Hundreds of charities have been set up over recent years to help veterans returning from Britain’s recent combats. Due to the financial cutbacks following the end of the war in Afghanistan, their services will be in much demand as about 20,000 servicemen and women leave the armed services. Millions of pounds are raised every year from a sympathetic public who want to help the returning ‘heroes’. Combat Stress is still treating thousands of veterans from previous conflicts, of whom those who served in the ‘Troubles’ of Northern Ireland provide the largest number, although the charity still receives requests for help from veterans from the Falklands War and the first Gulf War. Research indicates that about 4 per cent of veterans from the recent wars in Iraq and Afghanistan (one in twenty-five) are suffering from PTSD, although the proportion is higher (6.9 per cent) among those who experienced front-line combat. Veterans from the earlier conflicts who present themselves do so on average fourteen years after their discharge from the military. Veterans of Iraq and Afghanistan present about two years after leaving the military. Despite the current awareness of the difficulties faced by ex-servicemen, and the high public profile of groups like Help for Heroes, it seems that servicemen and women are still reluctant to seek help for mental health problems while they are serving in the military. The macho image still prevails, and many servicemen or women, especially officers, think that admitting to nervous conditions will stigmatise them and damage their career prospects. Many of those who present themselves in the years after leaving the armed forces have a range of other conditions that are sadly typical of war veterans; there is a high incidence of alcohol disorders, depression, unemployment, periods of homelessness, behavioural problems manifested by outbursts of anger and violence, and spells in prison or in the criminal justice system. It is a gloomy modern litany of the consequences of damage to the mind caused by the stress of combat.
Trauma is a difficult issue to define. Everyone suffers from the stresses and strains of life: the death of friends or relatives, the loss of jobs, the break-up of relationships. Almost everyone gets depressed at some point in their lives. This is all part of being human and what we would call ‘normal’. But some people respond to distress in a particular way, experiencing a strong sense of inadequacy, delusions of guilt, or a complete loss of hope. In some circumstances the depression that follows is so severe that sufferers may self-harm or attempt to take their own lives. That is abnormal behaviour. But where is the line between the two? When does a normal response become abnormal? In the case of ex-servicemen and women, the line is even more difficult to define because, added to the universal complexities of everyday life, they are presented with the challenge of reintegrating into civilian society when a conflict is over or when many years of service come to an end.
Soldiers are trained not only to survive under the extreme pressures of the battlefield, when the fear of death or mutilation is commonplace, when they might witness friends being dreadfully wounded or killed, but to continue to function and to maintain the killer instinct in these circumstances. Such instincts are utterly alien to most civilian life. The individual values that prevail in most civil societies are replaced by the group spirit and group loyalty that underlies most military organisations, usually summarised as esprit de corps. That is what a period of ‘basic training’, as it is called in most armies, is designed to instil. Weeks of drilling, parades, inspections and tough physical training separates a soldier from a civilian by equipping him or her with the psychological mechanisms to carry on operating when tired, hungry, cold and under fire. The values that are inculcated are obedience to authority, aggression, loyalty, and intense pride in the military unit in order to give the protection of colleagues a higher priority than mere self-protection, to build a ‘band of brothers’.10 On returning to civilian life these qualities are no longer required and can be massively destructive, while at the same time ex-soldiers find they have lost the strong camaraderie and sense of purpose that comes with being in the military.
Forty per cent of the £15 million annual funding for Combat Stress is provided by the state, through the Ministry of Defence and the National Health Service. The remaining 60 per cent comes from private charitable donations. Headley Court with its state-of-the-art rehabilitation facilities was funded by Help for Heroes. It seems extraordinary, one hundred years on from the intense public debate about shell shock and the difficulties encountered by veterans attempting to settle back into civilian life after the Great War, that the state should be so reliant upon private charity in the form of Combat Stress, Help for Heroes and the many other organisations that help ex-servicemen and women reintegrate into society. Perhaps it is a sign that modern traumatic disorders are largely delayed and so are reported after a veteran has left the military. Maybe it suggests that those who are trained by society to kill on its behalf will always struggle to reintegrate into normal, peaceful civilian life. Or perhaps it simply makes one ask if society has learned anything in this regard in the last one hundred years?
There is a clearly observable cycle in military psychiatry since the First World War. A great deal of expertise in treating the trauma suffered by soldiers is built up during a war, and this overflows into the rest of psychiatry, improving the treatment of all nervous cases and trauma victims. But, in the cutbacks of expenditure that follow most wars, this knowledge is put aside and forgotten, and consequently has to be learned anew in the next conflict. Most of the lessons learned during and after the First World War were lost in the 1920s and 30s; as a result, they had to be learned again during the early years of the Second World War. The progress made by 1945 was again forgotten over the next few decades and had to be rediscovered after the Vietnam War. With the wars in Iraq and Afghanistan now hopefully over, we are once again at the end point of the learning cycle. A great deal of expertise has been built up and real progress has been made in understanding the psychiatric injuries of combat and trauma. Will all this be forgotten again in the decades to come? This will be one of the challenges of future decades.
