As is so often the case in times of conflict, the Great War saw rapid developments not only in technology and tactics but also in medical research, a plethora of medical papers being published encompassing just about every condition it was conceived that a soldier might encounter.
Many of these papers make fascinating reading (really – they do!), particularly from a viewpoint of one hundred years, and one such, entitled…
…details some cases that, as examples of the issues confronting both soldiers and clinicians, I suggest were far from uncommon. I am in no way attempting any kind of detailed study of shell shock here, good grief no, just presenting an insight into the diagnoses of some of the first cases studied, and as such we shall begin with a little background information.
In the years between the Boer War and the outbreak of the Great War, there was a general acknowledgement in military circles that in any large-scale European war there would be more nervous casualties due to the potential scale of the conflict and the likely increase in the destructive power of new weaponry. Fair enough.
Faces of the Russo-Japanese War. Medical witnesses among the many foreign observers (previous shot) present during the conflict between Japan & Russia in Korea & Manchuria between 1904 & 1905 noted that ‘neurasthenia and hysterical conditions were numerous and severe’ among both officers and men exposed to massed artillery fire and heavy fighting.
At the time men suffering from neurasthenia or hysteria were generally sent to a general field hospital (Russian triage & first aid post pictured above), prescribed rest and a special diet, and often recovery would occur within a few days. All well and good, except it began to be noticed that recovered men would often, indeed usually, quickly relapse when returned to the heat of battle.
In the years preceding the outbreak of war in 1914, it was generally believed that this type of reaction could only be explained by the fact that the rapid mobilization of the warring armies had brought men who were inherently neuropathic, and thus unsuited to military life, and that the rigours of warfare had merely triggered an innate defect. In 1912 the British doctor A. G. Kay put forward the view that during future, longer, conflicts, physical exhaustion, hunger, thirst and lack of sleep would lead to nervous collapse among professional soldiers, and the mobilization of large numbers of reservists and civilians would inevitably lead to many other cases of a more severe nature.
Nonetheless, during the early months of the Great War nervous illness was not seen as a serious problem when compared to diseases like trench foot, dysentery and the various fevers that were afflicting the troops. The first five months of the war saw 56,301 British hospital admissions for battlefield wounds in France & Belgium, and 74,615 for sickness or injury. Alongside these casualties there were just 2,414 in total for diseases of the nervous system (a term covering a multitude of illnesses), mental illness, and DAH (which stood for ‘disordered action of heart’). Trench foot accounted for 6,455 hospital admissions (4.9%), and various fevers including malaria accounted for 9,372 hospital admissions, about 7%. Thus the figures gave little reason for the military medical authorities to single out nervous illness as requiring special attention, the figures more suggesting that nervous illness did not pose a serious threat to the efficiency of the army, and was nothing more than part of the general daily wastage on the Western Front.
The Canadians (above) had spent the winter of 1915 enduring the appalling conditions to the south of Ieper (Ypres), their trenches often waterlogged, the high water table making any kind of improvement in the conditions a hopeless task. Between March & November 1915, around 6% of the 8,000 non-fatal casualties suffered by the Canadians were documented as cases of shell shock, neurasthenia or hysteria; over the winter months, between December 1915 and the end of March 1916, this percentage more than doubled despite Canadian non-fatal casualties of around a quarter – just over 2,000 – of the previous nine months*.
*these figures take no account of men temporarily affected by nervous illness, who would receive a course of treatment and quite possibly then be returned to their units.
During the spring of 1916 cases of nervous and mental illness among the men of the Canadian Corps fighting at St. Eloi & Mount Sorrel increased significantly. Caused in part due to the static fighting and intensive artillery bombardments, but also by the changing nature of trench warfare, the understanding by the men involved of the horrors that they and their comrades faced, and the subsequent de-stigmatizing of nervous breakdowns, by the summer of 1916 a wave of nervous breakdowns was sweeping through the BEF, as rates of mental and nervous illness shot up among British & ANZAC troops, rising more than 300% as the epidemic peaked during the Battle of the Somme. And so, in the summer of 1916, the first specialised shell shock centres were set up on the Somme, catering for both men suffering from nervous disorders and gas cases, mainly because the military authorities at this time still considered both to be injuries open to abuse. Faked gas cases were not difficult to establish, but cases of shell shock proved far more complicated, prompting armies’ medical corps to seek out doctors with expertise in nervous illness to oversee diagnosis and subsequent treatment.
