In the early days of the war the attention of newspaper readers was attracted by the stories of queer behavior on the part of men exposed to prolonged and violent bombardment. Men reported as being ‘gibbering idiots’ emerged from the battered Belgian forts, men with reduced intelligence wandered about in a dazed and dreamy state, men were partially or completely paralyzed, were blind or deaf or insensible to pain. It was immediately thought that these conditions were the result of violent concussions occurring in the vicinity, and the striking but misleading term of ‘shell shock’ came into being. The name was applied to all queer nervous and mental symptoms, and these patients suddenly acquired considerable notoriety. To be added to the group later were any nervous phenomena not definitely and obviously connected with peace-time neuroses, and all were thought to be satisfactorily explained by proximity to exploding shells.
The alliterative name caught popular fancy; everybody, soldier and civilian, heard of it; the soldier exhibited it as evidence of how thoroughly he had done his duty, and the victims of ‘shell shock’ were the object of much misdirected but well-meant philanthropic effort. It was thought to be a satisfactory excuse for any anti-social act that brought a soldier before the courts. The misconceived idea that these symptoms were due to shell-explosions led the soldier to think them a natural consequence. If he had no wounds, then he should have nervous symptoms. If he had neither, perhaps people would not think he had participated in all the experiences of present-day warfare—which, of course, was an intolerable thought.
It is important that the psychological aspects of the development of war neuroses receive some attention, and that they become known to the public. The danger of mismanaging the American soldiers so incapacitated will then be less acute, and we may avoid some of the mistakes made by the Allied countries during a period of stress and hurry.
The nervous symptoms included under the misleading and forbidden term, ‘shell shock,’ are now called war neuroses, or simply nervousness. They are known to be similar to peace-time neuroses, and they are peace-time neuroses with a war-time coloring. The names—nervous prostration, nervous exhaustion, neurasthenia, and hysteria—are known to everybody. They represent symptoms for which there is no organic explanation; that is, they are not associated with any structural changes, and the gap caused by the absence of an organic explanation is filled by a psychological explanation.
It is believed that there are but two fundamental instincts, the instinct of self-preservation and the instinct of reproduction. In civil life one has no concern as to his safety. We live sheltered lives, and it is only the very timorous who ever thinks of his personal safety. Most of the maladjustments in civil life centre about the reproductive activity of the individual, and on this fact a well-established, but not universally accepted, psychological theory has been built, first promulgated by Freud, but greatly elaborated by others. It is enough to say here that it is generally believed that Freudian principles are very important factors in the precipitation of peace-time neuroses. The neurosis is a maladjustment of the individual to his environment; his way of meeting a difficult situation. It is not the best way, but it is a way accessible to the individual. It is an avenue of escape, chosen unconsciously; it gets him out of the difficulty and does it in a manner acceptable to the individual’s temperament. His conscience will not permit him openly to evade his duty and responsibility; but lacking the will and determination to stick to the job, his real desire to escape is gained by back-door routes, by an illness which he thinks is real; and his end is accomplished in an acceptable manner. Of all this the patient is not aware. He does not recognize his motive; he speaks of it and clearly shows it, but until it is called to his notice he does not see it, and even then he has great difficulty in accepting the explanation.
In discussing war neuroses as well as those of peace it must always be borne in mind that, although the language used is that of conscious action, the results of a true neurosis are never conscious and voluntary.
There are many causes for a war neurosis, but the foundation of all is a difficult situation. This difficulty may range from a lack of courage to the slight feeling of having been unfairly dealt with in a man who has given many examples of personal courage. The constant and unavoidable association with people whose natures grate on his own; the feeling that someone else should have been given a disagreeable assignment; the belief that blame has been unjustly placed; the strain of constant and unwarranted petty criticism; the knowledge that one cannot rely on one’s associates, that leaves have not been fairly distributed, and that considerations other than merit govern promotions—all of these and many other similar sources of irritation produce more neuroses than does shellfire.
After brooding over real or fancied wrongs, getting desperately sick of the situation, perhaps sleeping poorly, being cold, wet, and hungry, fighting an internal conflict in addition to the one with the enemy, a shell lands near, and there results a fit, a period of unconsciousness, a dazed state, blindness, deafness, inability to speak, or coarse jerky tremors which may be so severe that locomotion and other voluntary motions are impossible and the soldier is taken to a dressing-station and eventually is put in a hospital. The whole trouble is credited to the shell-explosion, which may have occurred nearer to many others without damage to them; or the individual may be the sole survivor of a group.
