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Shell shock was a term used to describe the reaction of soldiers in World War I to the trauma of battle. During the War, the concept of shell-shock was ill-defined. Cases of "shell shock" could be interpreted as either a physical or psychological injury, or simply as a lack of moral fibre. While the term 'shell shock' is no longer used in either medical or military discourse, it has entered into popular imagination and memory, and often identified as the signature injury of the War.

In World War II and thereafter, diagnosis of "shell shock" was replaced by that of Combat stress reaction, a similar but not identical response to the trauma of warfare.

History

During the early stages of World War I, soldiers from the British Expeditionary Force began to report medical symptoms after combat, including tinnitus, amnesia, headache, dizziness, tremor, and hypersensitivity to noise. While these symptoms resembled those that would be expected after a physical wound to the brain, many of those reporting sick showed no signs of head wounds. The term "shell shock" came into use to reflect an assumed link between the symptoms and the effects of explosions from artillery shells. The term was first published in 1915, in an article in The Lancet by Charles Myers.

The number of shell shock cases grew during 1915 and 1916, but medical and psychological understanding of it remained confused. Some doctors held the view that it was a result of hidden physical damage to the brain, with the shock waves from bursting shells creating a cerebral lesion that caused the symptoms and could potentially prove fatal. Another explanation was that shell shock resulted from poisoning by the carbon monoxide formed by explosions.

At the same time, an alternative view developed describing shell shock as an emotional, rather than a physical, injury. Evidence for this point of view was provided by the fact that an increasing proportion of men suffering shell shock symptoms had not been exposed to artillery fire. Since the symptoms appeared in men who had no proximity to an exploding shell, the physical explanation was clearly unsatisfactory.

In spite of this evidence, the British Army continued to try to differentiate those whose symptoms followed explosive exposure from others. In 1915 The British Army in France was instructed that:

Shell-shock and shell concussion cases should have the letter 'W' prefixed to the report of the casualty, if it was due to the enemy; in that case the patient would be entitled to rank as 'wounded' and to wear on his arm a 'wound stripe'. If, however, the man’s breakdown did not follow a shell explosion, it was not thought to be ‘due to the enemy’, and he was to labelled 'Shell-shock' or 'S' (for sickness) and was not entitled to a wound stripe or a pension.

However, it often proved difficult to identify which cases were which, as the information on whether a casualty had been close to a shell explosion or not was rarely provided.

As the size of the British Expeditionary Force increased, and manpower became in shorter supply, the number of shell shock cases became a growing problem for the military authorities. Among the consequences of this were an increasing official preference for the psychological interpretation of shell shock, since if men were 'uninjured' it was easier to return them to the front; and also an increasing amount of time and effort devoted to understanding and treating shell shock symptoms.

By June 1917 all British cases of "Shell-shock" were evacuated to one of four dedicated psychatric centres which had been set up close to the Front, and were labelled as NYDN – Not Yet Diagnosed Nervous". "But, because of the Adjutant-General’s distrust of doctors, no patient could receive that specialist attention until Form AF 3436 had been sent off to the man’s unit and filled in by his commanding officer." This created significant delays but demonstrated that between 4-10% of Shell-shock W cases were "commotional" (due to physical causes) and the rest were "emotional".

Disciplinary responses

During the war, 266 British soldiers were executed for "Desertion", 18 for "Cowardice", 7 for "Quitting a post without authority", 5 for "Disobedience to a lawful command" and 2 for "Casting away arms", some of whom may have been victims of shell shock. Controversially, on 7 November 2006 the government of the United Kingdom gave them all a posthumous conditional pardon.

Proximity by circumstance

Because of the delays AF 3436 was producing, medical officers started keeping their men in their units. This was perhaps the practical beginning of the concept of proximity. Col. Rogers, RMO 4/Black Watch wrote,

You must send your emotional cases down the line. But when you get these emotional cases, unless they are very bad, if you have a hold of the men and they know you and you know them (and there is a good deal more in the man knowing you than in you knowing the man) … you are able to explain to him that there is really nothing wrong with him, give him a rest at the aid post if necessary and a day or two’s sleep, go up with him to the front line, and, when there, see him often, sit down beside him and talk to him about the war and look through his periscope and let the man see you are taking an interest in him.

Cultural references

Author Pat Barker explored the causes and effects of shell shock in her Regeneration Trilogy, basing many of her characters on real historical figures and drawing on the writings of the first world war poets and the army doctor W. H. R. Rivers.

See also

• Combat stress reaction
• Posttraumatic stress disorder

References

1. Jones, Fear and Wessely 2007, p.1641
2. Jones, Fear and Wessely 2007, p.1642
3. Jones, Fear and Wessely 2007, p.1642
4. ^ Shephard, Ben. A War of Nerves: Soldiers and Psychiatrists, 1914-1994. London, Jonathan Cape, 2000.
5. Jones, Fear and Wessely 2007, p.1642
6. Taylor-Whiffen, Peter (2002-03-01). "Shot at Dawn: Cowards, Traitors or Victims?".
7. "War Pardons receives Royal Assent". ShotAtDawn.org.uk. Archived from the original on 2006-12-06.

Sources

• Jones, E, Fear, N and Wessely, S. "Shell Shock and Mild Traumatic Brain Injury: A Historical Review". Am J Psychiatry 2007; 164:1641–1645
• Myers, C.S. "A contribution to the study of shell shock". Lancet, 1', 1915, pp.316-320
• Shephard, Ben. A War of Nerves: Soldiers and Psychiatrists, 1914-1994. London, Jonathan Cape, 2000.