In fact there is evidence that soldiers have suffered various sorts of mental disturbances throughout the history of warfare. Historians have found descriptions of what could be classed as war trauma in Herodotus’s account of the battle of Marathon in 490 BC, in Homer’s Iliad and in the work of Roman writer Lucretius. Shakespeare describes symptoms that would have been familiar to many First World War MOs in Henry IV Part 1 when Lady Percy asks her husband, Hotspur:
Why dost thou bend thine eyes upon the earth
And start so often when thou sit’st alone?
Why hast thou lost the fresh blood in thy cheeks;
And given my treasures and my rights of thee
To thick eyed musing and curs’d melancholy?
In thy faint slumbers I by thee have watch’d
And heard thee murmur tales of iron wars.2
The problem with all reported cases of mental disorders among soldiers at war until the mid-nineteenth century is that writers could describe symptoms in very different ways. So a wide variety of accounts might have described those suffering from war trauma but there is no way of proving it. From the seventeenth century soldiers were sometimes described as suffering from ‘nostalgia’ – a type of melancholy thought to be produced by a longing to return home, which in some cases could easily have been a form of trauma brought on by the stress of warfare. A Swiss physician, Johannes Hofer, published a detailed study of this mysterious disease in 1678 and proposed various treatments in the form of purges to improve digestion and release a man’s vital spirits. Another term for a malady identified within military ranks was ‘soldier’s heart’ or ‘irritable heart’, of which the symptoms were exhaustion and breathlessness, a high pulse rate, sweating, a parched tongue and attacks of giddiness. Again this may have been a manifestation of war trauma. On the other hand, during the Napoleonic Wars a large number of soldiers in the French army who were perhaps suffering from trauma were simply classed as insane and were discharged with no real attempt to identify the cause of their insanity.
The intensity of the fighting during the Crimean War from 1854 to 1856 produced more cases that baffled the doctors. One officer described joining the survivors of his unit two days after the Battle of Inkerman: ‘Every general and staff officer in our division was killed or wounded. The people who are left appear dazed and stupefied and unable to give us any idea of our position or chances.’3 At the time, doctors again put this down not to nervous exhaustion but to what they called ‘disordered action of the heart’. Roger Fenton took the first photograph of a victim clearly suffering from war trauma in 1855 in the Crimea. This extraordinary photo is of Captain Alexander Leslie-Melville, Lord Balgonie, of the Grenadier Guards, who had endured several Russian bombardments during the siege of Sebastopol. Only twenty-three years of age, Lord Balgonie is not in uniform as elite army officers usually were when photographed after battle. Instead, dishevelled, he looks out beyond the photographer with classic staring eyes. Balgonie was sent home from the Crimea but died only two years later.
During the American Civil War from 1861 to 1865, it was recognised that soldiers could suffer injury to their nervous systems without any signs of a physical wound. There was no agreement as to what caused this nervous disorder and a variety of explanations were put forward. Some maladies were put down to a phenomenon called ‘windage’, where it was thought that a man had been affected by the close passing of a shell or bullet. It is possible that the term ‘windy’, referring to someone who lacks courage, derives from this. Another doctor came close to describing what would later be called shell shock when he gave an account of injuries produced by the explosion of a shell near a man, causing ‘compression of the brain’ and leading to physical symptoms like blindness, deafness or paralysis.4
Throughout the rest of the nineteenth century military doctors sought explanations for strange behaviour of soldiers at war that did not appear to have physical origins. In the British army a debate about ‘disordered action of the heart’ came to focus on whether the traditional soldier’s belt, pack and knapsack straps were too tight, and on long route marches or in the hot climates of India and Africa acted to constrict the heart. As a result of this debate adaptations were made to the traditional uniform of the British infantryman.
