|A WW1 Soldier suffering from shell shock|
Shell shock was a word first used in 1915 about soldiers on the Western Front who developed a psychological state after exposure to the trauma on the battlefield or its close environs.
Typically, it was demonstrated by signs and symptoms ranging from a desire to flee the battle-field, to nervous tics, or grotesque body movements, and even physical and mental collapse and paralysis, The very worse cases went into a catatonic (= sleep-like) state which persisted for years.
Such signs and symptoms were by no means restricted to the Western Front, and occurred in all the major battlefronts e.g. Gallipoli and Italian. Moreover, they have been reported over the centuries in association with the trauma of battle; particularly in association with long campaigns, heavy bombardments and sieges.
Etymology of shell-shock
The Oxford English Dictionary (O.E.D.) defines the word 'shell-shock' as: Derangement of the nervous system deriving primarily from explosion at close range. But, strangely, the O.E.D. gives no attributes to the source, or origin, by date, or author. However, the definition itself is close to the reason for its genesis on the Western Front in 1914. It specifically relates it to the actual cause of the syndrome as then understood, i.e. The effect of having the senses affected by a close detonation of a shell, the ensuing heat and air blast, and the heaving of the displaced adjacent ground.
On the other hand, the French and German army doctors got closer to a more modern interpretation with their respective description of: la confusion mental de guerre (= the mental confusion caused by war) and Kreigsneurose (= war neurosis).
Early recognition and medical diagnosis
Although the condition was recognised by many of the ordinary soldiery, presumably the following early examples of the names by which the condition was known were given by the military physicians of the time:
- Spanish soldiers in 30 Years War (1614-48) = Estar Roto (Broken/In despair)
- Swiss mercenaries (1678) = Nostalgia (Homesickness).
- German soldiers (1700's) = Heimweh (Longing for home).
- American Civil War soldiers (1861-75) = Da Costa's Syndrome (Nostalgia) and (1869) = Neurasthenia (Nervous debility).
Other common synonyms were: Soldier's Heart, Irritable Heart and Effort Syndrome.
The probable first recorded modern medical diagnosis of the condition occurred in the Russo-Japanese War of 1904-05, which was noted for its early form of trench warfare, sieges and heavy bombardments. About 2,000 cases of war trauma were reported and given treatment. Overall casualties were 390,000 out of the 900,000 combattants.
Accordingly, shell-shock cases represented 0.5% of all casualties and 0.2% of the combattants.
Medical diagnosis and treatment of shell shock in the Great War
The first British cases on the Western Front, of what became to be called shell-shock, occurred in the early fighting around Mons and during The Retreat from Mons. By the end of 1914, over 100 British officers and 800 Other Ranks (ORs) had been treated for what was described as a 'severe mental disability'. Particular note was made of the fact that few of the affected men had received serious physical battlefield injuries and that quite a few had hardly any injuries of any kind. Hence, the concept of shell shock due to direct trauma being solely a result of the proximity of the victim to an exploding shell(s) became rather tenuous.
Significantly, the number of cases recorded amongst the officer cadre compared with ORs during the Great War (1:6) was proportionally much higher since the ratio of officer to ORs in an infantry battalion was 1:30. Many commanding officers regarded complaints by Other Ranks as at best malingering, and at worst cowardice. Some soldiers, who later on in the war would have been diagnosed as bona fide shell shock cases, were found guilty of desertion or cowardice, and were executed by firing squad; events that still echo in the public conscience today, nearly 100 years on.
Similar complaints of 'disability' in the officer class were usually more benignly considered and were often put down to have been due to overwork and heavy responsibility. Accordingly, they were often diagnosed by euphemisms such as Effort Syndrome and D.A.H. (Disordered Action of the Heart).
Trick-Cyclists, Nut Pickers and Shrinks
A Cambridge academic and psychologist/ neurologist - Dr. Charles Samuel Myers - first used the term shell shock in early 1915. It appeared in article about this new medical phenomenon, although even then he did not feel this term properly fitted the wide range of mental and physical aberrations he had already encountered in soldiers sent to him for diagnosis with this condition.
