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SHELL-SHOCK
A DIGEST OF THE ENGLISH LITERATURE

V.
 HENRY  VIETS,  M.D.
First Lieutenant, M. R. C, U. S. Army

           BOSTON
58'

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Reprinted from The Journal of the American. Medical 'Assocyiiioti  '
        Nov. 24, 1917, Vol. LXIX, pp. 1779-1786    \j / ,


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             Copyright, 1917
        American Medical Association
Five Hundred and Thirty-Five North Dearborn Street
               CHICAGO 
 
           SHELL-SHOCK *

A  DIGEST  OF  THE ENGLISH LITERATURE
     HENRY  VIETS,  M.D.
First  Lieutenant, M. R. C, U. S.  Army

             BOSTON
   In the last three years, the neurologists and psychia-
trists of the United States have  viewed with  interest
the reports that have come to us  from abroad regard-
ing the remarkable war neurosis, shell-shock.  While
these papers excited our interest, it  was not until our
country entered the war that the problem became one
that demanded our serious attention.  At the present
time, however, we ought to be fully acquainted with
the data  already accumulated by foreign workers  in
the three years  of war; to be able to give successful
treatment  in the many cases that are sure to  arise in
our armies and, vastly more important, to  gain a clear
insight  into the condition so that we may be able  to
exclude from our draft army at the time of enlistment
the men most liable to  shell-shock,  and thus  prevent
"the wastage of the  recruiting office," which has been
such  a burden to the European countries.
   Moreover, the importance of the problem cannot  be
overemphasized.  Osier,1 in a  recent communication,
speaking  of the neurasthenic  as he appears at the
recruiting station, says that the unfit should be checked
at the recruiting office and kept at home; "the trenches
is no place for  a man  with unstable vasomotors.   In
the strain of war they break like dry twigs and become
a  heavy  burden in  the  hospitals  and  convalescent
homes."
  * Read at the staff meeting, Boston Psychopathic Hospital, Oct. 17,
1917.  The  contents of this paper are based on observations made in
England from May, 1916, to February, 1917, under grant of a Moseley
Traveling  Fellowship  from   Harvard  University.   Indebtedness is
acknowledged to Sir William  Osier  and Dr.  Frederick W. Mott for
their kindness in making these observations  possible.
  1. Osier, Sir William: War Wastage: A  Note of Warning to Exam-
iners of Recruits, The Journal A. M. A., July 28, 1917, p.  290. 
2
   June 1, 1917, Dr. Thomas \V. Salmon, in a letter to
 the  National Committee  for Mental  Hygiene,  wrote
 from London in regard to the shell-shock cases:

  The extent of these casualties  is almost beyond belief.  1
 have not yet had access to the official records, but apparently
 the neuroses constitute one of the most formidable problems
 of modern war.  These people are certain to go to pieces in
 the presence of danger or hardship, and are not only useless
 to themselves but are also a serious drag upon their comrades
 and the army in general.

   When  one sees, also,  the vast number of  these
 patients  collected  in .England in  the  various special
 hospitals  devoted to their treatment, one cannot but
 realize that, if we, in this country, could only prevent
 such wastage, our work would be of inestimable  value
 to the government.  Therefore, in view  of the impor
 tance  of  this  problem,  one  feels fully  justified  in
 bringing to notice the work already  done on the sub-
 ject by British neurologists and psychiatrists.

                    SHELL-SHOCK
   The term "shell-shock" came into use in the English
 army the latter part of 1914, but the  first reported
 i ases that I have been able to find in the English litera-
 ture were by Myers- in  February,  1915.   He reported
 three cases under the term "shell-shock" with  loss of
 memory,  vision,  smell  and  taste.   He  expresses the
 opinion that his cases "appear to constitute a definite
 class  among others arising  from  the effects of shell-
 shock."  Even at this early date it was found that the
 term  "shell-shock"  was a  very loose one, and that
 many of  the  patients  coming back  from France to
 England in this group  had  never  been "shocked"  by
 the concussion of a shell, but had been  buried under
 debris when'the shell  exploded;  in  some cases the
 patients^ had never been  under shell fire  at all.  March
 27, 1915, the Lancet, in  an editorial, commented on the
 effect of shell explosion on the central nervous system,
 especially in its  relation  to the  special  senses, and
 thought that most  cases would fall into one of three
 classes: fatigue-paralysis, "commotio,"  or traumatic
 hysteria.   In other words,  the numerous cases  with
protean symptoms  of  nervous disorder were  being
2. Myers: Lancet, London, 1915, 1, 316. 
3
thought  of  from  the etiologic  standpoint,  and  the
neurasthenia and hysteria cases were being separated
from those of supposed commotion or concussion with
probable organic brain changes due to trauma.
   It was  not, however, until February,  1916, that we
had the  first  clear classification  of the  shell-shock
cases.  Mott,3 the London neuropathologist, in a  series
of lectures on "The Effects of High  Explosives  Upon
the Central  Nervous  System," divided  his cases into
three groups from the pathologic point of view:
   1. The immediately  fatal.
   2. The wounded with injuries to  the central nervous
system.
   3. The traumas to the central nervous system  with-
out visible injury.
   The last group, according to Mott, forms the true
shell-shock cases.  Thus,  from the pathologist's  point
of  view,   all cases  are "commotio"  with or without
visible injury to the  central nervous system.  Shell-
shock, however,  as seen from the  practical clinical
point of view, includes all functional or obscure neuro-
logic cases.   In  many cases  now grouped as  shell-
shock,  the  patients   have  never been  within  the
zone of  active  warfare.  Henry Head,4 in a protest
against the use  of the  term "shell-shock," is quoted as
having said that it  represented "a  heterogeneous col-
lection of different nervous affections, from concussion
to sheer funk,  which have merely  this much in com-
mon, that  nervous control has  at last given way.  To
me it would be  just  as reasonable  to  sweep up  the
various fruits  which  fall from the trees in a strong
wind and  then  to  discuss them without  first stating
that some fell  from an apple and  some from a pear
tree."
   A workable classification  from the  clinical point  of
view is that of  Buzzard 5:
  1. Pure exhaustion cases.  These were quite common in the
early part of the  war, but are rarely seen now.
  2. Neuropaths  and  psychopaths, who develop shell-shock
symptoms very early and quickly.
  3. Martial misfits; the "objector," who hates war but goes
because he must and often malingers.
3. Mott, F. W.: Lancet, London, 1916, 1, 331, 441, 545.
4. Head, Henry: Lancet, London, 1916, 1, 306 (quotation).
5. Buzzard: Lancet, London, 1916. 2, 1095. 
4
  4. Concussion cases.
  5. Cortic.il  injury, a few of which get into the shell-shock
group by mistake.
  6. Cases of hysteria who show the major and minor symp-
toms of hysteria as in civil life.

