Every person has their limit. Some are stronger than others and able to adapt to trauma. Few, though, were left unaffected by the bloody, muddy mess of the so-called Great War.

Men who left the battlefield physically intact carried with them deep psychological scars. Previously well soldiers were crippled by blindness, memory loss, panic attacks and bizarre pains that mimicked the injuries they inflicted on their foes. With time, symptoms like these gained the label 'shell shock' – a syndrome now considered to be a form of post-traumatic stress disorder, but which came with all the baggage of a war that centred on the mass-destruction of human life.

Background

It is difficult to understand just how serious an issue shell shock was without first looking at its background: the First World War. Previous wars had been conducted with glorious cavalry charges followed by combat between foot soldiers where men fought face to face. It was thus expected that, having swept through the Germans on horseback to enjoy tea in Berlin, the British and French would win the war before Christmas. However, modern advancements such as the machine gun made offensives difficult and turned the affair into a war of attrition, with each side trying to wear the other down to break the stalemate.

Soldiers' lives became mere numbers to those in charge. Massed attacks, such as that at the Somme, highlighted a complete disregard for their welfare. Such tactics were perpetuated by the fact that Field Marshal Douglas Haig had experienced combat in wars won through sheer weight of numbers and believed he needed as many men ready to fight as was possible.

It is easy to imagine the response to news that men were refusing to fight. Ideals of honour and chivalry were still popular in those days, so any man not willing to fight was branded a coward and traitor. There was little concept that men without visible injuries might be ill. Many soldiers complaining of mental illness were treated by doctors who, if specialised at all, came from the field of medical insurance fraud. The aim was to send them back to the front-line as soon as possible. Those who refused to fight were disciplined and faced the threat of mock trial and execution.

Myers

In February, 1915, an article entitled 'A Contribution to the Study of Shell Shock' was published in The Lancet. It detailed three strikingly similar cases seen by Charles Myers, a captain in the Royal Army Medical Corps. Each had amnesia, constipation and a loss of vision, smell and taste following a traumatic experience involving exploding shells. One soldier had been blown off a pile of bricks, another had become stuck on barbed wire amongst exploding shells, and the third had been buried in a trench after a shell caused its collapse.

Myers commented that, although each patient developed symptoms of loss of vision, smell and taste, they suffered no hearing loss despite the main insult being the noise of the explosion. He compared the 'shell shock' seen in these patients with 'hysteria', a diagnosis popular in Victorian times in cases where well-off women exhibited fatigue and became dependent on others to support them.

It is clear from Myers' report that shell shock was starting to be recognised as a disease with symptoms that were treatable with bed rest. However, the mechanism behind it was still unclear. Head wounds were common following explosions, and it was thought that shell shock was a specific result of unseen damage by shells to the nervous system. However, following further research, Myers began to theorise that the syndrome had an 'emotional' cause – the trauma of war. Not all cases were due to shells, and many other symptoms were noted, including dizziness, loss of appetite, anxiety, depression, muscle problems, paralysis, limps, nightmares, and sympathy pains that related to injuries inflicted on enemies. Labels alluding to psychological trauma, such as 'without producing a visible wound', soon came into use in the military medical lexicon.

Kirkwood

It would be tempting to think that, with the diagnosis of shell shock available, soldiers would have started to receive better treatment. However, the ideals of honour and chivalry were overpowering, as the case of George Kirkwood illustrates.

Kirkwood was a lieutenant in the Royal Army Medical Corps and medical officer of the 11th battalion of the Border Regiment. Out of the 850 men in the battalion who fought at the Somme on 1 July, 1916, less than 300 returned. The survivors were ordered to recover items from their dead friends' backpacks, and also recover bodies from a battlefield that was constantly shelled. Needless to say, when 100 were picked to fight in a further raid a week later, many reported ill to Kirkwood. The lieutenant diagnosed 20 of the soldiers with shell shock, but he was ignored and the raid went ahead. After the raid failed, the commander, Sir Hubert Gough, admonished the men for lack of courage and spirit, and had Kirkwood dismissed as a scapegoat:

Sympathy for the sick and wounded is a good attribute for a doctor, but it is not for him to inform the Commanding Officer that his men are not in a fit state to carry out a military operation.
– Sir Hubert Gough

At the time, Kirkwood was exceptional in his support of the soldiers. The pressure placed on doctors to return men to the front-line meant most conformed to the military's will, sending ill men back to the front-line rather than risk their jobs in order to protect them.