However, one hundred years ago, the First World War left British society deeply scarred by the experience of war. Five million men had fought in the army. Two million women had either volunteered for the armed services, to join nursing organisations or to work in wartime factories. One in six adult males had been killed or wounded by the war. The survivors tried to adjust to civilian life some without limbs, many blinded, others haunted by traumatic memories they could not cast off. Those who had fought for King and Empire ended up filling the dole queues after the war. Even a high proportion of those who had survived without serious physical or mental wounds suffered an ongoing sense of guilt, that they had survived while others alongside them had not. Harold Macmillan, a future Prime Minister, never got over the feeling that the best of his generation had been lost on the Somme and elsewhere on the Western Front and only the second-raters had survived to inherit the post-war world.11 Very few adults who lived through the years from 1914 to 1918 were unaffected by the experience of war. Historians have written about the changes that deluged British society.12 But within the tsunami of suffering that engulfed all European societies, the story of those who had suffered from mental trauma stands out. It was not understood at the time. It was often misdiagnosed. The sufferers were frequently blamed for their problems, either as degenerates or as malingerers. In the worst cases they were shot as cowards. This is not a war record to be proud of. Nor is it a story one can be dispassionate about.
The debate about the treatment of shell shock and the development of military psychiatry in the First World War did, however, have two immensely significant outcomes. First, it showed that mental health difficulties were not exclusively the problems of the weak, the feeble and those genetically geared to insanity. Anyone could face such problems. Even the fittest and most highly motivated soldier could suffer from battle neuroses. Second, it was clear that Victorian attitudes were entirely wrong, that mental diseases could be treated and that ‘lunacy’
, as it was called, in its different forms was not incurable. The learning process now extends back one hundred years to the first cases of men attending front-line aid posts with mysterious shakes and curious paralyses that left doctors puzzled. From this early incomprehension a great deal of important work was done and a huge shift in understanding mental health followed. The lasting consequences of the shell shock debate were a recognition that anyone could suffer from mental ill-health and that it was possible to be cured of mental disease; the traditional locking away of lunatics as ‘incurables’ was no longer acceptable. Out of the immense suffering of the wartime years came at least some progress.
APPENDIX 1
Numbers
‘Unfortunately we have been unable to obtain any reliable statistics covering cases of “shell shock”.’1 So wrote the authors of the Report of the War Office Committee of Enquiry into ‘Shell Shock’ in 1922. The ‘absence of statistics’ caused much concern to the members of the committee, who greatly regretted that they had ‘failed to obtain’ the information they thought was essential to assess the true scale of the problem. If this was the case in 1922, it is no less true today that, one hundred years after the events this book deals with, it is not easy to calculate precise figures for the numbers of psychiatric casualties during the Battle of the Somme.
What is not in contention is that from day one of the battle there was a massive increase in the incidence of shell shock. Every source without exception confirms this. But precisely assessing from the available evidence the numbers of those affected is immensely difficult. Most lists of the wounded make no differentiation between types of wounds – head wounds, abdominal injuries, bullet or shrapnel wounds, or war neuroses. Furthermore, the different categories into which shell shock victims were assigned, Shell Shock ‘W’, Shell Shock ‘S’, Neurasthenic and later NYDN (Not Yet Diagnosed Nervous), makes analysing the total number of those suffering from psychosomatic injuries even more difficult. The Official Medical History records that there were 16,138 battle casualties in France from shell shock in the months July to December 1916. This was over four times more than in the previous six months, when there had been 3,951 casualties; and more than twelve times greater than in the six months July to December 1915, when there had been 1,246.2 If this gives an indication of the rate of increase in the incidence of shell shock, it still does not convey anything like the real number of cases; it only includes Shell Shock ‘W’ and not Shell Shock ‘S’, nor does it include all of those diagnosed with Neurasthenia. According to the Official Medical History the total number of cases would have been at least double this, while Ben Shephard claims that numbers ‘probably need to be multiplied by at least three to give a real sense of the scale of the problem’.3 Most historians would agree with the eminent psychiatrist who wrote that ‘the true proportion which neurosis bore to the total medical casualties of the War was vastly underestimated in official statistics.’4 Whatever the exact number, shell shock had been transformed from a disease into an epidemic almost overnight.
There are, however, other ways of trying to calculate the numbers involved. At the end of July 1916, the 2nd Division was sent down from the quiet sector at Vimy to join the fighting on the Somme. On 26 July it relieved the 3rd Division and took over its role in the struggle for Delville Wood, which it finally succeeded in capturing a few days later. On 8 August, the 2nd Division attacked again to the south of the wood towards Guillemont. New to the Somme fighting, the divisional medical authorities recorded precisely the type of casualties incurred in the two-week period from 26 July to 11 August. The total number of wounded was 2,945. Of these, the number of shell shock cases was 501.5 Shell shock victims therefore amounted to 17 per cent of the total number of wounded.