By the end of the century, a condition popularly called ‘railway spine’ had been identified in civilians who suffered from trauma as a consequence of having been in a railway accident. This was put down to the violent shock caused by the accident, which led to inflammation of the spinal cord producing a disturbance of the central nervous system. Sometimes a victim was unaware at first of having been affected, feeling perhaps merely a little giddy, but within a couple of days he or she might be physically incapacitated and unable to carry out basic tasks. This became a major issue in late Victorian society as lawyers sought to blame the railway companies for the trauma suffered by accident victims. On the other hand, lawyers working for the railway companies produced medical opinions that put the symptoms down to pre-existing conditions in those claiming compensation.
The new concept of ‘neurasthenia’ was moreover introduced from America in the last decades of the century. The term described a disease of the nervous system without physical origins but which could nevertheless substantially weaken or exhaust an individual with varying degrees of severity. Nervous exhaustion was thought to generate a range of physical symptoms, including paralysis of the limbs. This was believed to be a function of modern, urban, stressful living. A small number of men were diagnosed with neurasthenia during the Boer War of 1899–1902. But overall that war did not alert the newly formed Royal Army Medical Corps to the problem of nervous diseases. More than 6,000 files have survived relating to pensions awarded by the Royal Hospital at Chelsea to Boer War veterans. Less than 1 per cent of them relate to cases of psychosis, depression or psychological disorders.5
In the Russo-Japanese War from 1904 to 1905, many cases of psychiatric casualties were recorded in the Russian army, and in a revolutionary step the Russians set up a forward hospital for the treatment of such cases. More than 3,000 cases were counted. Observers from France, Britain and Germany noted these casualties and warned of their likely existence in future wars. But in Britain this did not act as a wake-up call. Only one medical observer, Captain R.L. Richards, tried to sound the alarm. In the army medical journal Military Surgeon, he wrote: ‘A future war will call at least equally large numbers of men into action. The tremendous endurance, bodily and mental, required for the days of fighting over increasingly large areas and the mysterious and widely destructive effects of modern artillery fire will test men as they have never been tested before. We can surely count then on a much larger percentage of mental diseases requiring our attention in a future war.’6 They were prophetic words. But no one seemed to hear them.
APPENDIX 3
Shell Shock in Other First World War Armies
All the armies fighting during the First World War experienced a high incidence of war neuroses. The various conditions were given several different names. The Germans used words including Nervenschock, Kriegshysterie (war hysteria), Granaterschütterung (shell disorder) and Granatexplosionslähmung (shell explosion paralysis); the French used terms like Traumatisme dû au bombardment (trauma from a bombardment), syndrome commotionnel (commotional disturbance), choc traumatique (traumatic shock) or psychose traumatique. Both the French and German armies took a harsh line towards their psychiatric casualties.
In the decades before the Great War, the acknowledged leading experts on hysteria, hypnosis and psychotherapy were French. In the late nineteenth century, Professor Jean-Martin Charcot became known as the father of modern neurology and helped to define many mental disorders including epilepsy, stroke and hysteria. His successor at the Salpetrière Hospital in Paris, Jules-Joseph Dejerine (see Chapter 3), was a pioneer in psychotherapy. But despite their international influence the neurologists of the Salpetrière Hospital held little sway over the French army
.
In France, as in Britain, the military medical authorities, led by Prof. André Léri at the Army Neurological Centre, decided initially to separate victims into two groups: first, those suffering from ‘commotional’ and physical damage to the brain and nervous system caused by proximity to a shell explosion; second, those suffering from an ‘emotional’ disorder, where the physical paralyses were seen as a manifestation of hysteria. In 1915, the French army was the first to set up forward treatment centres near the front in order to treat patients within a military environment. Georges Guillan, a senior military neurologist, argued that psychiatric disorders ‘are perfectly curable at the onset … such patients must not be evacuated behind the lines, they must be kept in the militarised zone.’1 The French consequently led the way that the British and other armies would follow.
