnotism there are four factors which majr come into play, namely: first, vividness or intensity of the stimulus; second, degree of recency; third, frequency of stimulus; fourth, its relevancy or applicability. It has been found that occupation of some kind invariably has benefited them very much. A game of cards may be all the man can stand at first. Perhaps it will be only a very small amount of light reading. He can progress from this to less violent games and as his strength increases be given something more productive. For this reason well equipped workshops are invaluable, particularly for privates and non-commissioned officers. I found in my study and investigation of Walter Reed Hospital, the leading and best equipped hospital in the United States, that in three of the psychopathic wards vocational and reconstructional work is given the shell-shocked soldiers. Ladies who have had special training in constructive work are employed by the government at a salary of one hundred and fifty to two hundred dollars per month to come to these wards six days each week and instruct these patients in making mats, leather articles, boxes, toys, belts, and, in fact, all kinds of fancy or constructive work. These boj-s were well contented, apparently, and very much interested in their work. I was told by their teachers that their progress was rapid.
The object of these occupations is two-fold: the first being to detract the man’s mind from the worries that had so much to do,in the establishment of his neuroses; and second, to give him that confidence in himself which is so often painfully lacking and which can be established only by the patient actually achieving something. I noticed with interest that these patients were proud of their work. Many of them showed me what they had accomplished. One came to me holding in his outstretched hand a belt which he had just finished himself and said, ‘’This only cost me forty-five cents which was the material. I am going to take it home with me and wear it.” Another patient who had been very much frightened, thinking all the time that he was going to be cremated, has now started working on some fancy work. He is becoming very much interested at this time and his teachers say that his recovery is being made very rapidly. His mind is detracted from his troubles. Female companionship affords an excellent form of detraction to the soldier who has been for many months in a purely military and masculine environment. I have noticed with great interest the mental effect produced on the soldiers in my ward, as well as the boys at “Walter Reed, when the Red Cross and other ladies would make their weekly visits.
The final cure for this awful malady is yet to be found, and thus the field of research for the psychologists is filled with great opportunities and possibilities. In order to orient the reader with the specific nature of this neurosis, it may be well to note a few special cases which came under my direct observation. In most of the cases I have given a short sketch of their family history to show the relation which may exist between their past life and present condition. The home environment of the soldier may have weakened him to such an extent that such factors may play some part in determining the greater susceptibility of certain men to shock.
Case 1.?The following history is typical of the development of a normal shock. The patient was a man of twenty-seven years of age who had never been ill in his life. He went to school at the age of seven and continued there until he was seventeen years of age. He was a normal lad who kept up with his classes and played with his fellows. After leaving school he worked for his father on the farm, and enjoyed home life and thus grew up a rather strong, sturdy boy. He was never addicted to the use of drink except a little beer occasionally. During his early life he never had any special ambitions, but just took life good-naturedly and easy. In 1913 he came from his father’s home in Ireland to seek his fortune in the land across the way, America. lie located in Boston and went to work taking care of baseball grounds, making about twenty-five dollars per week. Then he went in the building business and made from twenty-five to forty dollars a week. He was never troubled with nervousness nor hallucinations of any kind. None of his family was ever troubled with any nervous trouble nor excessive alcoholism. His father is living at the age of eighty-five years, but his mother died when he was a mere boy. He informs me that some of his ancestors lived to be over one hundred years of age. He enlisted as a private on July 10, 1917, and received his training in Massachusetts. He was sent to France in September, 1917, and served in the second-line trenches. While there he adapted himself pretty well, making many friends among his fellow soldiers and enjoying his work very well until after he had been at the front for some time. At first the shells did not seem to trouble him very much but as they continued to come near him and he saw his comrades falling all around him he became very nervous. About this 40 THE PSYCHOLOGICAL CLINIC.
time he was severely gassed while in his dugout. This mustard gas severely burned his air passages, eyes and mouth, and it also seemed to affect his heart and his nerves. As a result he became very weak, and his nervousness continued to increase, accompanied with a steady increase of sleeplessness. At one time he went as long as twelve weeks without normal sleep.