   From this brief  outline on classification  and olefin i
tion,  it can  readily be seen that the term "shell-shook"
is a  blanket diagnosis to cover  all the traumas  and
disorders of the central nervous system without visible
injury,  occurring in modern warfare.  The term  is a
poor one. and Eder,6 in  his latest  book, has used tin-
title,  "War-Shock:  The  Psycho-Neuroses  in  War."
He  markedly  limits himself,  however,  by  defining,
"war-shock" as "hysteria occurring in a  person  free
from hereditary  or personal  psychoneurotic antece-
dents, but with a  mind more responsive to  psychical
stimulus than the normal."  Such a narrow definition
seems to me unpractical,  as  many cases  other  than
these  must  be  treated  as  shell-shock  in  hospitals
devoted  to  the care of the  neuroses of the war.  An
expression much  employed  lately is "war-strain," but
this is lacking in not emphasizing the dominant role of
the central  nervous system.  As shell-shock is now so
widely  used, it does not  seem practical to  change it.
G. Elliot Smith7  did  not use  either  "war-strain" r.r
"war-shock" in his  book  on "Shell-Shock and Its Les-
sons," and  preferred "shell-shock"  "as a  popular but
inadequate  title  for all  those  mental  effects of  war
experience  which are  sufficient to  incapacitate a man
from the performance  of his military duties." A  new
and excellent  classification  by Hurst8 is  too long to
reproduce here.   It is, by far, the best one that has
been made.9

        PREDISPOSING  CONDITIONS  TO  SHOCK
   It  has been found that in a  large majority of cases
of shell-shock the patients have a neuropathic tendency
or inheritance.   Some of Mott's  patients "gave  a his-
tory of either  previous  nervous  breakdown  or  of a
timid disposition,  easily  frightened, emotional, or
afraid of the  sight of blood;  in a few, the fact  was

   6. Eder: War Shock, London, William Heinemann, 1917.
   7. Smith and  Pear:   Shell-Shock  and  Its Lessons,  Manchester,
England, 1917.
   8. Hurst: Guy's Hosp. Gaz., 1917, 81, 109.
   9. Mental Hygiene, 1917,  1, 468. 
5
elicited that they had a,  fright  in  early  childhood and
thatthis  recurred in dreams."   In a case reported  by
Feiling,10 the boy ran away from school at 13 because
he was "tired of it," and also worked at various trades,
at none of them apparently with any very marked suc-
cess.   In one of the best of the articles on shell-shock,
Forsyth11 says,  "In all cases coming under the writer's
notice with symptoms which were more than mild and
transitory,  a history of  some  earlier nervous trouble,
slight or severe,  was  forthcoming."  In twelve  con-
secutive cases the following notes were  elicited:
  Nervous breakdown two years before.
  Highly nervous and irritable.
  Often depressed; worries over things.
  Longish periods of depression.
  Always  been shy; still shy, though middle-aged.
  Nervous breakdown four years  ago.
  Self-conscious.
  Very depressed; worries unnecessarily.
  Of nervous temperament.
  Intensely self-conscious; married, but sexually impotent.
  Highly strung and excitable since a child; violent tempered.

   Later Forsyth  says, "The  occurrence of a definite
neurosis  is to be looked  for only in psychopathic indi-
viduals, the onset representing the collapse of what is
already psychically unsound."
   Adrian and  Yealland,12  in  a report  on 250 cases,
say:
  There are certain mental abnormalities which  are  present
to some extent  in  nearly  every  patient.  The majority of
patients are below the average normal intelligence as judged
by the Binet-Simon scale,  and others who are more highly
equipped prove to have an  unstable history either personally  N
or in  the family.

   Mott13 again insists:
  Of  even greater importance than the extrinsic conditions
in the causation  of military unfitness from exposure to shell
fire are the intrinsic  conditions,  for  if  there is  an inborn
timorous or neurotic disposition,  or an  inborn or acquired
neuropathic or  psychopathic  taint,  causing  a  locus minoris
resistentiae in the central nervous  system, it necessarily fol-
lows that  such  a one  will  be  unable to stand the terrifying
effects of shell fire and the stress of trench warfare.
10. Feiling: Lancet,  London, 1915,  2, 63.
11. Forsyth: Lancet, London,.  1915, 2, 1399.
12. Adrian and Yealland: Lancet, London, 1917, 1,  867.
13. Mott, F. W.:  Brit. Med. Jour., 1917, 2, 39. 
6
        CONDITIONS   AT  THE  TilMK  OF  SHOCK

   The  conditions in the  front-line  trenches  that  put
the soldier's  nervous system "on ed^C and  sometimes
are the  sole  factor  in causing a war neurosis  are inti-
mated in a letter from an English officer to his mother,
telling of  his first experiences under shell fire:
  The shelling all day was awful.  Before  I  had  been  in the
trench three minutes,  a bit of shrapnel made a clean  cut in
my breeches,  only  scratching  the  skin.   The  sights  were
awful,  dead men all  over the place, some  half buried  by
shells.  The ground and trenches had all been flattened out
by our artillery fire, so there was hardly any shelter.   I told
the men to  scratch themselves in with their entrenching tools.
but it was simply  a case of looking death in the  face and
waiting  to  be hit.  Never for a moment did  I  expect  to get
out alive, as the shrapnel rattled  all day long on  my helmet,
and of course  the Boche might have  counterattacked  at any
time.  Many men got  buried and  had to  be dug out.  It was
dreadful  to see  men's  nerves give  way  and a  man  of  40
whimpering like a child and crying his soul out.  Very  catch-
ing this disease too. so I had to send  him back.   I  never got
into a  smaller ball  than I did that day, and of  course the
sights next one made  eating impossible.  When  night came
nerves got even worse, and there was  hardly a man  who was
not shivering like a leaf. That day and night was a  night-
mare.   It is the only  time I ever felt the sweat of  fear, but
then it dropped off me in one  continuous stream, as  I thought
in the dark my nose was bleeding.

   From the  foregoing note one gets a  slight  idea of
active  trench warfare.   Mott13  expresses  it in this
way:
  It must be obvious  that through  all the sensory avenues,
exciting and terrifying impressions are continually streaming
to the perceptual centers in the brain, arousing the  primitive
emotions and passions,  and their instinctive  reactions.  The
whole nervous system, excited and  dominated by  feelings of
anger, disgust, and especially fear,  is in  a condition of con-
tinuous  tension; sleep,  the  sweet unconscious quiet  of  the
mind,  is  impossible or  unrefreshing because broken or dis-
turbed by terrifying dreams.  Living  in trenches  or dugouts,
exposed  to wet, cold,  and often  (owing to  shelling  of the
communicating trenches) to hunger  and thirst,  dazed  or
almost stunned by  the increasing din of the  guns,  disgusted
by foul  stenches, by the rats and by  insect tortures of flies,
fleas, bugs and lice, the minor horrors of war, when  combined
with frequent  grim  and  gruesome  spectacles of  comrades
suddenly struck down, mangled, wounded, or  dead,  the mem-
ories of which are constantly recurring and exciting a dread 
7
of impending  death  or of being blown up  by  a mine  and
buried alive, together  constitute experiences so  depressing
to the vital resistance of the nervous system, that a time must
come when even the  strongest man will succumb, and a shell
bursting near  may produce a  sudden loss of consciousness,
not by concussion or commotion, but by  acting as the "last
straw" on an utterly exhausted nervous system,  worn out by
this  stress of trench  warfare and want of sleep.