In January 1917 a centre was opened for the treatment of cases of ‘shell-shock’ at No 4 Stationary Hospital at Arques, near St. Omer in France, about twenty miles south west of Poperinge (the photo actually shows 7th Canadian Stationary Hospital, also at Arques, in August 1917). The centre remained open for nine months, during which time 4,700 patients passed through its doors, the records of which formed the material on which this study of what was referred to as war-neurasthenia – defined as a state of fatigue of the central nervous system, without organic change, manifested by asthenia, loss of physical and emotional control and disturbance of visceral functions – was based. The writer explains the use of the term as follows; “If the popular word ‘nerve’ correctly expresses the capacity to resist emotional strain, then I think the word neurasthenia, ‘weakness of nerve’, is an accurate one for the condition found when that capacity is exhausted. But neurasthenia has other associations in most people’s minds, and is frequently used in a derogatory sense, and if I have any point to make it is that there is nothing derogatory in neurasthenia honestly acquired on service. I have therefore prefixed the word ‘war’ as a qualification, since ‘polemo-neurasthenia’ would merely be precious, and would add yet another title to a list already too long.’
In the early part of 1917, when patients were less numerous, a clinical study was made of the first 1,300 of these patients by physicians deemed experienced enough in diseases of the nervous system to make accurate diagnoses between organic and functional conditions. The history of each case admitted – service history, work and leisure activities – would be first ascertained, along with other attributes such as personal ‘nerve’ (nerve here in a slang sense, as the study points out, as in working at heights), previous strain (wounds or shock and after effects), shock (being blown up or buried, or ‘gradually oncoming failure’), symptoms (pain, appetite, digestion, respiration, sleep, etc), and physical signs (integrity of the motor and co-ordinating systems).
One problem was that all the patients had passed through field ambulance and casualty clearing stations before admission, and thus all cases were seen at least one, but generally two or even more days after the onset of symptoms, and so no experience could be gained of the immediate conditions produced by shock, but cases were, as a rule, of a recent onset.
Once diagnosed, the objective of treatment was to return fit patients to duty, preferably within a month, with all cases still unfit at that time being transferred to a base hospital; this was a practical necessity from a space point of view, if nothing else. Many of these severe cases would be marked as ‘NYD, N’ (not yet diagnosed, nervous) and could be divided into two general categories; those with gradually acquired nervous breakdowns, not specific to any one incident, and known as Chronic War-Neurasthenia, and those with rapidly induced symptoms, often caused by a specific incident such as being blown up or buried, called Acute War-Neurasthenia, but which at the time became known as Shellshock (‘a most ill-advised but now established term’ – 1917).
Of the 1,300 patients studied, 612 were cases of acute neurasthenia, 314 of chronic or established neurasthenia, and 354 were cases that were complicated with some other form of disease (frequently bronchitis, rheumatism or fever) requiring transfer to different departments or hospitals.
Now, some of what I have just written is précised from the original paper (a mere forty three pages) which, should you so wish, you can ask me nicely and I will arrange to send you a copy – I can see my email inbox bulging at some future point after that offer. Otherwise, we shall take a look at some of the cases mentioned, although just before we do, I should mention that the hospital photographs so far included in this post are all unpublished and were chosen from a private photograph album showing men recovering back in Blighty. There is no suggestion that any of these wounded men were in any way affected by shell shock, although that could have been the case – they are shown to represent, and to remind.
The images that accompany the cases that follow are all stills, some probably familiar, from contemporary films, and these men are all shell shock victims (some of whom, it should be pointed out, were, we are told, rapidly ‘cured’ which, to be fair, is rather the point of the films), most taken on the south coast at The Royal Victoria Hospital (above – often known simply as Netley Hospital), near Southampton in Hampshire.