But it would be wrong to think that the French army took a soft line towards its psychiatric casualties. Far from it. French doctors were obsessed with weeding out cases of malingering and, following the approach of Joseph Babinski, adopted a tough, brusque attitude to soldiers suffering from nervous disorders. Often the treatment went little further than giving a soldier a few days’ rest and then forcefully telling him that he had recovered and must follow his duty and return to his battalion, that he was ‘either a loyal, self-sacrificing wounded poilu or a cowardly, self-serving, simulating embusque [shirker], a victim or a villain’.2
Dr Clovis Vincent at a hospital in Tours was known for his harsh techniques, which combined electric shock therapy with a vigorous verbal assault, telling his patients they must pull themselves together and face up to their soldierly duties. Vincent achieved notoriety when in 1916, gleefully holding out two electrodes, he approached a new patient who rather than succumb to painful electrotherapy punched him five times in the face. The man was put on a charge of assaulting a senior officer. At the military trial, scientific opinion rallied behind Vincent but public opinion was largely behind the soldier, and although he was found guilty he was given only a suspended sentence.3
Optimism in the first years of the war that the French medical authorities had the problem under control declined later as the general morale in the French army deteriorated sharply during 1917. More and more soldiers were apparently developing hysterical symptoms in areas behind the line during their treatment for physical wounds and were unwilling to return to their units. There are no complete sets of figures for psychiatric casualties in the French army between 1914 and 1918, but in an army of that size there is no question that it would have run into many hundreds of thousands.
By contrast, the official medical history of the German army, the Sanitätsbericht, is very precise and lists the total number of cases treated for war neuroses between August 1914 and July 1918 as 613,047, or 4.6 per cent of all the men who passed through the army during the war.4 This figure is probably of a similar order to that in the armies of all the major protagonists.
In Germany, psychiatry was more highly respected before the war than in Britain, but there was still disagreement between psychiatrists as to how to interpret the many hysterical symptoms that seemed to appear in soldiers at the front. Hermann Oppenheim argued, just as many British neurologists did at the start of the war, that war neuroses were the result of physical damage, tiny lesions in the brain and the nervous system that caused the many strange forms of paralysis. However, by 1916, the prevailing opinion in Germany was that these neuroses were of emotional or psychological origin. Max Nonne, probably the most famous German military doctor, treated more than 1,600 patients during the war and acquired the reputation as a Zauberrheiler, or magic healer, although his technique was the relatively familiar one of hypnosis. Nonne, who had studied in France before the war, initially believed that no German soldier would ever suffer from hysteria, but soon had to reassess this view as hundreds of soldier patients came before him displaying classic symptoms.
Max Kaufmann, based in a hospital near Mannheim, adopted a more radical approach. He was another who saw treatment as a battle of wills; he would apply strong doses of electricity for several minutes at a time while shouting orders at his patient (see Chapter 10). Although he had many successes, about twenty patients died while undergoing his electric shock therapy and at one point there was a revolt of patients awaiting treatment. Even the provincial German assemblies, and finally members of the Reichstag, began to question the validity of this form of treatment.5
The Americans came into the war late and were determined to learn the lessons picked up by the Allied armies in the first three years of war (see Chapter 10). They treated most shell shock victims near the front, and only transferred the most serious cases to a specialist neuropsychiatric centre known as Hospital 117 in the calming and beautiful setting of the Vosges mountains. By the last months of the war this enabled the American authorities to claim a high recovery rate among their shell shock victims. Of the recorded 7,500 psychiatric cases during the battle of St Mihiel in September 1918 (approximately 5.5 per cent of those who took part in the battle), 65 per cent returned to duty after a few hours or a couple of days of rest at the front; 20 per cent after up to two weeks’ treatment at one of the neurological hospitals; and 14 per cent after treatment at Hospital 117. The ‘wastage’ level of victims, those who were evacuated to the United States, was only 1 per cent.6
One figure who might have been expected to be active in the intense debate about the causes, symptoms and cures of psychosomatic disorders was Sigmund Freud. However, he remained completely remote from the conflict. Not only was he terribly disillusioned by the outbreak of war, seeing it as a failure of civilisation to subdue man’s primitive instincts for violence, but he was also bewildered by the use of science to generate ever more dreadful forms of killing. Freud remained in Vienna, treating his dwindling number of private patients and lecturing at the university, but he contributed nothing to the treatment of psychiatric casualties in the Austro-Hungarian army. He wrote a paper on the physical manifestations of hysteria but did not publish it. He seems to have preferred to maintain a sort of scientific neutrality with respect to the war effort. The Great War had torn to shreds the pre-1914 world of science where ideas and scientists could cross borders so easily. But Freud chose to stand apart and hope that in the future, science would once again be a unifying force in world affairs.
