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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.

Origin

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. By December 1914, as many as 10% of British officers and 4% of enlisted men were suffering from "nervous and mental shock".

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. Some 60-80% of shell shock cases displayed acute neurasthenia, while 10% displayed what would now be termed symptoms of conversion disorder, including mutism and fugue.

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.

Acute management of shell-shock

At first, shell-shock casualties were rapidly evacuated from the front line - in part because of fear of their unpredictable behaviour . 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. At the Battle of the Somme in 1916, as many as 40% of casualties were shell-shocked, resulting in concern about an epidemic of psychatric casualties, which could not be afforded in either military or financial terms.

Among the consequences of this were an increasing official preference for the psychological interpretation of shell shock, and a deliberate attempt to avoid the medicalisation of shell shock. If men were 'uninjured' it was easier to return them to the front to continue fighting. Another consequence was an increasing amount of time and effort devoted to understanding and treating shell shock symptoms.

By the Battle of Passchendaele, the British Army had developed methods to reduce shell-shock. A man who began to show shell-shock symptoms was best given a few days' rest by his local medical officer. 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.

If symptoms persisted after a few weeks at a local Casualty Clearing Station, which would normally be close enough to the front line to hear artillery fire, a casualty might be evacuated to one of four dedicated psychatric centres which had been set up further behind the lines, and were labelled as "NYDN – Not Yet Diagnosed Nervous" pending further investigation by medical specialists.

Even though the Battle of Passchendaele generally became a byword for horror, the number of cases of shell-shock were relatively few. 5,346 shell shock cases reached the Casualty Clearing Station, or roughly 1% of the British forces engaged. 3,963 (or just under 75%) of these men returned to active service without being referred to a hospital for specialist treatment. The number of shell shock cases reduced throughout the battle, and the epidemic of illness was ended.

During 1917, "shell shock" was entirely banned as a diagnosis in the British Army, and mentions of it were censored, even in medical journals.

Shell shock and cowardice

Some men suffering from shell shock were put on trial, and even executed, for military crimes including desertion and cowardice. While it was recognized that the stresses of war could cause men to break down, a lasting episode was likely to be seen as symptomatic of an underlying lack of character. For instance, in his testimony to the post-war Royal Commission examining shell-shock, Lord Gort said that shell-shock was a weakness and was not found in "good" units. The continued pressure to avoid the medicalisation of shell shock meant that it was not, in itself, an admissible defence.

Executions of soldiers in the British Army were not commonplace. While there were 240,000 Courts Martial and 3080 death sentences were handed down, but only in 346 cases was the sentence carried out. 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.

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. McLeod, 2004
3. McLeod, 2004
4. Jones, Fear and Wessely 2007, p.1642
5. Jones, Fear and Wessely 2007, p.1642
6. ^ Shephard, Ben. A War of Nerves: Soldiers and Psychiatrists, 1914-1994. London, Jonathan Cape, 2000.
7. Jones, Fear and Wessely 2007, p.1642
8. Mcleod, 2004
9. Mcleod, 2004
10. Jones, Fear and Wessely 2007, p.1642
11. McLeod, 2004
12. McLeod 2004
13. Wessely 2006, p443
14. Jones, Fear and Wessely 2007, p.1643
15. Wessely 2006, p442
16. Wessely 2006, p442
17. Wessely 2006, p440
18. Taylor-Whiffen, Peter (2002-03-01). "Shot at Dawn: Cowards, Traitors or Victims?".
19. "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
• Mcleod, A.D. "Shell shock, Gordon Holmes and the Great War" J R Soc Med. 2004 February; 97(2): 86–89.
• 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.