However, the issue of shell shock was not of concern to the army alone. The press eagerly picked up the question of the mental state of the country’s soldiers and during 1915 it became a subject of great public interest. In the main, both the press coverage and the public debate were sympathetic to men who had broken down under the intolerable pressure of modern warfare. The Times, for instance, in May 1915 had a feature on ‘Battle Shock’ in which it tried to explain to its readers about ‘The Wounded Mind and Its Cure’. Arguing that ‘wounds of consciousness’ should receive ‘the same serious attention as wounds of flesh or bone’, the article explained how ‘a brave man’ could be brought down by ‘the effects of severe shell fire’.29 Physical wounds were as old as war itself, but mental disorders among soldiers seemed to most people to be a uniquely modern form of injury.
By the early twentieth century, moreover, the idea of a ‘civil society’ in which individuals, organisations and the state had both rights and responsibilities was beginning to take root. The Workmen’s Compensation Act of 1897 had recognised the responsibility of employers for accidents to their workers. In its social welfare reforms, the pre-war Liberal government had introduced old age pensions in 1908 and three years later made (limited) provision for workers’ health care and unemployment benefits. And by 1914, both soldiers and their families were beginning to regard medical treatment in the army as an entitlement, as their right. Kitchener’s New Army was a citizen army and modern concepts of citizenship, justice and good health care were increasingly widespread. It was therefore seen as the duty of the army to provide appropriate health provision, in return for the agreement to serve; all wounded men were entitled to modern and efficient medical treatment.
But the public became particularly sympathetic to the sad cases of men who had broken down under the pressure of war. They did not want them consigned as ‘incurable’ lunatics, they wanted them treated and returned to active service. In a typical article in April 1915, The Manchester Guardian reported that ‘the appalling conditions of modern war’ had played havoc with the nervous systems of ‘hundreds of men’. It reported one soldier as saying ‘Shell fire is damnable. Most of us will face any amount of rifle fire without a murmur … but we fairly get the wind up when shells begin to drop.’ The newspaper noted that a breakdown was usually only temporary and that ‘the mental disorder arising from war shock usually vanishes with good nursing and perfect rest. It is clearly the duty of the State to ensure that these shall be forthcoming quickly, fully, and under the most acceptable conditions.’30 In this small but significant way, the debate about shell shock helped advance the case for the welfare state.
By early 1915, as the conflict in the west ossified into a static war along the trench lines of the Western Front, the armies on both sides developed systems of medical care that relied upon evacuating wounded men from the front line to an established hierarchy of medical aid positions. In the British army, any man with an ailment would go first of all to his regimental aid post or advanced dressing station. This was usually only two or three hundred yards behind the front line, situated where possible in an old farm building, in the cellars of a village house or in a large dugout. Each battalion in the army had its own medical officer, a qualified doctor who worked in the aid post with a small group of orderlies.
The MO was a familiar figure in each battalion, living with the men in the trenches and dealing with daily issues relating to soldiers’ health, like regular colds, fevers and specific problems like trench foot. In addition, he was the first port of call for the wounded. Being so close to the front, regimental aid posts were frequently exposed to enemy fire and were only marginally safer than the front lines themselves; as a consequence more than a thousand medical officers were killed during the war.31 During a major offensive, the situation in the aid posts would become chaotic as large numbers of wounded were brought in. There were often only minimal supplies of clean water and rarely enough space. But the intention was that every injured man would be examined and cleaned up. If possible a wound would be dressed, sometimes by coating it with iodine, or by setting a fracture in a splint.
When it came to nervous disorders, there was universal agreement on one thing as the war progressed: that the battalion MO played a vital role. First, he would probably know each man and be able to distinguish between malingerers and those with genuine symptoms. Second, a soldier was likely to treat with respect anything his MO said to him, for the men usually held such professionals in high regard. A good MO could calm a man down, give him rest, and get him out of the firing line for a few days; all of which could greatly help with recovery if the nervous disorder was mild. In fact treatment for most victims of shell shock did not go much beyond this. A man was given plenty of rest, along with good and regular meals; a doctor or his MO would then tell him that he did not have a disease and should pull himself together and get back to his battalion. The treatment was simple but effective, and ‘it not infrequently ended in the man coming forward voluntarily for duty, after having been given a much needed fortnight’s rest in hospital.’32
Lieutenant-Colonel Rogers, MO of the 4th Black Watch battalion, outlined his approach after the war: ‘A good deal depends on the Medical Officer; in fact I think most depends on the MO attached to the battalion – his knowledge of men in general and his knowledge of the men in his unit in particular. He ought to know the men personally and take an interest in them. There is no reason why he should not have an elementary knowledge of psychology … and if you are able to explain to him [a patient suffering from neurosis] that you have investigated his condition and that there is nothing really wrong with him, give him a rest at the aid post if necessary and a day or two’s sleep, go up with him to the front line, and when there see him often, sit down beside him and talk to him about the war or look through his periscope and let the man see you are taking an interest in him, you will not get nearly so many cases of anxiety neurosis.’33 Rogers saw his role almost as that of the friendly, wise, local family doctor.