But the direct association between the alliterative words 'shell shock' and the known conditions at the Front stuck in the minds of the general public, and it remained the common term used for the condition until the use of 'Post Traumatic Stress Disorder' (PTSD) became common usage in recent times. The use of the words such as 'Trick Cyclist' was the typical mocking response of the Tommy to a subject he did not understand, and wasn't too sure about its propriety or efficacy.
The reaction of the British government to Dr. Myers' paper on the subject was to send him on an inspection tour of France. And in March 1915 he became 'Specialist On Nervous Shock'. Soon, the humorous synonyms 'Trick-cyclist', 'Nut-picker' and 'Shrink' became common usage for the British soldier in the field. As the numbers of cases of shell-shock being reported steadily increased with the accelerated adoption of trench warfare, and the ever augmented use of artillery and other means of total war, the medical authorities were overwhelmed by the numbers of cases of shell shock. They were also confused at the best way to treat them and to get them back into active service. All of the 20 suitable British facilities for treatment of 'the wounded of the mind' were over-subscribed by mid-1915.
All kinds of encouragement to downplay shell shock was tried from the carrot to the stick: lectures; public shaming; physical exercise; infliction of pain (typically by electric shock); aversion therapy and, by the more enlightened practitioners, psychotherapy and rest from arduous duties.
Whatever means were deployed in the treatment of these war trauma cases, the prime preoccupation was speed in the return of the effected men to duty. Indubitably, many shell-shocked men were returned to their units whilst unfit for active service duty, only to relapse into a far more serious condition, or die on the battlefield.
The classification of shell shock
Based on the recommendations of Dr. Myers, in late 1915 the Army Council attempted to classify shell shock as:
- Shell Shock (W) = Wounded by direct action, i.e. exploding shell.
- Shell Shock (S) = Sickness, i.e. mental disturbance/nervousness.
Those classified as W were entitled to a wound-stripe and, possibly, a pension. The S classified was not entitled to a wound-stripe or a pension.
In June 1916, these classifications were revised as:
- Concussional, or commotional shell shock i.e. blown up by a shell.
- Nervous shock or emotional (stress).
However, in practice, the 1915 classifications W and S were still widely used as a deterrent. It should be appreciated that commanding officers, even at the battalion level, exercised an extraordinary level control over their troops in the Great War, and as long as their unit performed satisfactorily on the battle field, few questions would be asked about their methodology. One teetotaller commander absolutely refused his troops the standard rum ration routinely given to soldiers on active service, without any adverse comment from his superiors.
New principles of treatment for shell shock
Largely as an effect of the First Battle of the Somme that began in July 1916, and the huge number of shell-shock cases it produced - between July and December 1916, 16,000 cases classified as shell-shock (W) were repatriated to the UK- it was decided that certain changes in the treatment of shell-shock would be made.
In an effort to decrease the numbers of shell-shock soldiers referred to the UK, and thus taken out of the active service area, it was decided that treatment should begin immediately as close as possible to the battlefield, as happened with other battlefield trauma. The referral system would aim at transferring diagnosed shell-shock cases to treatment facilities within the active service area.
Treatment centres for this purpose, including special rest camps. were established as required. The first of these centres was established at Boulogne - the British Army's major clearance port - and others followed elsewhere. The prime objective of these changes was to engender in the soldiery an expectancy of a return to duty.
In June 1917, the treatment of shell-shock cases was again modified so that all cases had to be first reported to the Regimental Medical Officer for review. If he considered it justified, he classified them as NYDN - Not yet diagnosed as nervous. The RMO then issued the appropriate Army Form (AF3436) and referred the suspect shell shock case back to the specialist unit on the Western Front or the UK for a definitive diagnosis.
Treatment of commissioned officers
As was the case in treatment of injuries and illness, separate treatment facilities existed for the officer corps. As mentioned earlier, there was a firm belief in the High Command that the responsibilities of command put special pressure on officers of all ranks. And, indeed, examples exist where especially committed officers were driven to a breakdown by the stress of their commands. But all indications are that the effects of the nervous trauma of battle vis à vis shell shock was equally prevalent in all ranks.
