Craiglockhart has become famous thanks to its war poet patients. But officers were sent to rest and convalesce in dozens of other smaller hospitals and country houses around Britain. The proportion of officers who suffered from war neuroses was higher than among the other ranks. The ratio of officers to men at the front was approximately 1:30, while that of officers to men among the wounded was slightly higher at 1:24. Among those admitted to special hospitals in England suffering from shell shock in the year from May 1916 to April 1917 the ratio was as high as 1:6.30
The treatment of many of these officers was dominated by what has been called an obsession with a ‘rural idyll’.31 From 1916, a Country Hosts Scheme was established in which the owners of country houses could open their doors to convalescing officers. There was a belief that the countryside offered a morally wholesome environment which would be an aid to recovery. In addition, it was widely held that plenty of fresh air and healthy outdoor activities were ideal for both officers and men recovering from shell shock. Sir John Collie managed what were called Homes of Recovery, in which recovering shell shock patients were encouraged to carry out light gardening work. Allied to this was a belief that agricultural labour was a great help to men recovering from war neuroses.
Of course, one simple way of keeping down the numbers officially suffering from shell shock was to stop using the term altogether and make it harder for MOs to diagnose. Within days of the end of the Somme battle, Gordon Holmes and the army medical authorities came up with a new classification system which all front-line MOs were required to adopt. The army still felt that MOs were too sympathetic to the men, that they were too close to them and their diagnoses were not to be trusted in such a controversial area and at a time when ‘wastage’ had to be strictly limited. So, on 21 November 1916, only three days after the last Somme offensive had ground to a halt in the snow and sleet, the Director General of Medical Services announced that ‘the expression shell shock’ should no longer be used. Any case displaying nervous symptoms of any sort was simply to be classed as ‘Nervous’ and ‘under no circumstances [to] be recorded as a battle casualty’.32
Moreover, the directive introduced a new term, ‘NYDN – Not Yet Diagnosed Nervous’. MOs were no longer to diagnose possible cases of shell shock but were to send them back to the specialist centres that had been set up by this time. Only here could a man receive an accurate diagnosis. The centre then sent a further form, W3436, not to a man’s MO but to his commanding officer. As if the officers in the front line did not already have enough to do, they now had to fill out a form verifying if a man had been near an exploding shell or had shown any other symptoms of mental disturbance. Predictably, this led to long delays. Officers filled out the forms as and when they could. Meanwhile, potentially serious victims of war neurosis had to wait for days in hospital wards before being officially diagnosed, let alone treated. After all the form filling had been completed, in periods of normal activity approximately 40 per cent of those classified NYDN were eventually diagnosed as Shell Shock ‘W’ and 60 per cent were diagnosed with the lesser condition of Shell Shock ‘S’. This proportion went up to roughly 50-50 during major battles.33
Without doubt this new categorisation prevented many genuine victims of war neuroses from being counted as such. It certainly meant that the official statistics looked far more acceptable. Holmes reported that during the four months of the Third Battle of Ypres, from July to October 1917, the titanic struggle that became known as the battle of Passchendaele, Fifth Army counted only 5,346 cases of diagnosed shell shock.34 In an army of roughly half a million men enduring the mud and horror of Passchendaele, this approximately amounted to a mere 1 per cent of the total force, a figure that defies all belief. Even the uncritical Official Medical History concluded, ‘Considering the nature of the conditions in this battle area and the nerve-racking character of the struggle, this must be regarded as a very low figure.’35 This is a dramatic understatement. During the last year of the war, only 3000 further cases were diagnosed. Although this again seems extraordinarily low it is more believable in relative terms, as the battles of 1918 became more mobile and fluid, and in these conditions the incidence of shell shock was always likely to be lower. The term Shell Shock ‘W’ had finally outlasted its time; in the final months of the war, its usage was abolished altogether.36 Outwardly, the army could congratulate itself that the crisis of shell shock had been solved. In reality, it simply refused to count such cases any longer.
It must be asked how effective were the different forms of treatment for shell shock and what was the recovery level of victims? Again, the records are not always complete. Of those diagnosed with shell shock during the Battle of the Somme it is impossible to calculate exactly how many men recovered. According to some records, a figure as high as 87 per cent of those reported to be suffering from shell shock were back on front-line duty within a month. Other figures suggest it was 79 per cent.37 This would have included all those men who were given a few days’ sleep and rest in a dressing station, as well as those diagnosed either with Shell Shock ‘S’ or ‘W’. Between August and October 1917, at the height of the Third Battle of Ypres, detailed records were kept of the far smaller number of official cases than in the previous year. Sixteen per cent of patients were evacuated to base hospitals. Of the rest who were kept in Army Areas, 55 per cent returned direct to their battalions for duty and the remaining 29 per cent were directed to take part in one of the schemes in which recovering patients went to various farms for a month of agricultural labour. After this they automatically returned to their units.38 The percentages for the remaining thirteen months of the war were similar but with a larger number being sent to base hospitals.