Myers added something else to this approach. He came to believe that doctors should attempt to treat minor shell shock victims without delay and as near the front as possible, if there was to be any hope of returning men to their units quickly. He argued that dealing with cases of mild shell shock near the front line was far better than sending a man down the line to a field ambulance unit or a CCS, both of which were equipped more like small hospitals, with operating theatres, wards and specialist surgeons, out of range of the enemy’s artillery.34 Myers tried to persuade the army to set up specialist wards only a few miles from the front. But traditionalists in the army were hostile to the idea; their view was that there was no place for men with mental problems near the front line, more earthily expressed in the statement that it did not want to be ‘encumbered with lunatics in Army areas’.35 Even though approaches to the treatment of victims varied enormously, Myers at least had some success in establishing specialist centres for more serious cases of shell shock, in what came to be known as ‘forward psychiatry’.
Regimental medical officers did not usually have the scientific language to assess or describe conditions that came under the ‘shell shock’ heading. William Tyrrell was an MO on the Western Front from 1914 with the 2nd Battalion Lancashire Fusiliers. In describing a man’s store of ‘nervous energy’, Tyrrell used the easily understood analogy of having a current and a capital account in a bank. After dealing with hundreds of shell shock cases, he summed up his position: ‘A man instinctively masks his emotions almost as a matter of routine. In trifling everyday affairs this is involuntary and automatic with a negligible expense of nervous energy … This expenditure is usually out of his current account, consequently it is not missed and has no untoward effect.’ However, Tyrrell believed, major crises drew upon a man’s capital account of nervous energy, and as he tried to cover this up and camouflage it, it drew deep on his reserves. ‘A continuous series of great crises without intervals for replacing spent
energy ultimately exhausts the capital account and you get a run on the bank, followed by loss of control, hysteria, irresponsible chattering, mutism, amnesia, inhibition of the senses, acute mania, insensibility, etc, with the diagnosis of nervous breakdown or “shell-shock”.’ Tyrrell put shell shock down to fear and the ‘fear of being found afraid. Any emotion which has to be repressed or concealed’, he believed, drew upon a vast ‘output of nervous energy’.36
Charles Wilson, MO with the 1st Battalion Royal Fusiliers, expressed this in similar terms: ‘A man’s courage is his capital and he is always spending. The call on the bank may be only the daily drain of the front line or it may be a sudden draft which threatens to close the account. His will is perhaps almost destroyed by intensive shelling, by heavy bombing or by a bloody battle.’ Changing his metaphor, Wilson wrote that ‘men wear out in war like clothes.’37
Of course, treating more serious battlefield neuroses was beyond the capacity of the over-stretched MO and the front-line regimental aid post. Without question it was necessary to send severe cases down the line for specialist care. Here too, however, the class attitude prevailed. While it was regarded as acceptable to send cases of neurasthenia (mostly officers) home to Britain for care, most specialists argued that cases of hysteria (rank and file) should be treated in France. Again, the emphasis was on providing rest, sleep, regular meals and a calm environment. A specialist medical officer treating these men should not only have a training in psychology and psychotherapy, but according to Myers ‘should possess enthusiasm, confidence, cheerfulness and tact, with wide knowledge of the failings of his fellows and an ability promptly to determine whether a policy of persuasion, analysis, intimacy, sternness or reprimand should be adopted. Only the experience of such a man can lead to the successful treatment of individual patients, the detection of the malingerer, and the avoidance of injustice to genuine cases.’ Myers added that no specialist medical officer should ever have more than 75 cases to deal with at one time. He argued that if these conditions were met then recovery was possible; otherwise, if psychiatric casualties are simply ‘herded together and left to themselves, they are almost sure to go from bad to worse’.38
This was a feature on which both senior military figures and the medical fraternity agreed. Shell shock and anxiety neuroses were likely to spread rapidly. Charles Wilson reported to the post-war Committee of Enquiry that shell shock was ‘very contagious, like measles’.39 A man displaying signs of strain, whether simply a case of the shakes or something far more severe like hysterical paralysis, deafness, dumbness or blindness, could both upset those around him and encourage others to simulate the condition. Behind this, partly, was once again the fear of malingering. If a group of soldiers saw a man whose nerves had ‘gone’ being taken back down the line for rest, recuperation and respite from the horrors of the trenches, then they would be encouraged to want the same. But there was also agreement as to how unsettling a man in a bad nervous state could be on the others in his section or platoon. Bombardier Harry Fayerbrother of the Royal Field Artillery was in a gun crew at Ypres when one of his team suffered a serious attack of shell shock. ‘He upset all of us,’ Fayerbrother later recalled. ‘There were just five or six of us in the dugout and every time a shell come over he went haywire, shouting and screaming as if he wanted to tear the place to pieces, and tear us to pieces too. We just couldn’t put up with it, so I grabbed him by the scruff of the neck and took him down the duckboard track to the dressing station.’40 One officer summed this up succinctly by reporting that ‘jumpy men make others “jumpy”’.41