Once the world’s longest building,…
…the whole thing was sadly demolished in 1966 – all the outbuildings behind seen in the first aerial shot following suit in 1978 – except for the chapel in the very centre of the building (above), which I believe you can visit to this day. I really must do so.
While we are talking Netley, not so long ago, Duncan the Elder, my sometime cohort when visiting Surrey churchyards, presented me with this little box, which has since gone down extremely well on a couple of Facebook pages dedicated to Netley. Anyway, on to the cases mentioned in the study:
Gradual onset (chronic type). Case 1. – Sergeant H., aged 22; two years in France. Previous nerve good, played football for battalion, boxer: has done very well, done everything, lasted through Somme, wounded, promoted Sergeant, D.C.M.. Suffering from general strain, no special explosion. For three months bad sleep, loss of concentration, worrying, losing flesh, irritable, avoids society, nothing to say, emotional, loss of self-confidence, formerly fond of risk. Case 2. – Sapper L., aged 32; two years in France. Nervous in any danger, no games or sport. Twice in blown-up mine, much frightened but not injured. Since then nerve worse. Kept back at headquarters. No recent shock; two weeks ago returned to line, under heavy bombardment, could not stand it.
Case 3. – Private M., aged 22; one year nine months in France. Nervous at night, otherwise nerve fair. Good in France, wound fifteen months ago, nerve unaffected, lasted well till recently, through the Somme, four times ‘over the top’. Two weeks ago heavy shelling, shell dropped in next bay, alarmed, not knocked down or unconscious. Since then has lost control in heavy shelling, no true shock. Recently four days under fire, became shaky, running about trench, not knowing where to go. Case 4. – Lance-Corporal K., aged 21; one year six months in France. Nerve never good at home, but good in France for nine months. One year ago ‘shell shock’, away four months. Served as pioneer through winter; all right till one month ago when battalion went into line, served one day, became excessively nervous, trembling in any shell fire, with praecordial pain.
Case 5. – Sergeant S., aged 28; one year five months in France. Nerve good, footballer, regular soldier. Out November 1914, wounded Neuve Chapelle; rejoined July 1915; shocks Somme, 1916; rejoined April 1917; nerve good till Somme, since then deteriorated. No good now, cannot stand any shelling. Five days ago, some hours’ bombardment, not very heavy, not laid out by any shell, taken to aid-post. Case 6. – Private McG., aged 31; one year two months in France. Previous nerve good, boxer, swimmer; good in France at first, no wounds; well till five months ago when next bay was blown in, stunned, unable to carry on; one month at transport, returned to line, sent down again three times. Shaky in all excitement, at first only under bombardment, now on the least provocation.
Case 7. – Gunner P., aged 34; one year one month in France. Previous nerve good, footballer, runner, cyclist; nerve good in France, no wounds or shock; deteriorating since the Somme, mate killed in dug-out he had just left. Six days ago battery shelled out, thrown across trench, dazed but not unconscious, could not carry on. Case 8. – Pioneer L., aged 20; one year in France. Nerve good at first; nine months ago blown out of bed, billet destroyed, mate killed. Nervous in Somme, some shock, but did not leave unit, no recollection of what happened for a fortnight, record of some unusual behaviour: permanent light duty since. Shocked again later, memory imperfect. No shock this time. Reported sick frequently with pains in head, weakness in legs, tingling limbs and inability to open fingers.
Case 9. – Private Le G., aged 18; ten months in France. Previous nerve never very good, but good in France; buried six months ago, away six weeks. Domestic worry, father, mother and brother all killed, nerve not good since. Sent out of the line two or three times. No recent shock, has several times fainted on the march. Case 10. – Private K., aged 21; nine months in France. Nerve poor at home, better than he expected in France. Gradual deterioration, no wounds or shock.
