By late 1917, there were one thousand beds available at Queen’s and a group of local satellite hospitals. Several distinguished visitors came down to see what was going on, most of them going away horrified but impressed. The Prince of Wales came to visit in 1918 and, against advice, insisted on visiting two wards that were known to the staff as ‘the Chamber of Horrors’. He apparently came out ‘looking white and shaken’.34
By the end of the war, the Queen’s Hospital had become internationally famous. Gillies and his team had carried out more than 11,500 major face operations, pioneering along the way nothing less than a new form of plastic surgery. Compliments poured in. Some of the men treated returned to civilian life and reported that they had been able to carry on normal lives with barely any signs of the terrible scars from which they had suffered. Others still felt difficulties assimilating into society and lived the rest of their lives alone or out of sight of most people. Overall it was an extraordinary achievement for Gillies and the dedicated team of men and women working with him, carrying out what must have been the most unpleasant form of surgery imaginable. And it was an extreme example of how the laboratory of war could provide an opportunity for medicine and science to advance.
Like so many participants in the Great War, the military medical services that went to war in August 1914 made some dreadful errors at first. But with the help of outsiders and consultants, and by the development of new specialisms, great strides were made and the slaughter of industrial war was tackled more effectively than might be imagined. The RAMC showed considerable flexibility in adapting and developing its procedures to deal with circumstances that had not been anticipated when the war began. The medical services available to the British Army that won victory in the autumn of 1918 were dramatically improved by comparison with those of the army that had gone to war four years before. The strength of the RAMC had gone up nearly ninefold, from 18,000 officers and men in 1914 to 160,000 in 1918. Ironically, it was the Home Front that suffered. There were shortages of both general practitioners as well as consultants at home, and in many of the large inner-city hospitals work was undertaken by unqualified medical students.35
Of the two million British soldiers who received battlefield wounds in France and Flanders from 1914 to 1918 and were treated in military hospitals, about 7 per cent died of their injuries and 26 per cent were returned to duty.36 The survival rates were much higher than those of previous wars and they suggest that the knowledge that good medical care existed must have helped keep up the morale of the British Tommy even during the worst days of killing on the Western Front. About three-quarters of a million British soldiers, sailors and airmen died during the Great War.37 That number was terrible enough. But had medicine and science not rallied to the help of the armed services, it would have been far higher.
11
The Mind
In November and December 1914 an increasing number of men with strange and unusual problems began to arrive in the Casualty Clearing Stations behind the newly established front lines of the Western Front. The men showed no visible signs of physical injury. They had not been hit by machine gun bullets, nor had they been struck by shrapnel. Their limbs had not been damaged. They had no apparent wounds to the head. Some of them had minor cuts and bruises but nothing more severe. But they all seemed to display similar strange symptoms that puzzled their doctors. They were suffering from peculiar forms of paralysis. Many were described as having ‘the shakes’. Some could not stand up or walk normally. A few appeared unable to speak coherently and were stuttering badly; others had been struck completely dumb and could not speak at all. Most appeared to be in a state of stupor and a few had completely lost their memory. Still others seemed to find it difficult to see clearly. Many seemed to have lost their sense of taste or smell. Some vomited repeatedly.
The doctors who tried to attend to them had never seen such symptoms before and were unsure how to respond. Many of the men were sent back to England with ‘nervous and mental shock’ but the War Office began to grow alarmed at the numbers of men being evacuated. After a few months, 7–10 per cent of officers and 3–4 per cent of other ranks had been sent home to recover. At this rate, the British Expeditionary Force, having already lost one-third of its strength in a single battle at Ypres in October, would cease to be a fighting force in a matter of months.1 Something clearly had to be done.