   Forsyth11 lays special stress on "the  ghastly sights
of carnage":

  These shake the self-control of all but the very strong,  and
when,  as  must  often happen,  a man sees his  best  friends
killed or horribly mutilated, the anguish of his own feelings
may  unnerve  him beyond control,  even  though,  curiously
enough, the effects may not be felt for  hours  or  even days
after.

   From the psychologist's standpoint, the situation is
interesting:

  At the time of the trauma, whether it is concentrated in a
few  moments or spread over days or weeks,  the situation to
be met derives its psychical importance from the fact that it
involves the risk of death.  Against  this, the  instinct of self-
preservation rebels,  employing  as  its weapon  the powerful
emotion of fear.  And this, it is not superfluous to recall, is
a  natural  emotion, and therefore ineradicable;  its function,
like that of its physical counterpart, pain, is protective, dictat-
ing an immediate flight from the danger arousing it.  In face,
therefore, of the prospect of sudden death, fear strains all its
powers to  enforce an escape, and it can be coerced only by a
still  more  powerful effort of will.11

   Just what happens at the precise  moment of  the
shock is  best  shown by quotations  from  a  few case
histories.   In  one of Myers2 cases,  the patient was
not  feeling afraid but  "rather enjoying it"  until  the
shells burst about him.  While  creeping  under wire
entanglements, some  shells  burst  near him.   "As  he
was struggling to  disentangle himself from the  wire,
three  more shells  burst behind and  one in  front  of
him.   Immediately after the  shell had burst in front of
him,  his sight  became blurred.   At the  same  moment
he was seized with  shivering,  and cold sweat  broke
out, especially round the loins."  Another patient "was
blown off a heap  of bricks 15  feet high  owing to a
shell bursting close to him."  Pemberton14  relates the
case of a sergeant  of a battery of field artillery: "His
gun  was No. 1.  A direct hit was made  on No.  2 gun
14. Pemberton: Lancet, London, 1915, 1,  967. 
8
with a high-explosive shell, killing three men.   I saw
Sergeant  ------  shortly  afterward,  and  although
naturally  excited, he appeared otherwise normal,  lie
went  on working his gun until dawn next day, when
he  collapsed and was  found lying across one  of the
disemboweled corpses."  In Feiling's10 case,  a  trench
in which  the patient was fighting was  blown  in and
he was buried for twelve hours in a mass of  mud and
debris.  Mott3 gives the history  of a captain as fol-
lows:  "His whole company had been destroyed, and,
while talking to  a brother 'officer, the latter  had half
his head  blown  off by a piece of  a  shell."   Another
patient said:  "There was something dropped into the
trench.   I think  it was a shell.   I felt  myself  go up
into the air, but I cannot remember falling."
  Forsvth11 gives the following case to show how light
trauma  may be:
  The patient, after being for  some  weeks in  France, where
his  battalion was completing its training, spent two  nights,
which  were quiet ones, in reserve trenches.   The  following
day, as his platoon was moving to the rear, a  shell exploded
close by, wounding  several men, but killing none. He  himself
was unhurt, though he thinks  some  earth thrown up by the
explosion  may have struck his right arm.  At any rate, on
getting back to his  billet, he found his right hand was weak,
and the next morning he  had  lost the use of  the right arm.
When  examined three weeks later, the limb was found to be
paralyzed and showed marked  involuntary movements, which
had spread to the  shoulder and right  side of  the neck.  No
organic cause of the condition could be found.  Three  months
later the movements had ceased, but the arm  was still weak.

           RESULTS  OF  SHOCK:  SYMPTOMS
   1. Loss of Consciousness.—Most patients lose con-
sciousness at the time of the shock, but many are only
dazed  or stuporous.  The ones  that die are usually
unconscious  from the time of shock.  A condition of
automatic wandering, like the  fugue of an epileptic so
vividly described by Marie, has been observed in some
cases.  Parsons15 says,  in a typical case "consciousness
is lost for a variable time, but often not so  far as to
prevent automatic movements, so  that  the man may
walk  in a dazed  condition to the dressing station."
   2. Amnesia.—One of the most  common symptoms
of shell-shock is  amnesia, or loss of recollection. Very
few patients lose consciousness for anything but  a short
  15. Parsons: Lancet, London, 1915, 1,  697. 
9
time, and  the memory  of many of the events during
most of the period of trauma may be brought  out in
various forms of treatment.  The temporary amnesia
may be very severe and  even complete.  Mott3  gives
the history of a man who was blown up by a shell and
who could not recollect any recent or past events.  He
did not recognize any coins or even his own written
name.  He rapidly improved and recovered completely.
One of  Myers'16 cases is an example of retrograde
amnesia:

  A private  was found wandering  in a neighboring village,
clad only in  his shirt and socks.  "He was unable to give his
name, regiment, or number.  He thought his age was between
20 and 30.   I tried him with  various Christian names, but he
replied that none of them seemed familiar to him.   He could
remember two men finding him  as he was  strolling  on the
outskirts of a village, and  could describe everything that had
occurred to  him since then. There was no means of identify-
ing him, and his past was a  complete blank; he could recall
nothing, for  instance, of the events of his childhood."

   Mott3 gives another remarkable case, the treatment
of which I  shall give later in this paper. He writes:
  The patient's mind was a complete blank, and this condition
was  reflected  in a dazed,  mindless, masklike  expression.
When asked where he lived, he said, "W---"; he did not
know it was in the West Riding.  He did not know the address
of his home; and when shown a letter from his father with
the address  on the top, he  did not recognize it or his father's
handwriting.  When shown a photograph of his home, with a
group of his father, mother, and three brothers  in front of it,
he maintained the  same wondering,  dazed  expression,  and
failed to recognize the nature of the picture. His father had
heard from  a comrade that he had been buried by  the explo-
sion of a shell in the trench; that he had been unconscious
for some time and  lost  his speech.