The contagious nature of shell shock touched on the larger issue of the need to keep up morale within a unit. As a consequence, patients with nervous conditions were almost always segregated from the rest of the wounded. When transported by ambulance train they usually travelled in separate locked carriages and were always the last to disembark when the rest of the wounded had been taken away. At Denmark Hill station in south London, next to the Maudsley Hospital, temporary platforms were built to allow shell shock patients to be admitted direct to the hospital out of sight of observers or other patients.42 A young VAD nurse, Claire Tisdall, later recalled the shame associated with these tragic victims. She was collecting a group of patients from an ambulance train when another train appeared unexpectedly. The second train was totally closed up, with all the windows barred and shut. ‘What’s this ambulance coming in?’ she asked an orderly. ‘Haven’t we done the train?’ ‘No, sister,’ came the reply. ‘This is for the asylum; it’s for the hopeless mental cases.’ The young nurse later wrote, ‘I didn’t look. They’d gone off their heads. I didn’t want to see them. There was nothing you could do and they were going to a special place. They were terrible.’43
When the War Office enquiry gathered evidence in 1922, several witnesses confirmed that in some units shell shock had been contagious and had resulted in the loss of many men, whereas in others the incidence had been low or even non-existent. General Horne specifically put the high incidence of shell shock within a unit down to ‘poor morale’, which was ‘due to the failure in training to the proper state of efficiency’. In addition to the ordinary sources of morale, such as ‘justice of cause, pride in regiment, and supremacy in the use of weapons, there is one thing that assists morale very highly – good food and good care taken of the men.’ As Horne concluded, it was not only ‘bad morale but physical conditions that influence shell shock’.44
Sir John Goodwin, an army surgeon all his professional life, had ended the war as Director General of the Army Medical Service. He observed that if there were two battalions side by side in the line and one suffered from a high incidence of shell shock and the other did not, then he ‘would look to the officers to see what their influence was with the men and how they were looking after them; how close they were to their men and how much they believed in their men’. He would also ‘look to the medical officers as to how much they knew and understood their men’. A poorly led battalion was more likely to suffer from shell shock than a well officered one because ‘in a well-trained, well disciplined regiment, no matter what the stress is, there is comparatively little in the way of breaking down.’45
Colonel Fuller, who had been a director of training at the War Office in the first half of the war, claimed that a ‘bad battalion’ with a high incidence of shell shock cases could ‘infect’ a good battalion alongside. He cited a case where a Guards battalion at Ypres refused to go into the line beside another battalion, saying they would prefer to take over that section of front line themselves rather than ‘go in with that battalion.’ Fuller regarded an excess of shell shock cases as a ‘discredit to the regiment’, a sign that ‘the commanding officer and officers of the regiment have not established in the men a sufficiently high morale’ and that there was ‘something wrong with the training and organisation of the unit’.46
It was this linkage with overall unit morale that made shell shock, in the eyes of such officers, so dangerous. The cohesiveness of a fighting unit was dependent upon maintaining a high level of morale. Being so contagious, shell shock and war neuroses could easily bring a whole battalion down. If this got out of hand, it would be fatal to the fighting spirit of the whole army in France.
It became clear that there was no single cause for the variety of symptoms described under the catch-all term shell shock. That was why the military was so puzzled as to how to respond. Many men felt a considerable sense of guilt and shame in being diagnosed, that they had let their peers down. This added to victims’ anxiety. Some men would hold on as long as they could, but the accumulated stress would finally get to them.
One anonymous officer who gave evidence to the War Office Committee of Enquiry into Shell Shock in 1922 had a remarkable story to tell. According to his account, it was ‘the repression of fear, the repression of the emotion of being afraid’ that made ‘the greatest tax’ upon his ‘mind and strength’. This officer survived the almost total destruction of his ba
ttalion three times in heavy fighting during the Second Battle of Ypres in the spring of 1915 but nevertheless carried on. Then he was in a dugout that received a direct hit. Three of his comrades were killed but miraculously he was left visibly unhurt, although his hair was slightly singed. He busied himself burying his comrades and once more carried on. Then he was buried by debris for several hours after a shell landed nearby. Having been dug out, he still continued in command. It was only when the quartermaster brought up a string of horses, not knowing that all the officers for whom they were intended had been killed, that the witness said, ‘I broke down and cried.’ He cried continuously and was helpless for a week. It was the cumulative effect of the horrors of trench life that did for this officer. Although in this case, remarkably, he returned to his unit six months later and fought on the Somme, saying of this experience, ‘I had no difficulty whatever in controlling myself – not the slightest.’47
In its typical way, the army decided to categorise cases in order 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 reflected the original sense of the term shell shock as some sort of physical injury sustained by proximity to an explosion. Men in this category were acknowledged as being wounded as a result of enemy action.
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