APPENDIX 4
The Somme Battlefield Today
The site of the Somme battlefield today is an area of beautiful, rolling countryside with few visible scars of the intense Great War fighting. In the 1920s the French government encouraged farmers to return to the devastated, crater-pocked landscape, still littered with the detritus of war, to begin the massive task of reclaiming the land for agriculture. After nine decades of intensive farming most reminders of the conflict have vanished and it requires an immense effort of the imagination to recall the horrors of battle. But a good battlefield guide can bring alive the stories that were once acted out there.
The most visible signs that this is the location of one of the longest and bitterest battles in history are the cemeteries and memorials scattered everywhere. There are French and German cemeteries, but far and away the most numerous are the 242 cemeteries maintained by the Commonwealth War Graves Commission on land given in perpetuity by the French nation. They contain 153,040 Commonwealth graves, of which approximately two-thirds bear the names of those buried. The other one-third contain the remains of bodies of soldiers who could not be identified.
The bodies of men recovered during the course of the war were hastily interred by their pals where they fell in dozens of tiny burial grounds, or in more formal cemeteries alongside hospitals and Casualty Clearing Stations. However, it was impossible to recover many of the bodies during the battle as the fighting raged on. When the Germans withdrew to the heavily fortified Hindenburg Line in February 1917, many bodies that had lain out in No Man’s Land or elsewhere throughout the winter were brought in and buried in hundreds of small cemeteries by the me
n of V Corps, who then occupied this stretch of the line. But, of course, by this point many of the corpses being recovered were unidentifiable.
After the Armistice the whole area was swept at least six further times for bodies and the cemeteries created in 1917 were concentrated into a smaller number of sites laid out by what was then called the Imperial War Graves Commission. The leading figure in this operation was Fabian Ware, an educationalist who had become commander of a mobile ambulance unit during the war. He took on responsibility for the Directorate of Graves Registration and Enquiries and began the task of listing and photographing all existing burial sites. After the war, Ware forcefully argued that all the dead should be properly buried, officers and men together, as near to where they had fallen as possible. He argued that the headstones should not be crosses (as in the French war cemeteries) as they represented the deaths of members of an imperial army that included Jews, Muslims, Hindus and Chinese as well as Christians.
A fierce debate ensued, but in 1919 the Secretary of War, Winston Churchill, backed Ware, arguing that the cemeteries should be sites of national remembrance befitting a democratic age in which everyone should be remembered equally. Every soldier, regardless of race, creed or status, was given a uniform headstone and the graves were laid out in straight lines. Rudyard Kipling was commissioned to come up with some of the phrases that adorn each cemetery, such as ‘Their Name Liveth for Evermore’ (Ecclesiasticus 44.14) and, on the headstones of the unidentified bodies, ‘A Soldier of the Great War – Known unto God’. Max Gill created a new typeface to standardise the lettering on every headstone. Some of the best-known architects of the day, including Sir Edwin Lutyens, Sir Reginald Blomfield and Sir Herbert Baker, designed features like the Stone of Remembrance and the Cross of Sacrifice, made of sombre Portland stone, which are to be found in all but the smallest cemeteries.1
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