The effects of the shells seemed to grow upon him. On one occasion he and his “pal” had been sent into “No Man’s Land” after water. The night was dark, and the field was full of shell holes. He fell into one of these, and while in this hole shells were bursting over his head. After this his nervousness increased very rapidly. At last he almost lost control of his thinking faculties and had great difficulty obeying orders. The climax came one night while he was stationed at his post on guard. He was standing behind a big tree. A shell burst so near him that it destroyed the tree and a shrapnel from it wounded him in the leg. He was unconscious for several hours, so when he awoke he found himself in a base hospital. “While stationed in this base hospital he had great imagination. He could see people clothed in white or other similar visions. The news of his sister’s death reached him at this time which caused him to be depressed more than previously. As a result of this he grew very weak. He was speechless from the time he received the shock until eight weeks afterward, during which time he would try very hard to talk to his friends, but it was all in vain.
He was brought back to the United States last September and placed in a hospital in Georgia. His improvement was quite rapid while there. On October 24, 1918, he was transferred to St. Elizabeth’s Hospital. He has been quiet and orderly since arriving here, but has been noticed going to the window and conversing with himself. At times I notice that he is not so jolly and agreeable as usual, especially after he receives a letter from his home. He tells me he is not troubled with dreams, delusions or hallucinations now. He spends his leisure moments smoking, reading and talking. This boy is a devout Catholic and I see him reading his prayer book every day. Rough language and smutty jokes are not used by him. He smokes some cigarettes, but not excessively. I found that his memory for remote events is very fair, except for difficulty in recalling dates. His special memory is very poor and when he was given the intelligence tests he fell very low. He has a tendency to be rather vague and thus gets time, places, events, et cetra, mixed. This patient’s progress has been rapid for the last several months. I have noticed him sleeping a great deal during the day, and his sleep during the night is normal. He does not care to speak of his past experiences, but he says he has no desire to live over his past year. He is now well and will be discharged from the service soon. This is a typical case of shell-shock which seemed to develop upon a strong, sturdy Irish lad. Most cases have had some previous mental or physical weakness in their lives.
Case 2.?This patient is a private in the artillery, aged twentysix, whose home is in Wisconsin. His grandparents on paternal and maternal side are dead of a cause unknown to the patient. He had one uncle who died of concussion of the brain due to an injury. His father is dead but he does not know the cause of his death. While the children were yet small, his father deserted his mother and left her with his four sisters and himself, he being the oldest. He began school at the age of six years and continued until he was thirteen, reaching the eighth grade, but he tells me he was foolish and did not finish the common school. He disliked school from the beginning and frequently played truant, but he always got along well with his playmates, although he was backward and shy. Since he left school he has lived away from home continuously and followed various occupations, such as farming, driving milk wagons and working in a sawmill. He traveled from place to place and frequently changed his occupation because of his ill health which was catarrh of the head and nose. Most of his earnings were spent on travelling in the West and also on the girls and drink.
He volunteered in the army March, 1916, and was sent to Camp Nogales, Arizona. His experience in camp was pleasant and he got along well with his officers, but not so well with his fellow associates. On September 17, 1917, he was sent overseas and was on the firing line in Lorraine, Toule, Montdidier and Chateau-Thierry sectors. He was on active duty in the field kitchen six months, and afterwards hauled ammunition and supplies to the front. It was while he was on this work that the shells began to cause him trouble and to make him nervous. Many time? the bursting shells would fall all around him and frighten him. He told me that on one occasion when he was hauling supplies a big shell struck the bank just in front of him. He stopped suddenly but just at that moment another one burst just above him. This seemed to affect him some but not enough to force him to go off duty. Within a short time after this he was in three gas attacks which caused him to feel dull and weak for some time afterwards. He never did recover entirely from the effects of these gas attacks. Delirious feelings were common and on one occasion while sleeping in a barn loft, he got up, walked to the door and jumped out.
While he was on the Montdidier sector he developed boils on his right shoulder which terminated in an abscess. He was operated upon and sent to a base hospital in Bordeaux and from there to other hospitals. The shocks, gas and abscess made more than he could bear in the field, so he was transferred from one hospital to another until at last he was sent to the States in November, 1918. When he arrived at St. Elizabeth’s Hospital he responded to his name and walked into the examining room in a slow and hesitating manner. His facial expression was rather apathetic and apprehensive, and the muscles of his forehead were wrinkled. He maintained a very erect position with hands resting on his knees and staring straight ahead at the walls, turning his head only when addressed. He always seemed to be hearing conflicting voices and appearing as if hallucinated, paying very little attention to his surroundings. He is retarded and tries to use big words, yet he reads a great deal and while reading I have noticed him underscoring each word with his pencil.