The army turned first to an unlikely candidate. Charles Samuel Myers was a lively intellectual from a wealthy Jewish family in London. In 1914 he was in middle age, an academic who had spent most of his career helping to establish the new science of psychology. He had grown up enjoying a wide range of interests including mountain climbing and tennis and was a talented violinist, but when he went up to Gonville and Caius College, Cambridge in 1892 he chose to concentrate on science. After graduating he went on to St Bartholomew’s Hospital in London but opted not to go into medical practice. Instead he joined a Cambridge anthropological expedition to the Torres Strait, where for the first time the techniques of modern science were to be applied to the study of so-called ‘primitive’ peoples of New Guinea. Myers spent a year studying the attitude of the natives to music while his Cambridge colleagues, William Rivers and William McDougall, recorded marriage customs and other aspects of their tribal society.
When Myers came back from New Guinea, he joined Rivers in teaching psychology at Cambridge, and did much to lay down the foundations of this new science in the decade before the war. In 1912 he raised funds to establish at the university an experimental laboratory in psychology, the first of its kind in Britain. Soon after this he became a Fellow of the Royal Society. When war was declared, he sought a role in the growing conflict but was turned down by the War Office because of his age. So he went to Paris to visit the internationally renowned neurologist Jules Dejerine, before securing himself a position at the Duchess of Westminster’s War Hospital at Le Touquet, one of the private hospitals attached at this early phase of the war to the British Army. It was here that in the last weeks of 1914 a group of soldiers arrived suffering from various forms of mental neurosis. Other doctors avoided these patients, but for Myers they provided a fascinating insight into a new type of disease.
Myers treated one soldier who had been trapped for hours in barbed wire in no man’s land. While out there several 8in shells had burst near him. The man, who had been cheerful and positive before this terrifying experience, was eventually brought back to the British lines in a pathetic state, crying and shivering in a cold sweat. His escape was described as ‘a sheer miracle’. He appeared to be suffering from blurred vision and felt a burning sensation in his eyes, making him panic that he was going blind. Writing about this case several years later, Myers described it as a turning-point: ‘It was clear to me that my previous psychological training and my present interests fitted me for the treatment of these cases’ He concluded that although the soldier was not wounded, he had suffered some form of physical concussion from the proximity of the shell explosions and that ‘the high frequency vibrations’ had caused ‘an invisibly fine molecular commotion in the brain’.2 Myers believed that the man was now displaying the symptoms of this physical disturbance. He wrote up the case, along with a few others, in the doctors’ journal The Lancet in early 1915 and described it, using a term coined by the soldiers themselves, as ‘shell shock’.3
The name caught on immediately, and rapidly became the generic term for a wide range of peculiar mental symptoms that doctors could not easily explain. It was simple, but had instant resonance with the strange cases that were coming in from the front. Doctors used the words shell shock to describe every sort of nervous breakdown. Although the stalemate of trench warfare was only a few months old, it was quickly realised that this form of immobile war was a new phenomenon. Men hunkering down in a trench with shells constantly landing all around them but unable to exercise the instinctive human response to get away, were suffering from extreme forms of anxiety or stress. The shells were far
more lethal than in previous conflicts and now consisted of high explosives that could be fired from miles away in rapid succession. Sudden, horrific and seemingly random death became a feature of trench life that every soldier had to live with. Tom Pear, a young academic psychologist, wrote that conditions in the trenches were unique: ‘Never in the history of mankind have the stresses and strains laid upon body and mind been so great or so numerous as in the present war.’4
The public soon became fascinated. Over the next few months, the press devoted hundreds of pages to the subject, analysing its causes and describing its effects. Broadly speaking, the newspaper debate created a sympathetic attitude among the public towards the victims of shell shock. Within the army, too, the term rapidly became commonplace and the public reaction to it forced the authorities to acknowledge its existence as a specific condition.