The Australian forces recorded the number of shell shock victims in the 1st Australian Division over a five-day period from 22 to 26 July. Of a total of 2,200 recorded as wounded, 376 were suffering from shell shock. Fascinatingly, this averages out at exactly the same proportion, 17 per cent, although on one day of severe shelling, the figure was as high as 29 per cent.6 The figure of 17 per cent was also the percentage of shell shock cases recorded in the 11th Border Regiment, the Lonsdales, in the months before going over the top on 1 July.7
At 17 per cent of the wounded, the number of shell shock cases during the whole of the Battle of the Somme would have totalled the colossal figure of more than 53,700.8 And yet we can still not be certain that these numbers, where they do exist, include all of those diagnosed as Shell Shock ‘S’ and all officers diagnosed with Neurasthenia. In innumerable cases, if a man was taken out of the line for a few days’ rest and reassurance and then returned to his battalion, he would not have been classed in any of the official categories as a battle casualty. It is likely, therefore, that the total number of cases suffering from the variety of nervous disorders that came loosely under the label of ‘shell shock’ was much higher.
Professor Edgar Jones of the King’s Centre for Military Health Research, co-author of the principal textbook on the subject, Shell Shock to PTSD, has also tried hard to calculate the total numbers involved. By studying 3,580 shell shock cases admitted to 4 Stationary Hospital between January and November 1917 he has been able to track the rise and fall of the incidence of shell shock. This, not surprisingly, correlates closely with the incidence of general wounds, as the army was involved in several major battles during those months.9 Furthermore, he has looked at the proportion of psychiatric casualties in later wars when numbers were more accurately reported during high-intensity battles. He calculates, for instance, that during the heavy fighting of the battle for Normandy in June–July 1944, the percentage of psychiatric casualties was expected to be between 10 and 30 per cent. In fact the three British army divisions in VIII Corps recorded rates of 21 per cent, 11.6 per cent and 14.7 per cent (an average of 15.8 per cent) in the first part of the battle and an average of 18 per cent during the final stages of the breakout, when the fighting was at its most severe. Data collected from the experience of the US Army in the Mediterranean and in the south-west Pacific theatres in October–November 1943 is also in line with these percentages.10 Jones concludes that in the heaviest fighting of the First World War, like that during the battle of the Somme, it is fair to estimate that 20 per cent of those wounded were suffering from psychosomatic disorders. This happens to coincide exactly with the figure reported in the US Army in the spring of 1918 before that army fully organised its neuropsychiatric care.11
It seems likely therefore that the total number of men on the Somme suffering from war neuroses was slightly higher than 17 per cent. We can consequently estimate the total number of psychiatric casualties to be somewhere between 53,700 and 63,200 (20 per cent of all casualties). This huge number equated to the loss of three whole divisions from shell shock in one six-month period. The official figure for July to December 1916 was four times as great as over the previous six-month period, and if this rate of contagion of shell shock was to increase at only half that level during the next year, the British army could have been looking at the loss of perhaps the equivalent of nine divisions (180,000 men) from shell shock during 1917.
There is no evidence that anyone calculated such exact figures at the time, or that numerical predictions of shell shock losses were on this scale. However, they did not need to be. It was clear to all senior figures in the army that from July to November 1916 the incidence of shell shock had reached epidemic proportions and was totally unacceptable. This loss of men was openly referred to as ‘wastage’. The Official Medical History admits, ‘the severe wastage of man-power which the psycho neuroses were causing in France made the problem of dealing with them urgent towards the end of 1916.’ War neuroses, it said, opened up ‘a flood-gate for wastage from the army which no one would be able to control’.12
This is one of the reasons why the term ‘shell shock’ became so unpopular with military medical authorities after the Somme and its use was officially banned in 1918. It
also explains why the new delineation of NYDN (Not Yet Diagnosed Nervous) came into use at the end of the battle and why the ‘official’ incidence of shell shock dropped so extraordinarily during 1917.13 The easiest way to reduce the numbers suffering from shell shock was simply not to record many of the thousands of cases that presented themselves.
In 1931, revised casualty numbers were published in a further volume of the Official Medical History. These indicated that during the period August 1914 to November 1918, 143,903 British soldiers were treated for ‘functional diseases of the nervous system (including neurasthenia and shell shock)’. But other categories almost certainly included psychiatric casualties, including ‘mental diseases’, ‘debility’ and ‘functional diseases of the heart’; if added in, these total a figure of 325,312. This amounts to 5.7 per cent of all Britons who served in the army during the war years, by comparison to 4.6 per cent of those in the German army.14
Shell shock was of course inextricably bound up with the general morale of the troops. As became clear in the evidence given to the War Office Committee of Enquiry in 1922, a battalion with poor morale was more likely to suffer from high levels of nervous disorder. Battalions with high morale might suffer from very little shell shock. So the haemorrhaging of large numbers of men had to be prevented. It is the actions taken by the army to try to do this during the battle of the Somme that are at the core of this book.
APPENDIX 2
War Trauma Before the First World War
During the First World War the epidemic of nervous diseases among soldiers was widely regarded as a completely new phenomenon, a side effect of the horrors of modern, industrial warfare. This led the War Office Committee of Enquiry in 1922 to note that ‘we have no evidence of “shell shock” in previous campaigns’, and to conclude that this was not extraordinary ‘when it is borne in mind that the use of high explosives, of the violence and intensity developed in the recent War, was wholly unknown in the conflicts of the past’.1
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