When the patient entered the hospital, he realized that he was very nervous, but up to the last he did not think that anything was wrong with his mind. He said he thought he ought to be out of the hospital and frequently asked me when he was going to be released, and told me that he could think as well as formerly if given a little time. His memory for remote events was fair for general content, though rather hazy as to details and very inaccurate as to dates. His memory for recent events was rather poor and lacked accuracy in details as to dates. Some of the intelligence tests were well answered, others poorly done, but in general they were very good. Since the patient has been under my observation, his characteristics and general mental status have been practically unchanged. On January 24th, I gave him the Binet-Simon test to determine his age of mentality. I found that his basic age was eight years and his mental age was eleven and three-fifths years. He sits around most of the time and reads, although at times he continuously walks the floor. I have noticed him sitting for some time gazing at one object or just sitting in a melancholy mood. He enjoys being alone and thus shuns company. I have frequently noticed him sitting on the floor with his head resting in his hands.
This case, just cited, illustrates shock produced on a patient who had a rather weak constitution, brought about as a direct result of his previous life. Fatigue was one main factor which entered into this soldier’s condition.
Case S.?This patient, aged twenty-two, is a private in the infantry. Previous to his enlistment he was employed for some time by a show company. He never attended school at all. There was no trace of abnormality to be discovered in his make-up, in fact, he had an extremely open, pleasant personality. He is a married man but I never learned the extent of his married life. His family is not subject to nervous breakdowns nor any form of insanity. He got along finely with his training in camp, but within a short time after he went to the front he became extremely nervous. He says that each shell affected him more and more until at last he could stand the nervous strain and fear no longer. He was taken to a French base hospital, but he could not talk for a period of four months, all this time desiring very much to speak to his comrades and nurses, but it was impossible for him to get his thoughts in form for expression. Many Red Cross workers tried to get him to talk but it was all in vain. He was conscious all the time and never was affected with dreams nor hallucinations.
This soldier was transferred to the States and was admitted in St. Elizabeth’s Hospital in August, 1918. He was in poor condition at that time, but is now improving very rapidly, yet he told me that he thought he never would totally recover. I have also noticed a decided improvement in his voice, although he still has considerable difficulty in trying to talk. While answering my questions he said a few words and stopped for a few seconds. Sometimes he would never get back to the point without my direction, as he could only think for a few seconds on one line of thought. 1 have noticed him walking the floor of the ward, and at times he would walk across the hall, stop and think or rather stand in a deep stupor for a few minutes, and then walk back very fast. By the Binet-Simon test he proved to have a basic age of six years and a mental age of ten years. I do not attribute this deficiency to degeneracy but to inability to concentrate his thoughts on any one line sufficiently to answer a direct question.
The characteristics of this case are similar to all others. It proves conclusively that the shock has impaired the thought process of this soldier. Judging from my personal observation of this patient I would conclude that his mind might be compared to a machine which continually hits and misses. In this case, as well as in so many others, the patient loses the ability to gauge the direction of the shells by their sound, which gives a beautiful illustration of how the unconscious works at cross purposes from the conscious mind. The unconscious conditions warp his judgment and fear is made much greater. We find that fear is a preventive reaction. The individual has to protect himself from real dangers, not only from without but from the unconscious cravings which are at variance with his social standards. All the preventive emotions of dreams are therefore probably operating in part to keep the unconscious tendencies in subjection.