It was in this context that, in March 1915, the army turned to Myers to deal with what was happening. He was given a commission in the RAMC and quickly dispatched to the Base Hospital at Boulogne. As a psychologist, Myers believed not only that he understood some of the causes of shell shock but that he could help to treat them as well. As an army doctor he accepted that his responsibility was to cure wounded men and get them back to their units as soon as possible. Within days of arriving he was dealing with several extreme cases. One young soldier was convinced he was still in the trenches and spent all his time dodging shells while hiding under his bed. Other men had dreadful stoops and could not walk straight. Myers treated one man who had been struck mute by a dreadful experience in the trenches, and within days was able to restore his power of speech. Using hypnosis at times to try and cure patients, Myers brought to his new role a sort of evangelical energy. He was thoroughly committed to showing that if the causes could be understood, shell shock could be treated successfully.
The army found it difficult to cope with the growing number of shell shpck cases. Soldiers, it was firmly believed among the military, needed regular, tough training and discipline, a harsh regime out of which the pride, cohesion and strength of a fighting unit would emerge. In the military view, soldiers were either fit and capable, or sick and wounded and so unable to fight. Forms of mental disorder were somewhere in between the two and, in this simplistic way of seeing things, complicated matters dreadfully. Soldiers were supposed to put up with difficult conditions and show a stiff upper lip in the face of adversity. In this context, mental breakdown – then called hysteria – was traditionally thought of as being un-masculine. Named from the Greek word for the womb, hysteria had until not long before the war been thought of as a woman’s condition. Showing signs of hysteria was therefore seen as an indication of weakness. Moreover, a hysteric might let down the rest of the troop.
As with all such matters, the army soon began to distinguish between the mental disorders of officers and men. It was believed that the men in the trenches could do nothing but passively watch and wait while shells exploded all around them. Their symptoms, of being struck deaf or dumb, or being paralysed, were often diagnosed as hysterical. But this term was rarely applied to officers, who had duties to perform and responsibilities to attend to, and so were seen as being more active. For them the more scientific term ‘neurasthenic’ was used. Neurasthenia was thought to be a consequence of the long, gradual wearing down of an officer’s emotional strength, a build-up of anxiety that often showed itself in symptoms of depression or suffering from bad nightmares.
The army was struggling to understand what has become quite obvious over the century since the Great War. Men under fire can suffer from a mental breakdown caused by the trauma they have endured. Today it is called post-traumatic stress disorder. Its symptoms are often physical but the cause is psychological. However, in the Great War many traditionally minded commanding officers thought that all forms of mental illness were a display of weakness. Their perception of how to treat a mental breakdown was governed by a moral judgement. But it was soon realised that the strange phenomenon could affect anyone. Even the best soldiers with the strongest ‘nerves’ and the most reliable officers, those who had a faultless record, could suddenly snap and break down. Many senior officers found themselves torn between the traditionalist view that all neuroses were some kind of weakness, and a realisation that this could happen to any soldier, even to their own sons serving dutifully at the front. But, for those officers, what lay behind everything was the fear that if the situation got worse and some sort of mass hysteria broke out, the army would collapse and cease to exist as a fighting organisation. This of course had to be prevented at all costs.
So the reaction of many senior figures – and indeed of several medical officers – was to suspect that many of those exhibiting symptoms of shell shock were in reality what in army parlance were called ‘skrimshankers and malingerers’, that is they Were pretending to have shell shock as a means to escape the horror of the trenches. Medical officers complained to Myers, ‘We have seen too many dirty sneaks go down the line under the term “shell shock” to feel any great sympathy for the condition.’ ‘“Shell shock” should be abolished’ was another response.5 Myers himself accepted that there were several instances of soldiers swinging the lead and trying it on. Men would turn up at a CCS and when asked what was wrong with them would boast, ‘Suffering from shell shock, sir.’ The army clearly had to pick out the malingerers and return them to their unit as fast as possible. Senior officers expressed this as the need to prevent ‘wastage’.