When it comes to the proportion of relapses, the numbers are again difficult to calculate on a reliable basis. All figures relating to the wounded were kept by Army groups, so if a man was sent back to his division which was then transferred from, say, Fourth Army to Second Army, it was impossible to track what had happened to him. If he had a relapse, he would be recorded as a new statistic. However, on the basis of the numbers that can be tallied, a surprisingly low figure of only 10 per cent of men sent back to the firing line had to be readmitted to hospital due to the recurrence of war neurosis. Just 3 per cent were readmitted twice or more. Those sent back down the line by this point were mostly serious cases of neurasthenia; only rarely did this occur with cases of hysteria, when it produced the severest physical symptoms.
All these figures have to be treated with suspicion. By 1917 the army was doing all it could to keep down the numbers classed with any form of nervous condition by using the new NYDN category. However, the figures enabled the Official Medical History to conclude that by the end of the war it was far better, in most cases of neurosis, not to place a man in a ‘sick atmosphere’, in other words in hospital, as this tended only to fix his condition. It was noted that the ‘majority of patients … rapidly improved’ when given rest and recuperation as near the front as possible. But at last it was also recognised that, serious, nervous conditions should be treated in special hospitals by specialist doctors as part of a programme properly co-ordinated by a ‘consulting neurologist’. This at least was progress of a sort.39
The United States of America was the last major power to enter the Great War in April 1917. By then the debate about the causes, symptoms and treatment of shell shock had been well publicised. Determined to benefit from the lessons painfully learned in the European armies, a month after the declaration of war a senior American neurologist, Dr Thomas Salmon, visited the British and French armies to carry out a scientific investigation into the treatment of war neuroses. As a result of his investigation, a neuropsychiatric team accompanied the American Expeditionary Force when it began to build up in France from the spring of 1918. After Salmon’s report, the US army decided to follow exactly the procedures developed by that year in the British army, with the vast majority of shell shock cases being treated in dressing stations
near the front and only a third being sent back down the line to neurological hospitals, which were specialist wards within the equivalent of Casualty Clearing Stations. One US Army base hospital, known as Hospital 117, located in the small village of La Fauche in the picturesque foothills of the Vosges mountains, acted as a specialist neuropsychiatric centre. Only the most severe 15 per cent of cases ever reached Hospital 117. The guiding principle was to treat men as fast and as near the front as possible in order to keep what was called a ‘return to duty attitude’.40
The US Army was also good at keeping statistics, particularly from September 1918 when it began to operate as an independent force on the Western Front rather than as an adjunct to the British or French armies. Initially, in the spring of 1918, 20 per cent of all casualties reaching the base hospitals were shell shock victims and war neurosis was regarded as a ‘dangerous military menace’, as it had been in the British army on the Somme.41 But as the army grew dramatically in size over the latter three months of the war from 270,000 to 1,450,000 men, and as the conflict became more mobile, the level dropped to half of what it had been in the spring. By the last months of the war, the majority of men suffering from war neuroses were treated effectively near the front. The ‘wastage’ level of victims who had to be evacuated to the United States was only 1 per cent.42 These figures show the real improvement of treatment levels in the US Army; as the American model was built on the British and French experience, they also indicate how recovery levels had similarly improved in the Allied armies by the end of the war.
Although the primary task of military doctors was to get a man fit and reliable enough to return him to his battalion in the trenches, that was not all. There was a secondary responsibility, one that became more apparent as the war advanced and as tens of thousands of men were classed as not fit enough to return to duty. That was to advise the post-war pension system on whether or not a man was suitable for state support after his military service was over. The challenges presented by shell shock did not end with the Armistice in November 1918. The response of the medical establishment in the post-war world to the challenges of coping with war trauma would shape the experience of a generation.
11
The Ghosts of War
Charles Wilson was one of literally hundreds of thousands to have a near escape during the Battle of the Somme. During a barrage the shelling suddenly intensified, and Wilson and his colleagues ‘got down to the bottom of the trench, waiting, listening’. Then the situation grew even worse. ‘We heard a shell that seemed by its rising shriek to be coming near. Then there was a shattering noise, in our ears it seemed, a cloud of fumes and a great shower of earth and blood and human remains. As the fumes drifted away I had just time to notice that the man on my right had disappeared and that the trench where he stood was now only a mound of freshly turned earth, when another angry shriek ended in another rending explosion, and more fumes that enveloped us. Our bit of the trench was isolated now and as the shells burst all around us with gathering violence it seemed that the whole Boche artillery was watching this little island and was intent on its destruction.’ Wilson found that he could not think or act for himself. ‘My mind became a complete blank … Perhaps I should have got up and run if my limbs had seemed to belong to me.’ Eventually, the shelling ceased ‘and there was peace again and a strange quietness and the old queer feeling of satisfaction after a bad time as if something had been achieved, then utter weariness, a desire to sleep, a numb feeling.’
