Probably over 250,000 men suffered from ‘shell shock’ as result of the First World War. The term was coined in 1917 by medical officer Charles Myers. At the time it was believed to result from a physical injury to the nervous system during a heavy bombardment or shell attack, later it became evident that men who had not been exposed directly to such fire were just as traumatised. This was a new illness that had never been seen before on this scale. The condition was poorly understood medically and psychologically. Today, the condition is known as post-traumatic stress disorder and the treatment and attitude to it are very different.
The discussion of anxiety within this report does not match current opinion on the condition and may be upsetting for some readers.
Extracts from a report from the War Office Committee of Enquiry into Causation and Prevention of `Shell-Shock’, (Catalogue ref: WO 32/4748)
Delimitation of term ‘Shell-Shock.’
At our first meeting we decided that for the purposes of the enquiry we would treat ‘Shell-shock’ as falling under the following heads:-
- (a) Commotional disturbance [physical motion caused by a nearby shelling]
(b) and/or Emotional disturbance.
- Mental disorders
It will be convenient to state in general terms the reasons why the committee unanimously agreed to work on this basis.
Use and Abuse of the Term
We were charged with the duty of collating the expert knowledge derived by the Service medical authorities and the medical profession from the experience of the war, with a view to recording for future use the ascertained facts as to the origin, nature, and remedial treatment of ‘shell-shock.’ For this purpose we had to decide what ‘shell-shock’ is and what it is not. Without going too deeply into the history of the origin of the term, we conclude that it was born of the necessity for finding at the moment some designation thought to be suitable for the number of cases of functional nervous incapacity which were continually occurring among the fighting units. Undoubtedly ‘shell-shock’ signified in the popular mind that the patient had been exposed to, and had suffered from, the physical effects of explosion of projectiles. Had this explanation of the various conditions held good, no fundamental fault could have been found with the term. But with the extension of voluntary enlistment, and afterwards the introduction of conscription, it was discovered that nervous disorders, neurosis and hysteria, which had appeared to a small degree in the Regular Army, were becoming astoundingly numerous from causes other than shock caused by bursting shells. It even became apparent that numerous cases of ‘shell-shock’ were coming under the notice of the medical authorities where the evidence indicated that the patients had not even been within hearing of a shell-burst. On the other hand, it became abundantly plain to the medical profession that in very many cases the change from civil life brought about by enlistment and physical training was sufficient to cause neurasthenic and hysterical symptoms, and that the wear and tear of a prolonged campaign of trench warfare with its terrible hardships and anxieties, and of attack and perhaps repulse, produced a condition of mind and body properly falling under the term ‘war neurosis,’ practically indistinguishable from the forms of neurosis known to every doctor under ordinary conditions of civil life.
The Committee recognised, therefore, from the outset of the inquiry that the term ‘shell-shock’ was wholly misleading, but unfortunately its use had been established and the harm was already done. The alliteration and dramatic significance of the term had caught the public imagination, and thenceforward there was no escape from its use.
A combination of factors had led to a loose and indiscriminate use of the term ‘shell-shock,’ and a reconsideration of all the factors became imperative. From the technical point of view, as our colleague Sir Frederick Mott states in his valuable work on the subject of war neurosis, the conditions of functional nervous incapacity were in reality no new developments. Once their nature had been determined it was possible for the medical man who was previously familiar with the handling of cases of nervous and mental diseases to place each case under its proper caption. But, as Sir Frederick pointed out, only a comparatively few medical men prior to the war had had an opportunity of becoming thoroughly familiar with this very distinct branch of medicine, and it frequently occurred that a medical officer who was not so happily placed found himself in the position of having to deal with large numbers of such cases.
As regards the officially recorded cases of ‘shell-shock,’ there could be little doubt that included under this heading there were cases of many and various conditions. For instance disorders such as hysteria, anxiety neurosis and mental troubles of many kinds; and, the committee are in agreement with the bulk of opinion in saying that all these conditions can be regarded as reactions of the individual under stress of environmental circumstances, that they are bound together by their dependence upon fundamental psychological laws, and that any one case may be found to exhibit the characteristics of two or more types of reaction. Thus a hysteric may show signs of anxiety neurosis and may also exhibit evidence of congenital mental defect, while his irresponsibility in any specific conduct may be due more to his degree of mental defect than to his hysteria.
- Absense of Statistics
Unfortunately we have been unable to obtain any reliable statistics covering cases of ‘shell-shock.’ It would have been desirable to record the number of cases of the disorder under the general term ‘shell-shock’ and to supply tables giving figures of the varieties of disorder classified under that head. The Committee have failed to obtain this information. Much statistical matter was unavoidably lost during the progress of the war, and other material of a statistical kind, buried in the archives of the War Office and other Departments is at present inaccessible. The Committee were advised by Lieutenant-General Sir J. Goodwin, that it could not, in fact, be obtained without a prohibitive amount of labour and expense and an expiration of time which would have postponed our Report until the Official History of the War is published; that publication which must be of supreme interest and importance will no doubt contain exhaustive information as to the casualties of the war.