Case ?This was one case in which I was unable to secure all of his personal history, but it is a good illustrative case. The patient was a private in the infantry, aged about twenty-four. His company went to France shortly after the United States entered the war. His home is in Vermont, and, judging from all appearances and conduct, I would conclude that he came from a good home. He was a quiet and unassuming lad with strong moral principles. He told me on one occasion that when he enlisted in the army he resolved that he would come out pure and clean as he entered, and he thanked God that he had been given the strength to resist the alluring temptations that are so common in the army. This soldier endured many hardships while at the front which were indeed trying on him in general. He told me that the most difficult thing on him was the nervous strain produced by continuously seeing his comrades fall all around him and being forced to walk over and step upon the dead bodies of his fallen comrades. While he was on the firing line shells disturbed him very much and caused him to become very sensitive and nervous. A shrapnel from one bursting shell struck him on the head and fractured his skull causing him to be unconscious for some time. The wound which he received, plus the shell shock, caused him to remain in the hospital for some time. The surgeons removed a small portion of his skull which left an opening on top of his head. I felt the soft place with my hand. After a long period of suffering and nervousness he was brought back to the States and was admitted to St. Elizabeth’s Hospital in October. I noticed a great improvement in his condition during the two months which I had him under my observation. He was discharged and sent home in December. The conclusions which I reached in this particular case were that he was a strong and healthy country lad but not used to many changes of environment. He was very docile and thus the continual worry and loud noises were very trying on his nerves. The climax was reached when he was wounded which made more than he could possibly bear, although his shock from which he suffered seems to have been mild in degree, for after a few weeks’ rest he felt quite well with the exception of his wound. I find that a patient who has been previously subject to nervous and mental trouble is more subject to severe cases of shock and is more likely to be permanently and incurably affected. The general constitutional conditions have a great influence on what the nervous system can endure when placed under such strain.
Case 5.?This patient is a private aged about twenty-four who had a normal make-up apparently. It was impossible to induce him to give any data as to his subjective experience, in fact, he seemed to be one of those individuals who are totally incapable of any introspection. This is common in certain stages of this disease. This patient was born in Damascus and came to America in 1913. He has been engaged in the merchandise business ever since he came to the States. He is well educated and can speak several languages very fluently. He has a very intelligent personality and is a handsome young man. His mother is living in Syria but his father died since he has been in the service. I recently received a letter from Damascus, Syria, in regard to him. He served his term at the front in France where he received his concussion. His speech is affected yet and was during the time I had him under my observation, a period of three months. I found the study of this patient extremely interesting. At first he would stand around in the ward and pay very little attention to his comrades and surroundings. He would remove his outer clothing and walk the hall of the ward. Sometimes it would require great coaxing and diplomacy to get him to put them back on and act properly. He would say that he wanted some new uniforms as the one he was wearing was very old and worn. Others were issued to him, but it was some time before he resumed his old pride and kept himself well dressed.
At times, in fact most of the time, he was despondent and depressed. When in this condition I could very seldom coax him to talk with me. He has a splendid baritone voice and says he used to sing in public. At times he sings in the ward, and sometimes just after singing he would sit down on the floor, place his hands over his face and cry like a baby. It certainly was pitiful and pathetic to behold. The Red Cross ladies and other visitors would often bring treats to the boys, but this patient would pay very little attention to them. He would look at the “eats” or smokes and maybe take a few. Again he would become very active and be very enthusiastic, saying, “Let’s go home, boys,” asking for smokes and chews. He would also dance to the music of a violin and victrola. One day when he was in his normal mind, he told my assistant that he had been studying too much which made him feel worse and vowed that he was going to quit it. He enjoys taking baths. He would take a bath in a tub of warm water and would remain in it for hours; even went to sleep in it one day. This seemed to be his great mania. I tried very hard to get him to tell me his parent’s address so I could write to him. At last he told me and said that he wanted me to tell him that he would like to see them all, that that was his message. I usually had to lead him to his meals, but toward the end of the third month he began to go without any assistance and was even noticed calling another boy’s attention to dinner. Very often he would be standing still and perfectly quiet and then begin to laugh out loud or cry. When asked what the trouble was he would just say very modestly, “Nothing.” Sometimes when asked how he felt he would reply, “Very well, thank you.” This case is a very good example of what some psychologists call intermittency or alternating insanity caused from the shock.