The precipitating shock may be an emotional one. His chum is killed by his side; his officer is wounded in a particularly distressing manner; or, being detailed to escort walking wounded to the dressing-station, he is shocked by what he sees. In any event the situation has become intolerable, and without conscious mental activity, he finds that the neurotic symptoms accomplish his purpose; he is satisfied with the reaction, regards it as perfectly justifiable, and accepts the situation. It gets him out of his difficulty: he is incapacitated, everybody about him is wounded, and he justifies his presence in the hospital by the perpetuation of his nervous symptoms. He does not like to part with his neurosis, for getting well means a return to a mode of life to which he has not reacted in the average way, and he parts with his symptoms with considerable reluctance.
The psychological explanation is not flattering; he finds he is not the man he thought he was, and there is a reaction against the explanation, the person presenting the explanation, and the place in which the explanation was made. It is difficult for us to think well of the individual who tells us unpleasant truths. We must prefer to reject the explanation and keep our own misconceptions, particularly if they give us a comfortable feeling of self-satisfaction; but if the facts are put in such a manner that acceptance is unavoidable, then a reaction of dislike and criticism develops against everything and everybody connected with explanations which made the neurosis no longer a desirable experience.
The picture given presents the psycho-neurotic individual in a rather bad light. All are not so bad. Patients repeatedly have said that, if the explanation was correct, then their symptoms were without foundation, they were being imposed upon by subconscious mechanisms, — a condition that was not acceptable, — and a state of affairs existed that could not be continued. These patients get well at once, and are then better than ever before, for they are warned against the subtle approach of neurotic symptoms, the censor is on guard, and they are protected against an inner enemy by the knowledge of his tactics.
The man whom an hysterical paralysis protects from a hated return to the front does not consciously will his paralysis, nor does he easily believe it to be the result of a wish, unexpressed and unrecognized by himself. Sometimes the simple explanation that such is the case brings about a cure, so completely does the patient revolt against what seems to him his unconscious simulation. A very small percentage of patients show definite symptoms of brain-concussion. Men are violently thrown to the ground by exploding shells; sticks, stones, and clods of earth are hurled through the air, and organic changes take place comparable to the effects sustained when one is hit on the head by a brick falling from a chimney. These patients are dazed or even unconscious; but if without a fractured skull, they quickly resume a normal state and are willing and anxious to return. Men go for days without sleep, have insufficient food, suffer from lack of water, reach a stage of absolute physical exhaustion, and perhaps are nervous, dazed, and jumpy. After twenty-four or thirty-six hours rest, they are well and wish to return. Both the concussed and the exhaustion cases urge the medical officer to discharge them; they want to get back to the company, and present an attitude quite unlike the neurotic patient, who often asks to go back but at the same time shows symptoms which absolutely prevent his being sent back—symptoms which would not exist if the desire expressed represented a real wish.
A number of patients show no spectacular symptoms, and this applies largely to officers. They have an anxiety reaction. Officers doubt their ability and worthiness to lead and have the responsibility of men. This is a transference of the emotion of fear for themselves to the possibility that injury may come to others. The transference of an emotion from the real to a false object is a common psychological experience. These cases are stubborn and not as easily cured as are the gross physical-hysterical symptoms, such as paralysis, tremors, speech-disorders, and disturbances of smelling, seeing, hearing, tasting, and feeling.
States of forgetfulness (amnesia) are not uncommon. A soldier overreaches in an effort to forget painful experiences, and forgets his name, organization, and occasionally all the facts of his early life, reverting to an infantile state. If his reaction is infantile, he is in effect an infant, and infants do not fight—obviously the fulfillment of a wish. Such states are transitory episodes, the changes from a lisping, toy-playing infantile state to a normal adult reaction taking place within a few days, the condition having lasted from a few weeks to several months.
War neuroses are rarely found among the wounded, although the slightly wounded occasionally develop neurotic symptoms, and sometimes even the severely wounded, but only when convalescence becomes well established and a return to duty approaches. Prisoners of war never have a neurosis. Being wounded or taken prisoner accomplishes the same purpose as a neurosis, therefore neurosis is unnecessary. Even the thought of an active participation in war produces a neurosis in highly unstable individuals, and there are a number of so-called anticipation types developing as men are drafted, as the sailing time approaches, or when the European training period draws to a close. These cases show precisely the same symptoms which were formerly attributed to shells.
On the other hand, an over-sympathetic attitude or neglect, is likely to make permanent invalidism out of what should be a passing phase. These patients need employment, encouragement, suggestion, and explanation to help them on the way to recovery. Too much petting and too much attention make the neurosis a pleasurable experience to which the patient clings. Public glorification of the neurotic will be most unwise. Many will recover spontaneously after peace is declared; but there are failures to cure, and there will be a group of individuals superficially in a deplorable state, but in reality people who would rather have a neurosis than not. They will get well when the neurosis becomes as intolerable as the situation which caused it.
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