   3. Motor and Sensory Changes.—Paralysis  and dis-
order  of  gait are common symptoms.  In 250  cases
with  some  objective disorder, Adrian and Yealland12
found 37  cases  of  monoplegia  of  the arm or leg,
46 of paraplegia, 16 of  hemiplegia, and  18 of dis-
ordered gaits.  The suggestion of an external injury
is usually found in the history of these  patients.   The
man  who   has fallen  on his  shoulder will  have a
monoplegia of the corresponding arm.  Injury to  the
back often  precedes paraplegia.  The reflexes are nor-
mal or there may be an increase  in knee-jerks with a
16. Myers: Lancet, London, 1916, 1, 65. 
10
 spurious ankle-clonus.  I cannot  find  that  a  positive
 Babinski sign has been reported in a purely  functional
 case.   The overaction of antagonistic muscles is quite
 remarkable,  especially  noticed in  relation to  gait.
 Batten17 relates a case as follows:
   When first admitted and asked to walk, the patient grasped
 the top  of the crutches and pulled the body up by the strength
 of his arms; he then placed each crutch alternately  forward,
 allowing the  whole weight  to fall on  the advanced crutch,
 and would advance the legs synchronously  with  the crutch.
 Later, when taught to walk in the walking-machine, he would
 support  the weight of the body on the hands,  dragging the
 hindmost leg forward against a resistance produced by plac-
 ing all the antagonistic muscles into forcible contractions. At
 a  later  period  he  walked without the machine,  but with the
 hinder leg as if it were  glued to the ground, from which it
 could only be moved by the  most violent tugging  efforts.

   The  direct opposite  of  the glued-to-the-ground  foot
 is the dancing tremor,  in  which  the patient walks as if
 the  legs were on springs  of coiled  wire.
   The  paralyses  differ in no way  from the  hysterical
 paralyses of civil life.  Extensive paralysis  is  the usual
 thing, a whole arm or  leg.  They are  often associated
 with sensory changes.   Myers18 has  made  a  special
 study of these,  finding various disorders of cutaneous
 sensibility in about 25 per cent, of his patients.   Mottn
 found in severe cases  of  shock "loss  of sensibility to
 all forms  of stimulus, pricking, heat and cold,  and
 touch,  also of  deep sensibility, pressure  of  muscles,
 movement of joints, and  bone sensibility to  vibration
 of tuning-fork.   Hyperesthesia  is even more common
 than anesthesia,  and even the lightest  touch gives  rise
 to apprehension and movement of withdrawal  in severe
 cases."
   Tremors and coarser rhythmic spasmodic  movements
 are an  extremely common symptom.  Mott!  gives  an
 example of a  gunner blown up by a big shell  who was
 amnesic for  fourteen  days.   He says:  "When  I
 examined him he was  sitting in a  chair; legs,  hands,
 and  jaw were in continuous coarse  rhythmical tremors'
 like  those  of paralysis agitans, which became  exag-
 gerated when  he  was spoken to.  Every now and again
 he  starts and looks upward and  laterally,  as  if  he
 feared a shell would drop on him."   Fine tremors like
those of exophthalmic goiter have been noted, and also
 17. Batten:  Quart.  Jour. Med., 1915-1916   9, 73
 18. Myers: Lancet,  London, 1916, 1, 608. 
11
tremors of the intention type; but most of them were
coarse rhythmic tremors like those of advanced paraly-
sis  agitans.  In one of Mott's cases,  a  former pugilist
was terrified by the explosion of bombs dropped by a
Zeppelin and "developed a curious tic,  which took the
form of  jerky purposive movements of the shoulders
and head, as  if to avoid a blow, and  facial grimaces
such as a pugilist might assume in a fight."
  4.  Dreams, Terror  and Mental Changes.—In  shell-
shock, the patients often suffer from terrifying dreams.
These are associated with  the manifestations of fear,
such as  terrified  facial expressions, cold blue hands,
feeble  pulse  and respiration,  sweats and tremors.
These  dreams often take on the form of nightmares,
during which a soldier will go through the pantomime
of  some  terrible experience at the front.  I have seen
men stand up in bed, sweating  and pale, continually
shouting epithets at the invisible enemy, go through the
pantomime of a charge "over the top," and a hand-to-
hand or  bayonet attack on the enemy.   Mott3  gives a
case as follows:
  A captain, aged 20, was admitted under my care in a state
of restless delirium; he moved continually in the bed, sat up,
passing his hand across the forehead as if he were witnessing
some horrifying sight, and  muttering to  himself; yet, when
interrogated,  he  answered  quite   rationally.   This  motor
delirium I associated with the continuous effects  on the con-
scious and subconscious  mind of the terrible experiences he
had gone through.

  Sometimes  the  terror leads to mania:
  A young man, aged 19, was admitted,  suffering with shock
due  to  emotional  stress  and shell-fire.  He  suffered  with
terrifying  dreams,  and after he -had been in the hospital a
short time, he developed  sudden paroxysmal attacks of mani-
acal excitement.  One afternoon he had been helping as usual
in the kitchen,  and  then  he went and  lay  down on his bed
and  apparently went to   sleep;  he  suddenly awoke with a
startled, terrified  look, became flushed in the  face,  sweated
profusely, and made for the door as if to get away from some
terrifying  conditions.  He was restrained with  difficulty.  He
remained in this excited  state, glaring rapidly from  side  to
side, giving one the  impression  that he was  suffering from
terrifying  hallucinations  of sight and  hearing, although he
would make no  response  to interrogation. He did not recog-
nize his wife, the doctors, or the sisters.  Once when I, accom-
panied by two medical officers in uniform (strangers), came
up to speak to him,  he became violently agitated, as if some
terrifying  conditions  had been  aroused  by  the sight of the 
12
uniforms; the face was flushed and he sweated so profusely
that the  perspiration dripped in a stream off his  nose.  The
attacks would last from a few hours to a few days; they came
on quite  suddenly, like an epileptic fit, and often without any
apparent cause.  It may be mentioned that  there was  no
obtainable history of epilepsy or insanity in the family.  The
case rather suggests the psychic equivalent of epilepsy in the
attacks.