Wilson never forgot this vivid experience, the worst he ever endured as a MO on the Western Front. He had come within a few inches of death. For the next year ‘every shell that fell near the trench seemed to be the beginning of a new cataclysm.’ Wilson wrote that he did not remember being frightened during the incident, just ‘too stunned to think’. But it took its toll later. ‘I was to go through it many times in my sleep … Even when the war had begun to fade out of men’s minds I used to hear all at once without warning the sound of a shell coming. Perhaps it was only the wind in the trees to remind me that war had exacted its tribute and that my little capital was less than it had been.’1
Wilson lived a prominent and successful life after the war. He became a physician at St Mary’s teaching hospital in London, a Harley Street consultant and in the 1940s, as President of the Royal College of Physicians, was one of the principal architects of the new National Health Service. From 1940 he became Winston Churchill’s personal doctor, meeting with the Prime Minister every few weeks and regularly travelling with him on his gruelling trips abroad. Wilson, who became Lord Moran in 1943, never suffered from any serious form of shell shock or war neurosis. But still this incident under shell fire on the Somme would come back to him regularly, prompted by the tiniest thing. If the memory of being under shell fire remained with a medical man like Wilson who could understand and rationalise his emotions, it is easy to imagine how it must have haunted the lives of many thousands of others.
Men suffering from the after-effects of shell shock could be irrational and unpredictable, and frequently it was wives and children who suffered most. Tranquil, kind, loving and attentive one minute, a man might suddenly turn for no apparent reason and become brutal, violent and abusive. All sorts of things could trigger such violent mood swings. It might be simply the sound of the wind in the trees, reminding a man of the shriek of a shell (as with Wilson), or a military band playing on the radio. One man, every time he heard the phut-phut of a passing motorbike, thought he was hearing machine-gun fire; he would go into paroxysms of fear and had to find a corner to hide in. Other men continued to suffer from occasional shakes or tremors and would become furious if a wife or child noticed or commented on this. Many wives had to put up with their husbands’ violent nightmares, the men waking up at night screaming and recalling the terrible events they had experienced. Sometimes the nightmares went on for years, even decades, after the war’s end.
Very few ex-soldiers would talk about their wartime experiences. The attitude of the time was to draw a veil over memories of the war and to move forward. Men who had seen terrible sights and had witnessed friends being killed or blown to pieces alongside them were told, ‘Put it out of your mind, old fellow, and do not think about it; imagine that you’re in your garden at home.’2 Families knew not to ask husbands and fathers about what had happened to them. The ignorance of what lay at the root of a loved one’s anguish must have made living with those haunted by wartime ghosts even more dreadful to bear.
The fragments of surviving evidence only hint at the agony that thousands of families must have endured from the after-effects of shell shock. The wife of a private in the Lancashire Fusiliers reported two years after the war’s end, ‘He is always complaining of shooting pains in the head. He sometimes sits staring vacantly for hours and at times has not spoken for days, then suddenly gets up, goes out and gets drunk.’ Another soldier from Lancashire who suffered from shell shock was finally discharged from the Maudsley Hospital in July 1919; on returning home he tried to strangle his wife in bed. Donald Laing, who served with the Cycle Corps from 1914 and returned home suffering from shell shock, was able to get a job as a commercial artist and apparently settle back into normal family life. Four years after the end of the war he became increasingly unsettled, complaining that his workmates were persecuting him. Like others, he seemed to see Germans everywhere. Certain that he was being followed, he dragged his wife and baby out of bed one night and made them walk across Wimbledon Common in the pouring rain to avoid the pursuers. Sudden bursts of unmanly tears, bouts of intense depression, a sense of being surrounded and pursued by the enemy were all characteristic of the inner demons of these poor men.3
Most families did all they could to put up with a strange and alien father or husband back at home after a long absence at the front. But sometimes, in extreme cases, it was just too much. George Munston was at home for Christmas 1916. Then he went away to fight in Mesopotamia and was unable to come back on leave.
In the Middle East he suffered from a severe form of war neurosis. In the spring of 1919 he finally returned home to south London but, alarmingly, he arrived under escort from the Notts War Hospital. His wife Beatrice was no doubt delighted to see her husband, who also met for the first time his eighteen-month-old daughter, conceived when he was last at home. But Munston was not the same loving husband he had been. He made wild threats to thrash his wife and to murder his hospital doctor. Then he said he would drown himself. After only two weeks, Beatrice had to contact the authorities and beg them to take him back into hospital.4
From the spring of 1915, the government had accepted that they had a responsibility to provide welfare support for disabled veterans who needed help re-integrating into civilian life and finding suitable employment. After the terrible casualties during the Battle of the Somme there was a change of political leadership in Britain. Lloyd George became Prime Minister in December 1916, and created five new ministries to beef up Britain’s war effort. One of these new departments, the Ministry of Pensions, assumed the responsibility for the support of disabled soldiers in 1917 and took over the management of 900,000 pensions (including all pensions and gratuities to disabled men, widows and dependents). New pensions were being awarded at the rate of 14,000 per week.
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