Case 11. – Sergeant M., aged 26; six months in France. Gradual deterioration, nerve poor after shelling but carried on at first; later sent down by officer for a month, returned to line, tremulous under fire, twice sent down. Case 12. – Gunner M., aged 23; three months in France. Nerve poor. No good on guns, upset by our own fire; no shock, reported sick with nerves and loss of sleep. These cases illustrate well the different lasting power of different men, from fine soldiers like No. 1, to such ‘military misfits’ as No. 12, and the varying period which they take to arrive at the same conditions.
Sudden onset (acute type). Case 13. – Knocked out by heavy shell, unconscious probably an hour. Shaky, pains in head, emotional, laughing and crying. Case 14. – Buried, not unconscious, lost self-control; emotional, shaky, unable to carry on. Case 15. – In gun-pit, direct hit on gun; thrown about ten feet on to ammunition, stunned a few minutes, able to get out alone, shaky, not crying, very frightened.
Case 16. – Partly buried by trench-mortar shell, knocked out, could not carry on, trembling, not emotional. Case 17. – Asleep in dug-out, knocked over, not unconscious, could walk down, became unsteady, shaky, crying. Case 18. – In dug-out which was wrecked, unconscious half an hour, could walk down with help, unable to carry on, shaky, head aching, not emotional.
Case 19. – Knocked out by trench-mortar shell, unconscious more than an hour; later, mute for three days, stammering two days. Case 20. – Shell entered dug-out, unconscious an hour, shaky, walked down with help, lost speech, unable to carry on, emotional.
Case 21. – Caught up in wire, blown up, unconscious an hour, could not stand, giddy, dazed, emotional. Case 22. – Knocked out, buried, stunned a short time, dazed, imperfect memory, shaky and crying. Case 23. – Buried, stunned a few minutes, deaf, ringing in head, shaky, not emotional, could speak, unable to carry on, could walk down. Case 24. – Knocked out, unconscious a short time, buried, could not walk, trembling and emotional. The similarity of these histories is remarkable, and compared with those of the cases of the chronic type, shows that the only differences between the two are due to the rate of their onset, whether suddenly or gradually induced. Out of 1,200 cases, 822 were of rapid and 378 of gradual onset, roughly 70 per cent, and 30 per cent, rather more than 2 to 1. The exciting causes of war-neurasthenia then are physical fatigue, physical violence, such as being blown up and buried by shell explosions, and emotional strain such as continued alarm, the loss of comrades, other distressing sights and sounds, along with the continuous effort of self-control under impulses to seek safety.
Case 26. – Private G. could neither hear nor read, but was able to eat and to dress himself. Faradization with wire brush, strong current not felt at all for several minutes, but afterwards it became painful and he cried a little, and said, ‘ It hurts’. Flinched at sound of a loud bell. Copied movements. Next day consciousness returned spontaneously, he could hear but not speak; speech was restored in a few minutes, but with a stammer, which improved but was never quite lost while in hospital. His memory was quite clear up to the time of his shock.
Case 27. – Lance-Corporal H., stated to have been alternately laughing and violent at the regimental aid-post. On admission he could understand signs a little, but could neither hear nor read. Roused a little by faradization, and induced to stand. Next day there was some improvement: he could walk, but would walk out of the tent half-dressed; he flinched at the bell. A few hours later consciousness returned; he could hear one’s voice at about four inches, but could not speak; speech was restored in about an hour, but was very slow and hesitating. He was quite intelligent, but had persistent difficulty in finding the right word, either spoken or written; this was probably partly because, though an Englishman, he had lived chiefly in France, and did not know English very well.
Case 28. – Rifleman N., admitted unconscious, gesticulating wildly and talking gibberish. Under strong faradization recovered consciousness gradually, was induced to stand, answered his name, gave name and unit, and wrote his address, reversing several letters. Case 29. – Deafness, recovered. Case 30. – Deaf-mute, cured at once. Case 31. – Deaf-mute, induced to speak, hearing recovered in a week.