Case 6.?This soldier was a little fellow in stature. He was brought to my ward shortly after he came from overseas. It seemed that he must have received his main shocks at Chateau-Thierry. It was impossible to obtain his complete personal history. His condition was critical. Many times he would try to remove his clothing in public and do all kinds of outrageous things except fight. His facial expression was one of terror, and he would stare wildly when spoken to. I tried to talk to him but would receive no reply. At last I noticed that he was making some kind of noise and moving his lips, so I placed my ear near his face and discovered he was uttering some words but they were weak and faint. In this manner he told me of some of his experiences. In the course of time he improved very much, but I was transferred from this ward and was unable to observe him longer.
I found in this case, as in many others, that companionship means much to their welfare. They long to tell some one their troubles at times, and they find so very, very few who are really friendly to them, and who appear in any way interested in them. They want sympathy. I recall at this moment many cases in which a few kind sympathetic words opened the doorway to a hasty recovery. They do not care for the silly sentimental kind of sympathy but a true, strong fellowship which is found among men and even women who are sharing together the same hardships and are bearing one another’s burdens.
Case 7.?This patient is a colored man, twenty-six years of age, very happily married for nearly two years, who had been a farmer in Georgia all his life. His makeup seems to have been unusually normal. His father was subject to nervousness at times, but none of his people had ever been insane. His mother died several years ago after a prolonged illness of tuberculosis. He never attended school in his life. While he was a boy he received a wound in his left leg which caused him much trouble later.
In September, 1917, he was drafted into service and served in the infantry. He adapted himself well to the training but it fatigued him greatly. In October, 1917, his company was sent to France. While there he was in several battles but never received any wounds. He was at the front two months. During all this time he stood the bursting shells very well, yet they would seem to burst all around him and come near him. He became very nervous and this increased daily until at last it was more than he could stand. He broke down and was taken to a French base hospital. He was unconscious at times and could see visions and delusions, often dreaming of dead people. At one time he dreamed he saw his mother who had been dead several years. His head ached very severely, and he had considerable difficulty in talking as he found it hard to get the right words. In fact he could scarcely talk at all. This condition continued for two weeks. He was slightly confused and disoriented and troubled by his dreams which recurred every night, disturbing his sleep. When his memories returned he felt as well as ever, but he found it difficult to recall remote events. He did not care to be bothered and paid very little attention to his surroundings and those with whom he came in contact, passing through a period of stupor. At present this patient is much improved and converses very freely. When I gave him the Binet-Simon test his basic age was seven and his mental age was ten and two-fifths. These low figures are due to his lack of education. This is a typical case of concussion with little digression from the ordinary.
Case 8.?This patient is a private, aged about twenty-six, who came from the North. He is a rather large man physically and has the appearance of being exceedingly strong. He shows that he has come from a good family. As he refuses or is unable to talk, I was unable to secure any of his personal history except that he was shell-shocked last fall. I have been observing this patient day and night for a period of three months. At times I could get him to say “Yes” or “No.” If things seemed to please him he would smile. Sometimes I have heard him humming to himself. Most of the time he would stand around in the ward and hold his mouth open, paying very little attention to his surroundings. He read a great deal or at least would be seen with a book in his hand as if he were trying to read. At nights he would get up and walk around the ward, his sleep being very poor. It was very seldom that he would remove his clothing before retiring. Some one always had to lead him to his room every night and also to his meals. It seemed that he would forget how to find his bedroom and the dining-room.
This case is a splendid illustration of the stuporous stage as well as the speechless one. This is a severe case and it will perhaps be some time before he totally recovers if he ever does. But I am glad to mention that as this paper goes to print this patient’s mother has taken him home and he is progressing nicely.
Case 9.?This soldier patient is a private, aged twenty-five, who was inducted into the service in 1917 from Missouri. He was reared on a farm and was a typical country boy. His home life was pleasant and agreeable, but he was prone to be somewhat wild and reckless. His father and mother are living, and he also has several brothers and sisters, His father visited him while he was under my care.
