1 SEPTEMBER 1917, Page 18


Turanz are two. or three terms in_ use in the military diagnosis of disease which fill the lay mind with joy. A patient will be Wane- hared, for example, with only the mystic lettees "

" Pyrerde. (fever) of uncertain origin "—en his Medical Case Sheet. Or again he may be diagnosed ea - Myalgia "—i.e., muscular pain ! At lama one irreverent hospital is. wondering if it dare espreas he meaning in the letters, almost equally explicit. " S.R.L" (deems rather ill). Crass a young:physician in a great civil hospital had it, " 11,0.K."

" Shell shock" in used as a description of many- very varying states of mental and physical injury. It.may denote the appalling physical " shaking " experienced by a healthy man who is. blown twenty feet into the air in a shell explosion, or the state of the green boy recruit who is unnerved by freeing his pal blown to pieces at bin side, or the condition of the veterau N.C.O. or officer who has. been gradually wort down by the fearful strain of war and who can no longer face his responsibilities. In most cases it is dueto a mixture of such caused, " flavoured to taste "with exposure, loss of sleep, and pain. due to trench fever, gas, or wounde. It may show itself by loss of voice, terrifying dreams, loss, of power and sensation in one of the limbs, extreme emotionalism, tromer of the head or whole body, excessive fear or anxiety, loss of vision, somnambulism, or all these symptoms in rapid succession or kaleidoscopic mixture. The physical symptoms (except, in the writer's experience, tremors) are generally the first to yield to treatment, and it is with the patient's mental and psychological injuries that the writers of the present most interesting little volume are concerned. In their introductory chapter Dr. Elliot-Smith and Mr. Pear deal effectively with one popular idea concerning " shocked " patients of which we heard a good deal in the early part of the war :— " A common way of describing the condition of a man sent back with ' shock ' is to say that he has ' lost his reason ' or ` lost his acmes.' M a rule, this ism singularly inapt description of such a condition. Whatever may be the etateof mind of the patient immedi- ately after the mine explosion, the burial in the dug-out, the sight and sound of his lacerated comrades, or other appalling experiences which finally incapacitate his for service in the firing line, it is true to say that by the time of his arrival in a hospital in England Iris reason and Iris senses- are usually not lost, but ftmctioning with painful efficiency. His. reason tells him quite correctly, and far

too often feriae:personal comfort,that if he had not given, or failed to carry out, a particular order, certain disastrous and memory- haunting results might not have happened. It tells him, quite convincingly, that iu his present state he is not as other men are. Again, the patient reason, quite logically, but often from false premises, that sines he is showing certain symptoms which Ire has always been taught to associate with ' madmen,' he is mad too, or on the way to insanity. If nobody is available to receive this man's confidence, to knock away the false fomidations of his belief, to bring the whole structure of his nightmare clattering about his cars, and finally, to help him to rebuild for himself (not merely to reconstruct for him) anew and enlightened outlook on his. future —in short, if he is left alone, told to 'cheer up ' or unwisely isolated, it may be his reason, rather than the lack of it, which will prove to he his enemy. It is not in the intellectual but in the emotional sphere that we must look for terms to describe these conditions. Thesedieturbantes are characterised by instability and exaggeration of emotion rather than by ineffective or impaired reason."

Again, in a later stage, as the authors point out, the patient's reason will be found in all too vigorous life. It will Wiry-itself-in

• Shell 81..eck and is LeilOW By G. Elliot-Smith and T. II. rear. Looka: seesenat eat (b. (M. al, nett building syllogisms on the erroneous data supplied by his emotions —the process known to psychologies as "Rationalization " ; i.e., " the seeking of eonseierm and rational grounds for actions whose motives are largely unconscious and peehaps irrational." The archaeologist sees this process at work to parieetion if he consults local tradition as to the " reasons " for the lighting of bale-firm (in the Pyrenees), the carrying of a " Jack-in-the-Green " on May Day, or the unluckiness of hawthorn flowers indoors.— The patient will collect and co-ordinate his recollections of haEutinations, his fits of morbid melancholia, "changes of con- sciousness "—all that has " made his life a veritable hell " of late. "lie will soon argue to himself that these phenomena can have but one meaning : that he is mad or rapidly becoming, so. . . . Completely illogical, but to him entirely satisfactecy, explanations of his condition will then multiply." When a somewhat eloper analysis of the patient's condition is reached, and the.lino of treat- ment to be adopted is discussed, the authors of the present book enter upon the controversial. In both they hold a pretty central " trimming " position. They do not agree with Dr. Eder (of the Malta Hospital.). and the extreme school of the Psychocaaalysiats. This school seerne (roughly). to hold that the " blame " ie mainly due to a conflict between the subconsciousness and the rational self, or to some other more complex cleavage in personality, involving .(in Dr. Eder'. War Shock at least) everlasting harping on the sex motive. Their treatment is mainly by hypnotism.. Nor do they agree with the " Materialistic " school, who rely entirely upon such agents as rest, massage, the administration of extracts of the ductless glands, or alternatively upon "strong electric shocks, cold' douches, and other decorous substitutes for a sound Mashing." They advocate the use of a common-sense combination of methods, and especially of persusaion, by the physician and suggestion when the patient is in the waking state. Especially do they advocate a better education of the physician in psychology. The latter part of the book is devoted to this advocacy and to an indictment of our mad= system. Their assumption, by the way, especially after the statements wo have quoted from the first chapter, that the unfavourable termina- tion of shell shock will be. insanity, moms to us somewhat gratuitous Also, why do they omit all reference to the duties and qualifications of the naming- staff, who necessarily form sa much more constant a part of the patient's environment than ,the physician, and who must profoundly affect the patient for good or ill ?

The book is, however, exceedingly interesting—and, best of all. optimistic. It is well written and quite" watechnicaL Intended primarily for the general reader, it should prove of the, greatest use to those general practitioners who may have the care or the after-care of " shell shocks " on their hands.