‘Mental stress was by far the most potent cause of shell shock. The general effect of prolonged stress was much more important than the effect of specific incidents often emphasised. ‘Shell Shock’ due to emotional disturbance was vastly commoner than that due to commotional. There is evidence by those who saw much of these cases during the early stages that commotional disturbance had been distinguished by dullness and confusion rather than excitement. Tendon jerks diminished rather than increased, there was slight inequality of pupils and rupture of tympanum. In the later stages commotional disturbance could only be diagnosed where with history of explosion and in absence of visible lesions there were signs of undoubted organic nervous disease with or without emotional disturbance as well. Most cases of anxiety neurosis were wholly genuine to start with. Many remained so throughout, but some were consciously protracted and exaggerated later.
Asked whether he could distinguish genuine emotional neurosis from simulation or perhaps from mere cowardice, the witness said: ‘Frankly, I am not prepared to draw a distinction between cowardice and ‘shell-shock.’ Cowardice I take to mean action under the influence of fear, and the ordinary type of ‘shell-shock’ to my mind was chronic and persisting fear. I think the situation really is that the emotional mechanism of fear habitually stimulated, or intensely stimulated even on one occasion, can pass into a condition of over-action and that is practically what ‘shell shock’ is.’
- The term shell-shock should be eliminated from official nomenclature, the disorders hitherto included under this heading being designated by the recognised medical terms for such conditions. Abbreviations such as N.Y.D. Nervous or Mental, or N.Y.D.N., D.A.H., etc should be avoided, as they are liable to become catchwords, and so react unfavourably on the patients themselves and on others.
Classification of Casualties
- Concussion or commotion attended by loss of consciousness and evidence of organic lesion of the central nervous system or its adjacent organs (such as rupture of the membrane tympani) should be classified as a battle casualty.
- No case of psycho-neurosis or of mental breakdown, even when attributed to a shell explosion or the effect thereof, should be classified as a battle casualty any more than sickness or disease is so regarded.
- In all doubtful cases it is desirable to have the classification determined by a Board of expert Medical Officers after observation in a neurological hospital.
- Training – 1. Every possible means should be taken to promote morale, esprit de corps and a high standard of discipline.
- Training should be sufficiently prolonged to ensure that the soldier is not only physically fit and efficient, but also that he has had time to acquire such a standard of morale as will enable him to put the welfare of his unit before his own personal safety.
- Close observation should be made by officers, both regimental and medical, and by non-commissioned officers of the unit on individuals during the whole of their training, so that abnormalities from which mental or nervous instability may be inferred may not be overlooked. For this purpose there should be the frankest co-operation between regimental and medical officers.
- The study of character, so far as it is applicable to military life, is recommended for all officers with a view to teaching Man-Mastership.
- Special instruction should be given to Royal Army Medical Corps officers in the psycho-neurosis and psychoses as they occur in war; and selected officers should be encouraged to specialise in the study of these disorders.
(B) On Active Service – 1. The practice of withdrawal of officers and men showing incipient signs of nervous breakdown of over-fatigue for rest either in the battalion or divisional area should be officially recognised and systemised.
- So far as the military situation permits, tours of duty in the front line in stationary warfare should be short, especially in bad sectors. Adequate rest and organised recreation should be provided for units when out of the line.
- Monotony should be avoided by changing units, as circumstances permit, between fronts and sectors.
Leave home should be encouraged.
- The promotion of all measures making for good sanitation and the physical comfort of the men, both in the line and also in rest billets and base depots, should receive constant attention.
- Rest of mind and body is essential in all cases showing signs of incipient nervous breakdown, and when possible it should be given under conditions of security and comfort and freedom from all military duties.
- The fullest use should be made of Convalescent Depots for re-training and hardening men discharged from hospital. These units should invariably be pervaded by an atmosphere of complete cure.
The above recommendations, suitably modified to meet particular circumstances, should be applied to the other fighting services.
- In Forward Areas – No soldier should be allowed to think that loss of nervous or mental control provides an honourable avenue to escape from the battlefield, and every endeavour should be made to prevent slight cases leaving the battalion or divisional area, where treatment should be confined to provision of rest and comfort for those who need it and to heartening them for return to the front line.
- In Neurological Centres. – When cases are sufficiently severe to necessitate more scientific and elaborate treatment they should be sent to special Neurological Centres as near the front as possible, to be under the care of an expert in nervous disorders. No such case should, however, be so labelled on evacuation as to fix the idea of nervous breakdown in the patient’s mind.
- In Base Hospitals. – When evacuation to the base is necessary, cases should be treated in a separate hospital or in separate sections of a hospital, and not with the ordinary sick and wounded patients. Only in exceptional circumstances should cases be sent to the United Kingdom, as, for instance, men likely to be unfit for further service of any kind with the forces in the field. This policy should be widely known throughout the Force.