This patient received the shell-shock and also a severe gassing while at the front in France. He was for some time in base hospitals in France and was at last brought to the States and then to St. Elizabeth’s Hospital. He talked sensibly to me and his fellow , soldiers, was always jolly and agreeable. He would often spend some time walking the floor and talking to himself and would often sing frivolous songs to himself. He talked to himself as well as to others about a letter of recommendation which he claims was written for him by Secretary Baker’s secretary, and that Secretary Baker’s as well as many other prominent signatures were attached to it. He said that if he could only get that letter, he would walk right out of the hospital and go home. He said that a certain captain had it in his care. So he wrote him, had me and also the Red Cross to write but could get no information. He also speaks of getting his discharge, and says that if he ever gets out of this man’s army, he never will get into another. This boy smokes all the cigarettes he can get and seems to enjoy them very much, but he told me that they were not good for him and that he intended to quit smoking them. I found him a very interesting character to study both day and night, as I found that he was exceedingly restless at nights, often talking himself to sleep. I would speak to him about talking so much to himself, but he would say that he forgot. Maybe he would cease talking for a little while but would soon begin again. By the Binet-Simon test I found him to have a mental age of twelve and one-fifth.
This patient improved rapidly and was taken to his home in southeast Missouri by his father on December 26th. He was discharged from the service in January. This case is a good illustration of delusion caused from shellshock. Case 10.?This patient is a man of twenty-seven who is a private in the infantry. He was married in 1914 but it was a very unhappy marriage, resulting in a separation after only three years. His boySHELL-SHOCK. 49 hood days were all spent on the farm in Tennessee. He did not attain very high in the educational field, not completing the fourth grade, although he can read and write fairly well. This patient’s past history reveals the fact that he was subject to excessive nervous spells while at home on the farm. His parents are both living or at least he says they were the last time he heard from them. His father is just a common laborer on the farm. This boy is one of a family of five children. In August, 1918, he was inducted into military service and got along finely during the training period of general camp routine. He was sent to Camp Meigs, Washington, D. C., at the time of his induction but only remained there a few weeks. He does not recall the exact date upon which he sailed for France but it was sometime in the early fall of 1918. While he was at the front “somewhere in France” he received his first shellshock. The shells made him extremely nervous, and finally he was taken to a base hospital in France for rest and treatment. While he was there he had many horrible dreams and hallucinations but was never really unconscious. It seems that his speech was not injured. He could talk as well as usual, but I notice now when conversing with him his voice is very weak and that his memory is affected; especially is it defective in regard to remote events, as is so common in cases of this kind.
This boy is very agreeable and friendly, does not talk very much unless questioned. He always has a greeting for me when I come on duty in the ward every morning. His condition is much improved since arriving at St. Elizabeth’s, Washington, D. C., but the improvement is slow. As has been shown in previous cases, there is a tendency present, particularly among those having had a neurotic history before the war, to develop neurotic troubles of civilian type when convalescence from an anxiety state is achieved. We see that the previous mental and physical status of the patient has much to do in solving the present emergency.
Under normal conditions, the unconscious is kept under such severe repression that no ideas are allowed to come into consciousness which are not fully adapted to the situation at hand, so that the reactions of the individual are in keeping with his natural standards of behavior. This repression, however, is closely related to the higher mental functions, and for its perfect operation demands its fullest degree of both intellectual and moral judgment. The situation with concussion or shell-shock is, therefore, in a psychological sense, analogous to that of an ordinary mental shock. A purely psychic trauma so confuses the patient’s ordinary mental processes that his critical judgment is for the time being impaired, and the unconscious has an opportunity for fuller expression than it previously enjoyed.
Throughout this paper there has been considerable stress laid on the psychological aspects of the war neurosis. It seems certain that purely physical factors play a larger roll than they commonly play in times of peace in the production of functional nervous disturbances. The treatment of these conditions, in so far as they demand the attention of specialists, must be almost purely psychological, or, to put the matter in a somewhat more accurate form, it may be said, perhaps, that every method of treatment instituted must be carefully considered in the light of its probable psychological effect. The physical factors, although of the utmost importance, are beyond our present capacity to change specifically. The best we can do, as definite scientific knowledge is so scarce, is to meet them symptomatically with such simple measures as have been mentioned. Many of these patients will never totally recover and will thus remain a burden on the government and their families. These afford a great productive field of labor for the psychologists. If we should again be involved in such a struggle as this one, may the psychological and medical world be better prepared to deal with these serious problems. We have learned conclusively that it is only the physician who constantly maintains the psychological standpoint who will be consistently successful in treating one of the saddest of the many grievous products of the war, the shell-shocked soldier.
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