   Mott noticed other points of interest in his patients
Many complained of a falling or sinking feeling; often
in their dreams, patients were  heard to  cry out and
would awake to find themselves in a cold sweat; some
officers  gave commands to their men and  urged them
on to battle; and some performed the pantomime of
raising  the gun to the shoulder and pulling the trigger.
   The revival of old associations in shell-shock dreams
is not uncommon.  In one of Mott's cases, the patient
would dream of meeting a  leper in a mine passage.
He had been alarmed previously by a leper in a South
African campaign.  A single predominating incident
may be repeated again and  again  in  these terrifying
dreams. A soldier who had seen a legless body of a
comrade at the  front had  many  dreams  in  which a
legless body was always the central figure.
   5. Special  Sense Disturbances.— (a) Vision:   The
usual disturbances  are photophobia,  with or without
blepharospasm,  "smoky vision,"  diminution  in  the
visual fields, and amblyopia.  The  photophobia is not
usually  a  serious  or  persisting  symptom; "smoky
vision"  may  last for  months.   Diminution  of  visual
fields alone  is  common.   Patients  with  amblyopia
usually  go to  special hospitals.  The first  and best
cases recorded are those by Parsons15 early in  1915.
Functional blindness is more common than  deafness,
loss  of  smell  or taste. "On  examination,  it is  found
that there are intense blepharospasms and lacrimation.
The lids are opened with great difficulty, and examina-
tion of the  eyes is almost impossible in the  early
stages." The man is struck blind instantaneously. In
two  to  three weeks  blepharospasm diminishes.   "The
fundi appear to be absolutely normal.   The  pupils
react to light, though in some cases the reactions are
sluggish, and sometimes one pupil differs  from the
other, being larger  or more  sluggish in its  reaction.
By this time  probably some  restoration  of  sight has
occurred, light is perceived and large objects may be 
13
distinguished.   As  improvement occurs,  the patient
manages to grope about, usually with his hands out-
stretched before him, but it is noteworthy that he does
not usually stumble against objects in his path.  As
soon as it is possible  to take the fields of vision, it
is  found that they  are markedly contracted,  and that
indeed to  a degree which seems scarcely consistent
with the avoidance of obstacles in walking. The recov-
ery of vision is slow,  but eventually it always seems
to be complete."
   In Pemberton's14 case which I mentioned before, of
the sergeant who suddenly collapsed twelve hours after
seeing  the gun-crew next to his hit, the amblyopia and
contraction of  fields  was marked  when  first seen.
There  were many sensory and motor disorders,  also.
   (b)  Speech:   The speech defects most commonly
noted are mutism, aphonia, stammering, stuttering and
verbal  repetition.  Mutism is  most common—about
one in twenty,  according to Mott.  The patients can-
not produce any audible sound; there is no sound when
they attempt to laugh, try to whistle or cough.  Most
of  these patients can write.  "Many who are  unable
to speak voluntarily call out in their dreams expres-
sions they have used in  trench warfare and battle.
Sometimes  this is  followed by  return of speech, but
more often not."  Mott3  continues,  "This mutism is
due to emotional shock;  it is  a psychic  rather  than
physical trauma, in my judgment, for it in no way dif-
fers from the  description of hysterical mutism thus
given  by  Bastian."   Anesthesia of the pharynx has
been noted.  Some cases  will be quoted later, in the
consideration of treatment.
   (c)  Hearing:  Deafness often accompanies mutism
or aphonia, causing the condition of functional deaf-
mutism.   "It is not at all infrequent for a man to be
deaf on one side and not the  other,  and the history
often shows in these cases  that a  shell has  burst on
this side of the man.  Auditory hallucinations are not
uncommon, and  the patients complain of hearing the
bursting of shells,  of the noise of  shells coming,.of
bullets whizzing, and  of  whistles blowing.   Hypera-
cusis, or extreme sensibility to sound, is a common and
very troublesome symptom,  making  the patient miser-
able and  apprehensive."   Mott found  that  many
relapses occurred during a Zeppelin raid (on London),
and one man, "a sergeant who had been a professional 
14
pugilist of great renown, suffered extremely, so that
the noise  of the click of billiard balls irritated him to
such a degree  that he  would protest forcibly against
the game  continuing.  His  fellow patients found that
they could easily cause him  to flee by taking their slip-
pers off and banging them on the ground sufficient to
produce a sharp loud noise."
   (d)  Taste and Smell:  Both  are often affected, but
owing  to  the difficulty of an examination which  is so
largely  subjective,  they are often omitted from the
case reports.   No very'definite data could be obtained
about them.
   6. Cardiovascular.—"Patients  often   complain  of
palpitation, breathlessness on exertion, and precordial
pain.  There may be physical signs  of  dilatation and
tachycardia.  The pulse is  often small  and increased
in frequency ; the blood pressure  is never high.  It was
often below 110, and never above 135.  The hands are
frequently blue or  mottled  and cold  ; and  often there
is cold, clammy sweating of the palms.  The surface
temperature may be very low; in one case  it was only
16 C."  (Mott).  Most of the patients  with  marked
cardiac symptoms go to special  hospitals.   The com-
plaints  of these  patients  are:  breathlessness, pain,
giddiness, palpitation,  and  exhaustion  on exertion
There are no physical signs of structural change in the
heart.   These  are the  cases of  "irritable  heart" that
have received so much attention by Dr. Thomas Lewis
and his  colleagues at  the  Military  Hospital, Hamp-
stead, England.11'  In the broad  sense these cases come
under  "shell-shock,"  as they are certainly functional
disorders of the nervous system that are peculiar to
modern warfare.
   The  vasomotor  conditions  are   quite  noticeable.
Osier mentions the "men with unstable vasomotors" as
unfit for the trenches.  Excessive  flushing and der-
mographia are quite commonly seen.
   Headache  is often a prominent  symptom.   Mott'
says:
  The commonest situation for the maximum pain is  the
occipital region and the back of the neck;  it is often  described
as a tight compression, like a helmet—the helmet of Minerva.
The pain may  be in the frontal region over one or both eyes,
over the vertex, in one or  both temples, or at the back of the
eyes.  The pain is variously described as burning, stabbing, or
19. Heart, 1917, 6. No. 4. 
15
a heavy, dull, dizzy feeling, a feeling like  a  tight hat, or a
red-hot wire being run through the temples.  It  is worse at
night, especially upon lying down and trying to  sleep.

                  NEUROPATHOLOGY
   The  neuropathology  of  shell-shock  has received
scant attention in  the literature except  for the work
at  Dr.  Mott's laboratory.   The reasons  are quite
obvious,  as  very few  patients  died  at  the hospitals
except  by chance  of intercurrent disease,  and those
that die on the field are  seldom examined postmortem.
In the  last  year, however,  more  provision  has been
made  for necropsies at or  near the front, and  by
arrangement with the Royal  College of Surgeons, Lon-
don, certain  brains are being sent back,  properly pre-
served  for  future study.  Dr.  Mott20 has  been for-
tunate enough to secure  a few of these, and his find-
ings are of great interest.  He first noticed the marked
similarity between the brain of a soldier  dead from
shell-shock and the brain of a man dead from carbon
monoxid  poisoning.   His study of carbon monoxid
poisoning before the war led him to think that the main
postmortem  findings were extensive capillary hemor-
rhage  in  the brain, especially in the corpus callosum,
the internal  capsule, cerebral peduncles  and centrum
ovale.21   Two  cases were  from  carbonyl  of  nickel
works.   There was a case of suicide by illuminating
gas.  In the first case of shell-shock,  a man had been
buried by a  shell blowing in a parapet,  and had died
two days later.   No visible wounds were  found  on
the body. Throughout the white matter of the centrum
ovale,  and  especially in  the  corpus callosum, were
multiple  punctate hemorrhages.  Mott3  says:   "This
appearance to the naked eye  corresponds  to that  which
I  have  described  in carbon  monoxid  poisoning.  The
«ame microscopic appearances were observed as those
seen in  coal gas (CO)  poisoning,  only the hemor-
rhages  were more extensive."   Apparently the fatal
cases are the gas cases,  as Mott has  found the same
appearance in later brains.  These are the true cases
of shell-shock with burial that form a very  small part
of the vast number of cases in men who return from
the front with symptoms of  a neurosis.    Whether
these also may have minor brain hemorrhages is prob-

  20. Mott, F. W.: Lancet, London, 1916, 1, 331, 441, 545; Brit. Med.
Jour., 1917,  1,  637.
  21. Mott, F. W.: Arch. Neurol., 1907,  3, 246. 
16
lematical. but we may feel certain that many men who
never  got  within the range of shells and yet develop
brain  symptoms probably  have no  such gross  patho-
logic lesions.   Most  neurologists  believe  with  Wilt-
shire22 that "chemical poisoning by shell gas cannot be
more than an exceptional cause of shell-shock."

