A LAND OF IMPOSSIBILITY: Shell shock and its legacies

The Great War brought into focus a condition that almost a century later is just beginning to be fully understood, says Dr Tony Pollard of the University of Glasgow

The machine gun might be the weapon most people identify with the trench warfare of the First World War, but the ajority of those millions who died n combat between 1914 and 1918, round 65% of them, were killed by rtillery. Shell shock must therefore ave seemed a very appropriate erm when it came to diagnosing the ymptoms displayed by an alarming umber of soldiers fighting on the estern Front.

It first appeared in The Lancet in arly 1915, in a paper by Dr Charles yers, a psychologist who had been ommissioned into the Royal Army edical Corps and sent to France. He described the symptoms of hree soldiers who after being in close roximity to shell blasts developed mixed set of symptoms, which ncluded loss of memory, taste and mell along with sight impairment. All were sent home and ospitalised, where hypnosis was mong the treatments applied, and hich Myers reported to have assisted slow recovery.

The previous century had seen a low improvement in the practice of ilitary medicine, from the Battle f Waterloo in 1815, when the only ay to treat a bullet wound was to ut off the stricken limb with nothing ore than alcohol to take the edge ff the pain, to the introduction of naesthetics and antiseptics. It had een apparent for centuries, however, hat not all wounds were physical. At the time of the American Civil ar (1860-65) terms such as irritable eart or the more vocationally specific oldier’s heart reflected attempts

to find a physiological explanation for symptoms not associated with physical wounds, which could include a quickening of the pulse, shortness of breath and heightened anxiety.

With the industrialised warfare of the early 20th Century came an increased capacity for slaughter, with artillery having the ability to transform landscapes and reduce the human body to atoms. It also brought with it at least some recognition that it was the mind as much as the body that could fall victim to war. Today, the grainy black and white films of broken men who shake uncontrollably or walk with strange, exaggerated gaits, sometimes referred to at the time as the ‘hysterical ice skater’s gait’ or the ‘hysterical dancing gait’, are disturbing reminders of just how extreme the symptoms of shell shock could be.

But there were other less obvious symptoms, such as the aforementioned anxiety, nightmares, or an inability to relate to loved ones on the return from the front. It was also noticed that unlike the cases cited in Myers’ Lancet paper, not all of the men afflicted had been close to shell blasts prior to their symptoms showing, and therefore a form of concussive injury had to be ruled out. Some female nurses also contracted shell shock, but their stories are only just starting to come to light.

Men might have remained sound of limb but otherwise be in no condition to continue the bloody work of war, and for the generals this created a serious problem. By April 1916, 11,300 men had been hospitalised with shell shock, but very soon fears of an epidemic came close to reality.

The official figure for British troops incapacitated by the condition at the Battle of the Somme alone – July-November 1916 – is 16,138 but this figure is today thought to be far too conservative.

The army’s own figures suggested 40% of all British casualties in 1916 were cases of shell shock.

The War Office had recognised shell shock as a war wound not long before the Battle of the Somme, and placed a priority on getting these men back into a condition where they could serve again on the front line. So it was that the medical services were encouraged to try whatever they could to find a cure, with an increasing number of military hospitals in the UK specialising in the treatment of shell shock. Craiglockhart Hospital for officers in Edinburgh is probably the most famous of these, thanks in no short measure to the residency of the war poets Siegfried Sassoon and Wilfred Owen.

Potential cures doled out at these institutions included massage, a milk diet, hypnosis and electric shocks, but it was at Craiglockhart that Dr WH Rivers developed a form of therapy that is still used today. He encouraged his patients to recall rather than try to forget their experiences, and in doing so to repeatedly revisit traumatic events and by talking them through make sense of them. This technique, which takes various forms, is today known as trauma-focused psychotherapy.

However, debate continued to range between Myers’ original association of symptoms with an agitation of the brain caused by shell blast and a mental breakdown caused by exposure to the horrors of war, a Myers himself came to support.

Some commanders continued to believe that shell shock was simply malingering, with many of the 228 men shot for cowardice or desertion probably suffering from the condition. All 306 men “shot at dawn” were given a posthumous pardon in 2006.

A post-Armistice War Office enquiry into shell shock, published in 1922, concluded that a soldier in possession of a strong constitution and upright character was less likely to fall victim to shell shock, with adequate training being the key to prevention.

These findings reflected a failure to face up to the fact a major cause of trauma was exposure to the horrors of combat and, along with this, a rejection of the advances in psychology that could provide an understanding of the causes and some of the tools to cure it.

By the time of the outbreak of the Second World War in 1939, no less than 120,000 men had drawn pensions for psychiatric disorders suffered in what at the time had been called the war to end all wars. Many showed no symptoms until after the war, and we now know that it can take a decade or more for symptoms to manifest themselves. It is hard, at this distance, to imagine the difficulties thousands of veterans and their families had in coming to terms to a condition that was still poorly understood. Some men were confined view to asylums by families who had no better idea of how to cope, while total breakdowns, domestic violence, alcoholism, unemployment and suicide appear to have been common occurrences.

Today, we have a clearer understanding of shell shock, which is now usually subsumed within the more generic acronym PTSD (PostTraumatic Stress Disorder). This can be applied to symptoms triggered by a wider range of causes than engagement in combat, including incidents such as involvement in a car crash or witnessing a disturbing event. Recent studies have, however, shown that the blast from explosive devices can cause a particular type of brain injury that can lead to symptoms similar to PTSD, indicating that the First World War debate about causes was a valid one.

Although some advances were made during the Second World War, when shell shock was known as Battle Fatigue or Battle Neurosis, much of the knowledge gleaned during the first war was disregarded, with sufferers initially branded as LMF (Lacking Moral Fibre). It took the Vietnam War before the Americans really began to get to grips with the condition, with PTSD officially recognised by the American Psychiatric Association in 1980, while in Britain, it was the 1982 Falklands War that renewed concern about the condition.

It is difficult to put a figure on the number of sufferers, but American statistics suggest that between 11 to 20 percent of military personnel who served in Afghanistan and Iraq have displayed symptoms at some point. Whether adequate resources are being put into the treatment of PTSD in the UK today is doubtful, with 50 British veterans having committed suicide in 2018 by the time of writing (September). Lieutenant Guy Botwright, who was invalided home with shell shock in 1917, described the battlefront as “a land of impossibility”, and sadly many of these men returned home to a land that continued to be just as impossible.