The presence of this separate chain of treatment for officers became more widely known because of two prominent war poets who were caught up in the treatment of shell shock. Captain Sigfreid Lorraine Sassoon and Lieutenant Wilfred Edward Salter Owen were treated together at Craiglockhart War Hospital, near Edinburgh, Scotland by the prominent neurologist Dr William Halse Rivers Rivers. The two poets became great friends and were involved in the writing and publication of several important anti-war poems. Sassoon returned to duty in 1918 only to be wounded again by friendly fire and invalided out. Owen also returned to duty in 1918, but was killed in action a few days before the fighting ended.
The management of shell shock
In terms of the prosecution of the War on the Western Front, the senior commanders of the BEF were continually demanding that the Army Medical Services return the maximum number of the treated shell-shock cases back to active service in the shortest possible time.
Some successes were claimed. After the fighting at Passchendaele in the Third Battle of Ypres, it was said that 50% of shell-shock cases were quickly returned to their units. A further 20% were said to have returned to their unit after two months relocation in the countryside engaged in non-stressful farm-work. Apart from returning the afflicted men to the bosoms of their own family, this farm-work remedy was found to be as efficacious as any. The comparative combat capability of men so returned to the Front, as fighting men, is open to debate.
In any event the official figures for the Great War showed that 80% of the shell-shock cases that were treated in hospital never returned to active military duty, whatever the reason.
Susceptibility to shell shock
As the war progressed the combat situations that made shell shock more likely became better under-stood.
One classic hypothesis, proposed by Lord Moran, a prominent medical officer, compared the onset of shell shock with that of a personal bank balance. When each individual entered the war-zone he had a positive and negative balance on his account. The positive balance was maintained by credits such as courage, commitment to one's comrades and regiment and, perhaps most important of all, a wish to maintain the family honour and to be seen to be doing so. The negative balance was fear, privation, exhaustion and prolonged duration of stress. When the credits were consistently exceeded by the debits, sooner or later signs and symptoms of stress began to appear. The moment that this occurred, and the specific cause(s) that it brought it on, was/were highly idiosyncratic and usually could not be forecast with any certainty.
The breakpoint was seen to present itself in various ways such as:
- The wild fighting type became quiet and moody.
- The sullen type became excitable and talkative.
- The careful type became reckless.
- The well-behaved type became a petty criminal.
Categories of soldiers that were particularly prone to a breakdown were:
- Soldiers over 40 years of age and long service, especially if married.
- Recent reinforcements/drafts of troops fresh from the training battalions.
- Specialists such as: snipers, sappers and tunnellers, machine gunners, tank crews and shock troops.
Numbers of shell-shock cases and those invalided out
The official total number of British shell-shock cases in the Great War is given as 80,000 of which 50,000 were said to be possibly eligible for a British army pension. Independent commentators quote the total number of cases as closer to 200,000.
However, we can be sure that the shell-shock cases invalided out of the Army and returned to their family, with or without pension, often presented their relatives with an extremely difficult and long-term problem that was generally handled well, without much public support. The general attitude being 'the war is over for you, you have survived, just get on with life'.
Anyone who lived in the Great War generation, and the one that followed it, became aware of the large number of relatives, friends and acquaintances who were said to 'be still suffering from shell-shock from the War'. Some were never fully rehabilitated and their lives were accordingly scarred forever.
During the course of the Great War, a cinematographic unit of the Pathé Film Company was employed to make a confidential film for the British War Office of the often-bizarre physical effects exhibited by some patients of shell shock. The subjects were soldiers hospitalised at the Royal Victoria Military Hospital, Netly, near Southampton, England. Netley was a major British centre for the treatment of shell shock.
Even today, this film is routinely shown to specialist army medical staff who may be responsible for the treatment and care of Post Traumatic Stress Disorder cases of future wars. Almost universally, the specialist audience is shocked and stunned by the graphic and extreme behaviour that they see displayed by some of shell shock patients. Other patients are completely apathetic or catonic. The effect it must have had on the generation that witnessed the apparition and display of shell shock on a wide scale is impossible to conjecture.