There was no single cause for the variety of symptoms that contributed to the condition known as shell shock. Many men felt a considerable sense of guilt and shame in being diagnosed, a sense that they had let their peers down. This intensified victims’ anxiety. Some men would hold on as long as they could, but the accumulated stress would finally make them snap. Captain H. Kaye, a temporary doctor in the RAMC, observed one officer who had carried on despite witnessing the almost total destruction of his battalion three times in heavy fighting during the Second Battle of Ypres in the spring of 1915. He then found himself in a dugout that received a direct hit, killing three of his comrades but leaving him visibly unhurt apart from singed hair. He busied himself burying his comrades and still carried on. Then, after a shell landed nearby, he was buried by debris for several hours before being dug out. Still he continued in command. It was only when the quartermaster brought up a string of horses, not knowing that the officers for whom they were intended had been killed, that the man completely broke down and cried for days.6 It was the cumulative effect of the horrors of trench life that did for many.
The cause of shell shock became the subject of much earnest debate among the medical community, both within the army and to a degree in the press. Was it caused by the physical consequences of being near an explosion, such as the sudden change of atmospheric pressure? By the mental strains of fighting in a modern industrial war? Or by the emotional reaction to witnessing some horrific scene, like seeing a friend blown to pieces or, in the case of Dr Kaye’s patient, simply seeing a group of horses all of whose riders were dead? As more men sought treatment with an increasing range of physical problems that clearly had some mental roots, the doctors looked on in amazement. ‘I wish you could be here in this orgie [sic] of neuroses and psychoses and gaits and paralyses’ wrote the Professor of Medicine at Oxford to a friend. ‘I cannot imagine what has got into the central nervous system of the men … Hysterical dumbness, deafness, blindness, anaesthesia [sic] galore.’7
In its typical way, the army decided to categorise cases to make the problem easier to deal with. Victims who had suffered from the explosive shock of a nearby shell were classed as ‘Shell Shock W’ (for Wounded). This was the original sense of the term shell shock -some sort of concussion caused by the proximity of an explosion. These men were acknowledged as being physically wounded and were given the care and dignity that they therefore deserved. Those thought to be suffering from some sort of hysterical response, a temporary breakdown of the nerves, we
re classed as ‘Shell Shock S’ (for Sickness). They were not classed as genuinely wounded and were to be returned to their units after rest, relaxation, regular meals and a period in a positive environment, during which doctors were to encourage them to feel better and to want to return to their duties. Sometimes this amounted to little more for a soldier than taking a break from the trenches for a few days and then being told by a medical officer to pull himself together and get back to his battalion. The final category, almost always reserved for officers, was neurasthenia, caused by prolonged mental strain and manifested by symptoms of chronic fatigue, headache and the loss of appetite.
This classification did little to improve the already confused situation. Obvious inequities soon became apparent. Men suffering from a genuine breakdown were not always given proper treatment, while others with similar or even less serious symptoms were evacuated to England. Myers noted the case of an artillery officer whose battery came under heavy bombardment during which he managed to keep going for as long as possible but eventually collapsed. He was diagnosed with a nervous complaint and categorised ‘Shell Shock S’. Two of his men who gave way as soon as the bombardment began were categorised as ‘Shell Shock W, having suffered according to regulations from the ‘effects of an explosion due to enemy action’. According to Myers, the two soldiers ‘by giving way immediately, became entitled to rank as wounded and wear a wound stripe’; the officer, by bravely carrying on, was sent down stigmatised as ‘nervous’.8
One thing was clear to Myers: all attempts to treat shell shock victims should be carried out quickly and as near to the front as possible, if there was to be any hope of returning them to their units. Once they were removed from the theatre of war by being evacuated to convalescent homes in England, the time taken for recovery would increase considerably. Myers noted that a popular and strong regimental medical officer could often persuade a man to make a rapid return, whereas if once sent ‘further down the Line, it may take many weeks or months before they are again fit for duty’.9 He tried to persuade the army to set up specialist wards only a few miles from the front. This principle of ‘proximity’ has since become the basis for all modern military psychiatry, but there was hostility to it at the time, as the traditional army view was that it did not want to be ‘encumbered with lunatics in Army areas’.10 Myers at least had some success here, even if the approach to treating shell shock victims varied enormously.
Secret Warriors Page 26