                     TREATMENT
  The treatment of the  war neuroses naturally divides
itself  into  a number of  separate  fields.   One  may
treat the symptoms, at the same time paying attention
to the general health of the patient.  This method is
the one generally used  in  the British  hospitals.  But
some authors believe that we  must go deeper than the
treatment  of symptoms  and  make a  study  of  the
underlying  mental  condition  that  enables  a  "fixed
idea"  to develop.  The  latter form of therapy  leads
us to the large question of psychanalysis and its place
in the  treatment of shell-shock. Laying this aside for
a  moment,  I  shall  take  up the  treatment  of  the
symptoms.
  Adrian and Yealland12 say  that the three principles
involved in those methods of  treatment that aim  only
at relieving the functional symptoms  are:  (1)  sug-
gestion,  (2)  reeducation,  and  (3)  discipline.   "The
aim  of suggestion is to make the  patient believe he
will  be cured, and  to lead him  on  from  this to  the
belief that he is cured."  These authors have obtained
the be<t results  by :
  A very brief suggestive treatment followed by rapid reedu-
cation,  which is continued, if  possible, without a pause until
the  normal  function is entirely  regained.   The  suggestive
treatment may take any form, but it is essential that the
patient  should be convinced that it will produce an immediate
recovery.  In untreated cases there is rarely any difficulty in
this, and the conviction can be strengthened by using  a form
of treatment which will be capable by itself of evoking  some
part of the  function which  is temporarily in abeyance.   For
instance, a case of mutism may be cured by tickling the back
of the mouth so as to induce reflex phonation.  The  patient
is compelled  to make a noise, and the fact that he has done
so will convince him that the  treatment  will be effective.  In
the same way, a strong electric stimulus will produce a sen-
sation and motion in a limb which is supposed to be anesthetic
and paralyzed,  and this  in itself  will be enough to convince
the patient that he is on the road to recovery.
22. Wiltshire: Lancet, London, 1916, 1. 1207. 
17
  The application of strong electricity by the faradic
current is a  very  successful  method of  augmenting
suggestion.  Of course, the secret of  success  lies in
the fact,  as these authors point out,  that "the patient
must be convinced  that the physician understands his
case and  is able to cure him.  This idea should be fos-
tered from the moment the patient enters the ward."
Many treatments have failed because  of a lack of con-
fidence of the  operator in himself.   The physician's
authority  must be  absolutely  unquestioned,  and  "an
air of complete assurance is far more convincing than
the most  elaborate  reasoning."
   Hypnotism is a form of treatment under the head of
suggestion.  It is very easy to hypnotize most patients
lightly, according to Adrian and Yealland:
  They  will readily accept  the idea that they cannot open
their eyes  or move their limbs, and they will comply with any
suggestion which does not relate  to their disability.  Unfor-
tunately they are not nearly so tolerant when  the suggestion
touches their fixed belief that they cannot speak or that their
legs are paralyzed.   With a patient who is intelligent and
anxious to get well, hypnotism may be extremely successful,
and it is  certainly of great  value in the treatment of  sub-
jective troubles such as insomnia,  fighting dreams, etc."
   Myers16 reports  that in twenty-three cases he  had
apparently complete cures in 26 per cent., and distinct
improvement in 26 per cent.   He failed to hypnotize
35 per cent., and found no improvement after hypnosis
in 13 per cent.  He says that  it "invariably  proved of
great assistance toward recovery." Eder23 found  that
out of seventy-eight patients  only three  could not be
hypnotized at the first attempt, and says that "hypno-
tism has been  most  successfully applied in the treat-
ment of  our soldiers."  Buzzard5 sums up the subject
by saying:
   My experience leads me to believe that any form of sugges-
tion,  whether applied under normal  conditions or under the
influence of anesthetics or hypnosis, may be successful; but
the  success depends  first  of  all  on the  willingness  of the
patient  to recover, and  secondly on the  adequacy  of the
suggestive stimulation.
   Strong suggestion in the excitement stage  of  ether
anesthesia has  been  tried, and has been  successful
in certain cases  of  mutism   and loss  of  hearing.24

   23. Eder: Lancet, London,  1916, 3,  264.
   24. Dawson:  Lancet, London,  1916, 1, 463.   Proctor: Ibid., 1915,
2,  977. 
18
 O'Malley-'"'  has  been very  successful in his cases  of
 aphonia  and deafness  by treatment  with  suggestion
 and  reflex excitation.
   The  second  principle of  treatment  outlined   by
 Adrian  and Yealland   is  reeducation.   I'nder  the
 heading  of reeducation they include the method  of
 simple persuasion,  in which the patient is  convinced
 by logical, argument that his condition is not  so serious
 as he supposes.   However,  it is  not  easy to convince
 a patient that his trouble is purely mental when he has
 physical symptoms and he naturally looks for a cure by
 physical  means.   Electricity is the best  and the  most
 mysterious to the layman of the physical means which
 we have  at  our  command.
   While  reeducation by physical means is a valuable
 adjunct to treatment, occupation plays a very  impor-
 tant  part.   Drills and  physical  exercises should  be
 replaced by productive occupations as soon as possible.
 Those  which are  nonproductive should be avoided.
 All  occupations, and especially those carried  on  by
 patients seriously  incapacitated,  should be  regarded
 merely as steps in the process of their education. Con-
 stantly more difficult tasks  should be  assigned  as  a
 means toward  the  restoration  of  the  lost or  impaired
 function.
   The third form of treatment is  by discipline.  Isola-
 tion is often used. It may supply "the needful stimulus
 to recovery  by  making  the  patient's  illness  a dreary
 and unprofitable  business, instead of a source of pride
 and satisfaction.   For this reason it is extremely  use-
 ful in cases  of functional tremors and pseudochorea,
 where the  patient becomes  quiet  as  soon   as he  is
 deprived of his audience."12
  The details of the treatment of various symptoms as
 carried out by Adrian and Yealland  cannot be gone
 into.   The essential elements consist  in  a very brief
 suggestive period followed by rapid reeducation.   The
 self-confidence  of  the  physician,  the  faith  of  the
 patient, and the rapidity  of operation are all important
 factors in the method of treatment.
  Other methods of treatment  consist  in the  emphasis
being placed on the general  condition of the patient
 rhis is Mott s method of procedure, and it certainly
has been very successful in his hands.  He3 says "Only
common sense  and interest in the  comfort,  welfare,
 25. O'Malley: Lancet, London, 1916, 1. 1080. 
19
 and amusement  of these neurotic patients are neces-
 sary  for their recovery."   He lays special emphasis
 on  the hospital and its environment.  At his beautiful
 institution outside of London, he  has:

   Light airy wards, and day rooms for meals and recreation,
 plenty of  single rooms for  the isolation of cases  that  are
 troubled with noises or require special  attention; and  espe-
 cially valuable  are the baths,  so  that every  soldier can  get
 a warm or cold spray bath every day.  The warm baths, and
 especially  the continuous warm baths,  are especially valuable
 for  promoting the  action of the skin, of relaxing the tired
 muscles, and  by the  soothing  influences helping to induce
 sleep, so that  less hypnotics are required  to be employed.