Treatment

Aside from being disciplined or sent straight back to the field, treatments for shell shock tended to be unproven and limited to the officer class. Ordinary soldiers would be lucky to be treated with bed rest and a good diet in an army hospital. Interestingly, though, a diagnosis of 'male hysteria' in the German forces was sufficient to be relocated to a farm or factory for a rather forward-thinking form of rehabilitation. Many British soldiers were committed to asylums, and those who were particularly unfortunate ended up undergoing experimental treatments such as 'Faradisation', a form of electroconvulsive therapy, back home in the UK.

The officer-class hospital Craiglockhart, near Edinburgh, was particularly notable for its treatment of shell-shocked patients, with psychiatrist WHR Rivers providing humane treatments including talking therapy and hypnosis. Rivers believed that patients deserved to be prepared to return to the front and spent a lot of time trying to convince soldiers they should go back to the war. Both Siegfried Sassoon and Wilfred Owen were treated by Rivers for 'shell shock', having refused to fight due to their anti-war convictions. Their time at Craiglockhart has since been fictionalised in the novel Regeneration.

Apart from the differences in treatment, it was the labels used that separated officers from poorer soldiers. While officers were more likely to be awarded diagnoses such as psychosis, ordinary soldiers would be described as fatigued, neurotic or lunatic. Those labelled hysterical were denied pensions on the basis that they were of unsound mind, as opposed to having been damaged during combat. In the end, the diagnostic label of 'shell shock' became disused, with doctors preferring recognised terms such as 'neurosis', 'psychosis' and 'neurasthenia'¹.

Collie

While thoughts of king and country permeated the battlefield, the public back home followed a different form of patriotism – one lacking references to honour and cowardice. They empathised with the soldiers, and calls were made to give out pensions to make up for the lack of good treatment. Sir John Collie, head of the army medical branch of the Ministry of Pensions, felt differently. Accused by ex-servicemen of being obsessed with the detection of malingering, Collie had little sympathy for men whom he believed suffered only from 'personal inadequacy'.

His views were widely published, and soldiers applying for pensions found themselves fighting a petty bureaucracy that took no account of individual merits. The result was that only 120,000 pensions were handed out – relatively few considering the number of soldiers disabled by the war. The government's official line continued to be that shell shock was at best an excuse rather than an illness.

Conclusion

During the course of the First World War, between 80,000 and 200,000 men suffered from 'shell shock' as a result of psychological trauma. Those who were executed were not pardoned until 2006. Although many more men died than suffered from this form of post-traumatic stress disorder, the horrors of war combined with the men's treatment by their commanding officers makes it of great note. Attitudes towards the syndrome are greatly illustrative of the prevailing ideals of honour and bravery that became a stick with which shell-shocked men were beaten.

Also, the consternation as to the causes of shell shock highlights the fact that the concepts of psychiatry and mental illness are relatively recent phenomena that were poorly understood at the time. Great steps were taken towards the formalisation of shell shock as a treatable disease, although disparities between the treatment of officers and normal soldiers are indicative of the fact that a welfare state was still many years away. 'Shell shock' has since become a recognised problem during military operations, and steps are taken to protect against its possibility during missions.

Further Reading

• Shell-Shock: Traumatic Neurosis and the British Soldiers of the First World War by Peter Leese. Published by Palgrave Macmillan, ISBN 033396926X.
• Regeneration by Pat Barker. Published by Penguin Books, ISBN 0140123083.