Case 32. – Hearing lost, gradually recovered. Case 33. – First day, could not hear own voice; second day, could hear noises but not distinguish sounds; third day, could hear fairly. This patient relapsed. Case 34. – Deaf-mute, speech restored, and with it some hearing, but this was completely lost later, although he flinched on shouting down the stethoscope. There was considerable organic damage to the drum.
Case 34. – An officer aged 41, three months in Ypres Salient, nerve unaffected. Eight days before admission was knocked out by a shell, unconscious a short time, then carried on for twenty-four hours. Suffered from severe headache and sense of numbness over occiput, difficulty in walking, great weakness and loss of control of legs, walked as if drunk. Passed no urine for two days, bowels not open for four days. On examination: Pupils sluggish but reacted to light. Transient squint. Great incoordination of hands of sensory type, missed his nose by several inches with the eyes shut, incoordination of legs, unsteadiness in standing much increased by closing eyes, gait incoordinate; sphincters, delay. Deep reflexes, knee-jerks increased, ankle-jerk present. The combination of sensory incoordination of arms and legs, transient squint, and delayed relaxation of sphincters, occurring in a man of 41 after prolonged exposure to severe campaigning is strongly suggestive of tabes, which was my diagnosis, but all symptoms cleared up after two or three days’ rest. In war-neurasthenia it is generally high, but I make no claim to a systematic study of pulse rates. The following were noted:— Case 35. – Best, 128 ; short exercise, 168. Case 36. – Exercise walking in tent, perhaps 10 yards. ; after five minutes’ rest, 130. Cases of pulse rate of 120 while merely attending an ordinary sick parade were very common.
Memory is often imperfect, though to a very variable degree – the following two cases showed positive amnesia. Case 37. – Lance-Corporal D., aged 20. Admitted March 14, 1917. Appears to have no memory of events since playing cricket in August 1914. Has heard of Kitchener’s Army, does not know of Lord Kitchener’s death. Does not remember joining the Army. Surprised to hear he is in France. March 15, 1917. – Remembers coming to France and being ill on board ship: the bombardment of Lowestoft; his Captain; the Esplanade Hotel; his mate being killed by an explosion; periscope, and seeing barbed wire. March 19, 1917. – Remembers much more: Calais; farm-billets; marching order; dug-out; several men there, bombs falling and a man killed; had to bind up other men. March 23, 1917. – Remembers enlisting September 1914, 1/5th Beds., not taken to Gallipoli on account of nerves. Trained at Newmarket, Southwold and Holtham. Came to France January 1917, battalion seems to have been in rest till lately. Remembers going down communication trench, resting in dugout till dark, and then going to bombing post in the dark; remembers bombs falling and some men being injured. Memory for immediate past very bad; does not remember dinner to-day, and only recalls these events during conversation, otherwise mind is blank. Evacuated to base hospital.
Case 38. – Private N. Admitted March 13, 1917, semi-stuporose; said to have been unconscious for about a fortnight; no recollection of past events. March 15, 1917. – still only partly conscious, obeyed instructions in unintelligent manner, but improved much in intelligence during conversation. Remembers saying good-bye to his wife and child, but no recent memories. March 19, 1917.—remembers seeing his brother-in-law in uniform, who wanted him to join up, but he would not; also being a collier employed in an Admiralty pit, and so in a starred occupation, he could not do so: no knowledge of France. This man showed no further improvement before evacuation to a base hospital. These cases are exceptional; as a rule amnesia does not amount to more than a blankness of mind about the occasion of the shock, and occasional lapses of memory, closely associated with inattention and lack of power to concentrate.
One further, generic, case on the left, and, right, symptoms chart with percentages for the men studied.
At the risk of repeating myself, this post has been nothing more than an insight into the diagnosis of war-neurasthenia through a single, early, study,…
…but it does, I hope, shed a little light on the predicament facing both sufferers and carers alike, as a long and bloody war, unlike any ever seen before, not only began to take its toll on the mental health of the men in the front line, but was, for the first time, perceived to be doing so.
Recovering soldiers raise a glass, although quite why they invited the bloke in the fedora at the far end of the table (see inset) is anyone’s guess……