   In these ideal  surroundings the patients are usually
 left to adjust themselves.
   When  indicated,  mild  suggestive  and persuasive
 measures are  used, as in the case  of  amnesia parti}'
 quoted.   The story continues as follows:

   We rward  from  his father that  he  was a  good  musician,
 and I said to  him,  "G----, I  hear  you are a good musician,"
 and I asked him  if he Could play the piano or sing;  there
 was the  same wondering, bewildered  look,  and he muttered
 something  which was to the effect that he  could not sing
 or play.   Three days  later I said, "Come, you can  whistle
 'God Save  the King.' "  He took no notice, but upon  pressing
 him, he looked up  and a glint appeared in  his eyes,  and he
 said "You  start me."  I whistled the first bar; he took  it up
 and whistled  it  admirably.   I then   asked  him to  whistle
 "Tipperary,"  but he could not do  it  till  I  started  him, and
 the same with several other tunes, but once started, he had no
 difficulty,  and  I  recognized  from  the  admirable  intonation
 that he was, as  his  father described him, an excellent musi-
 cian. I could not, however, that day get him to start upon his
 own initiative any  one of  the tunes  he had  whistled.  The
 next visit,  three  days later,  I  observed that his expression
 had  changed.  He smiled when I spoke to him, and I recog-
 nized clear evidence of a mind  that had  partly found itself.
 He could not whistle by himself any of the  tunes I had pre-
 viously started  -him  on  when  I called  for them.  [He
 relearned  to play  the  piano  by first  having his finger held
 on the keys and a  melody played.]  The next time  I  came,
he was able to play any music  set before him.  His associa-
tive  memory  and recollection of music were in advance  of
other associative memories.  Thus, eight months after he had
r-covered   his musical memory, he   had very imperfectly
recovered his memory of elementary facts regarding his pro-
fession as  a land  surveyor, and there was  still a  tendency
to a  vacant, mindless expression and prolonged reaction time
as shown by delay  and slowness in responding to  questions, 
20
as  if there were a  difficulty  in  linking  up  the  necessary
associations.

   Mott reports that about thirty-five cases of mutism
have come under his observation, with  recovery in  all.
Some of the recoveries take place under most amusing
circumstances:

  In one case the patient "was sitting in  his  wheeled-chair
playing baseball,  at which he was  quite good, when a runner
overturned him;  the  sudden emotional  shock  and  surprise
made him exclaim aloud,  and since then he has quite recov-
ered speech."   Strong faradic  stimulation to  the  larynx  in
this  patient had not resulted in phonation.   Another patient
"was in a punt and it was turned  over, and he  was capsized
into the  water, which made  him shout out.  Practically, he
had been mute for more than  eight months.  He often  shouted
words  in  his  sleep about trench warfare,  so he must have
had  dreams but forgot them." This patient  under the strong
suggestion  of  removal of adenoids did not  speak.  In regard
to a third patient, the following is  told: "His fellow  soldiers
thought he ought to hear  and speak, and they  adopted  ener-
getic measures to make him shout out  for help.  Two»of them
leathered him with a slipper and  then nearly throttled him.
He struggled and shouted  'Stop it.'"
  One dreamed he was falling  over a  cliff,  shouted out, and
recovered his  speech.  A  deaf-mute was heard to speak in
his sleep.  He was told of  it by  a comrade.  He said, "I don't
believe it."

   Mott's summary  of treatment is as follows:

  Be cheerful  and look cheerful is the note  that should ever
be sounded to these  functional  cases.  Sympathy should not
be misplaced, although it  should be shown to all these poor
fellows who have a fixed  idea of never recovering; it is not
their fault, it  is a real thing to them, and no  one could be
more grateful than these cases of functional  nervous dis-
ability for cheery  words.  I use many of these cases  that have
recovered as object-lessons. I do not find hypnosis or psycho-
analysis necessary or even desirable."

   Forsyth11 thus outlines his treatment:

  The only treatment  during  the acute stage  comprises  three
items—physical rest   in bed,  mental  quiet,  and  good  food.
A private room is best.  "Noises of all  kinds, indoor and out,
are borne  with  intolerance  and  are  harmful,   especially  if
they are unexpected  and  even remotely recall  the dreaded
shell explosions."  At  first  the patients should be left to them-
selves,  without being disturbed by  the taking of medical his-
tories or conversation.  "They  must expect to pass  restless
nights  with piercingly  vivid  dreams,  for  which even hyp-
notics are only palliative.  Those with the mildest symptoms 
21
can safely be allowed to get up within a few days, gradually
increasing this exertion, until perhaps in a week or a fort-
night they can get away to the quiet of the country or the
seaside;  and in  another six  weeks they will  probably  be
able, not indeed to return to the front,  but to take up light
duties at home."
   Most patients need bed  for  three to four weeks  or
longer,  followed by two  or three months of quiet liv-
ing.  "Throughout  the greater part of convalescence
any indiscretion in the way of mental or physical exer-
tion beyond the narrow margin of the patient's endur-
ance at the time seems regularly to entail a setback out
of all proportion to  the extra  effort."
   The symptoms of depression of spirits,  listlessness,
taciturnity, desire for solitude,  lack of confidence, poor
appetite and sleeplessness  are  "best and most  quickly
relieved when the  patient  has been induced  to  talk
 freely  of what is on his mind, the  opportunity at the
same time being taken to  present his  facts to him in
their true light, together with  the additional informa-
tion he needs to form a just opinion  of his conduct and
to rehabilitate himself in  his  own  esteem."   Forsyth
 looks at the neurotic symptoms as in a case  of every-
 day  neurosis, a  problem dealing with "the  psychical
 development of the patient since childhood; and the
 further treatment  must  follow psychanalytical lines."
 A patient who has  not  been  able  to  regain his  self-
 control after  three  or  four  months is  in  need  of
 extraneous help, that is, psychotherapy.
    Rows'26  treatment is  along nonradical lines.   He
 says that the patient's difficulty lies chiefly in the fact
 that:
   He has  little  or no insight into the  nature  and  mode of
 origin  of his mental  illness.   This insight can be  provided
 by explaining to him in plain language the  mechanism of
 simple  mental processes, by enabling him to understand that
 every incident  is accompanied by its own special  emotional
 state and that this emotional  state can be reawakened by the
 revival  of the incident in  memory.  The patient will  thus
 be led to see that it has been no gross disease and no super-
 natural  agency which  has disturbed him; he will be able to
 recognize the relation of cause and effect in the  origin and
 development of his illness.  When this relation is appreciated,
 both the patient and the physician will begin to_ realize that
 they have some ground in common.  The physician should
 be prepared to give at least an hour for  an  interview, and
 in most instances  several interviews will be necessary.
   26. Rows: Brit. Med. Jour., 1916, 1, 441. 
22
  The value of psychanalysis as a  form of treatment
has caused much controversy in England.  Adrian and
Yealland12 believe  it to be very valuable as a  form of
treatment for  the  state  of  mind of the patient  which
has allowed a fixed idea to develop.   The fixed idea
itself  that gives rise to the  functional symptom or
paralysis, loss of speech, etc., is best treated  by sug-
gestion, but at the  basis of  this is a state of mind that
will not vanish by these methods.   They say  that the
patient minus  his symptoms  "will  always be liable to
develop hysterical  troubles in moments of emotional
stress and exhaustion, just as a man with a malformed
chest  will be  liable  to attacks of bronchitis."  This is
borne out by the number of patients returned from the
front  with a  remission of symptoms  after apparent
recovery.  Psychanalysis, in  their  opinion, will  "cure
not only the hysterical symptoms but also the hysterical
mentality."  If the repressed desire is "unearthed and
explained to  the patient,  the repressed conflict will
vanish, and with it  not only  the hysterical symptom
hut also the state of mind  which made this symptom
possible." Practically it takes too long a period to tr-e
psychanalysis on the average  shell-shock patient, and
it  can be used only in  special hospitals.  One must
therefore  treat symptoms  during  the  war and  leave
this longer method  for more leisure moments.
  Eder23  also thinks psychanalysis valuable  but  not
usually expedient in war time.  He, however, uses it
"for purposes of diagnosis or with a view to helpful
suggestion in most cases."
  One of the most  important problems in the  early
part of  1915  was the question of  sending the appar-
ently  cured patients back  to  the  front.  Those that
went  back proved useless  as soldiers  in front-line
trench duty, for they broke down again either on the
way to  France or  soon after reaching the trenches.
Forsyth's views  are that "with an  increasing experi-
ence of these cases  a very strong doubt rises  as to
the judiciousness of sending any cases of nerve-shock,
with few  exceptions, back  to the firing line."   If the
patient knows  he will not return to trench warfare, he
makes a more rapid recovery.  Forsyth thinks that
these  patients should be  kept in England on light duty
because of the following points:
  1. Their untrustworthy  memory (one of  the  last
symptoms to disappear), by leading them to forget to 
23
carry out orders or to forget when they have carried
them out, may entail the miscarriage of plans.
  2. Their  example  may  infect  those around  them
with irresolution or even worse.
  3. When  the strain becomes severe, they will almost
certainly break  down  a  second time.
  The  hospital  building  and  its  surroundings  are
important in the treatment of war neurosis.  The Eng-
lish War Office has arranged two exceptionally fine
hospitals for officers,27 one on a quiet street in London,
of  thirty-three plain bedrooms with gray walls, with-
out pictures  or ornaments.   Here the patients  are
received from France and given from three  to  four
weeks of a  modified Weir-Mitchell  treatment of abso-
lute rest in bed in quiet  surroundings.  When some-
what recovered, they are removed  to a large  country
house, where they  remain for six weeks or longer and
receive the  treatment that has been outlined above.
  For the soldiers a complete series  of hospitals has
been inaugurated.28 There are two "clearing hospitals"
of  500 beds for all neurologic patients, including those
with functional  paralysis,   disturbances of  speech,
amnesia,  mutism,  deafness,  amblyopia,  motor agita-
tions, nervous debility, mild neurasthenia, simple men-
tal  confusion, anxiety psychoneurosis, simple mental
depression,  etc.  The treatment  here consists  of rest,
proper feeding, massage,  electricity,  baths,  psycho-
therapy,  simple suggestion and  occasional hypnosis.
From these two hospitals about 40 per cent, return to
light duty, 20 per cent, are invalided, and 20 per cent.
are transferred to special institutions.
  Of these special institutions there are two of about
550 beds, mostly with single isolated rooms. No new
patients are sent here, but only those transferred from
the neurologic hospitals.    Here  are treated severe
neurasthenia, mild psychoses, profound amnesia,  epi-
lepsy and mild primary dementia.  The treatment con-
sists of rest,  proper feeding, recreation and massage.
Psychanalysis is used in selected  cases.  About 40 per
cent, of these patients return to light duty.
  There are  also two hospitals of  700 beds for certi-
ficable  mental patients.   From 10  to  15  per  cent, of
these return  to light duty.

 J.7. Lancet, London, 1915, 2, 1155.
  28. Turner:  Lancet, London, 1916, 1, 1073. 
24
                   PROPHYLAXIS
  What can the Medical Corps of the United States
Army  do  toward  the  prevention  of  shell-shock?
Obviously it must be checked at the recruiting station
or in the cantonment camps before the men leave for
France.  There ought to be no question jn the minds
of the  medical officers as to the advisability of check-
ing this condition at the source, for  no one who has
seen the results of modern warfare on the unstable
mind can do otherwise than urge such measures  with
his utmost  vigor.  It becomes the  duty of each medi-
cal examiner to  weed out from the recruits such men
as are liable to shell-shock.   By  so  doing, an enor-
mously important advance  will be made in our army,
as judged by the experiences of the other  armies of
the Allies.
   We  have been strongly  advised  by Osier to check
the enlistment  of  the  neurasthenic.   It  is  obviously
difficult to pick him from the crowd, "as he may come
up in good form" and be  eager to go overseas.   But
it is not so difficult with  the  mentally  deficient, the
"queer  stick," the "boob," and the butt of the prac-
tical jokers.  He is soon observed  and noted  by  both
officers and men, and if he is  singled out and talked
with for five  or ten  minutes one  ought to have  no
difficulty in deciding his fitness for active trench  war-
fare.   One ought also to look especially carefully into
the past  history  of  the  depressed, the man  who
worries unnecessarily, the  self-conscious, the  shy, the
high-strung, excitable man, the violent-tempered, the
nervous, the timorous,  the easily  frightened, or the
neurotic individual.  Any  or all of  them may make
poor first-line-trench soldiers.  The task is a difficult
one, but that in itself should  not prevent our  try-
ing.  What an  advantage it  would  be to  our army
officers, and what a saving of life it would mean to
our men, if the shell-shock patients  could be elimin-
ated from  our forces that will fight overseas!   Such
Utopia is probably impossible, but I feel confident that
careful weeding out of  the mentally unstable will cer-
tainly  greatly  reduce the numbers  of shell-shock  cases
that are bound to appear in our casualty lists.