Was the discovery of ‘shell shock’ during the First World War the seminal event of medical history?
The First World War has been argued by many historians to have been the ‘seminal catastrophe of the 20th century’ and in many respects this seemingly hyperbolic claim has a firm basis in historical reality. Although there had been an assortment of conflicts between the great European powers in relatively secluded locations around the continent and around the world, such as the Crimean War and the Boer Wars, not since the era of the Napoleonic Wars had the nations of Europe fought in a conflict of such scale. What truly made the First World War a seminal event of the 20th century is that it was, as historians have rightly pointed out, the first industrial war. It was a conflict that introduced a plethora of new weapons, products of the century of industrialisation that preceded it, to the armies of the world: submarines, machine guns, chemical weapons, tanks, airplanes and explosives of high calibre that could be delivered without warning from afar. This subsequently meant that as the weapons of war increased in power the potential scale of human casualties likewise increased in tandem as did the measures armies took to protect and mend their rapidly depleting fighting forces. To say that a development is seminal means that it must have had a profound and influencing effect on events that followed it. While the development of high power artillery was a seminal development for warfare one result of the same was the emergence of shell shock as a neurological condition that changed the nature of medical practice in armed forces. The First World War saw the maturation of psychiatry and its full and professional implementation into the fabric of the medical corps of armed forces following the conflict. Therefore, therefore this essay will argue that the First World War was the seminal event of medical history and specifically for psychology and psychiatry. It will achieve this by using a collection of primary sources in the form of doctor and patient records as well as secondary source historiographical works when further contextualisation is necessary.
To begin explaining why the discovery of shell shock was a seminal event for medical history it is important to contextualise the state of the British army’s medical capacity before and at the onset of the First World War. Although the British army had employed medical personnel in varying capacities throughout the centuries they were often commissioned doctors who simply came into the service of the nation during times of conflict. The exceptions to this were the medical officers (MO) or regimental surgeons who were recruited at young ages for a lifelong career with the army. These MOs’ were not recognised as officers of official military rank and were even viewed as outsiders in the very army they served in, receiving a comparatively low pay grade and little recognition.  The solution that the British army formulated was the foundation of an official medical branch of the armed forces that would afford them the same standing and remuneration as enlisted officers of other branches, the Royal Army Medical Corps (RAMC). When the Second Boer War broke out in 1899 the RAMC was severely understaffed, due in part to their known reputation for maltreatment of enlisted doctors, so the fledgling RAMC was made to recruit civilian doctors once again to make up for the shortage. While the RAMC would learn from the lessons of its inaugural conflict it would be found completely wanting once again when the First World War broke out, specifically when the Battle of the Somme began in 1916. This was because they were simply not staffed, let alone equipped, for purpose in the face of a scale of conflict that had escalated immeasurably from their previous experience in the Second Boer War. Historians like Richard Gabriel have spoken up to the defence of the RAMC during the initial phases of the conflict by emphasising that ‘war had become an activity that had surpassed the ability of human beings to endure it’. It would therefore be unjust to condemn the RAMC for being unfit for purpose at the onset of the war as it had precious little medical historical experience to draw upon having been formed relatively recently, the British Expeditionary Force (BEF) was caught completely off guard in the face of such overwhelming firepower inflicting massive casualties.
While the surgeons of the RAMC struggled to keep on top of the stream of injuries induced by shrapnel from bullets, grenades or artillery bombardment one repeating ailment was causing both MOs’ and commissioned civilian doctors a great deal of confusion. The men who came to the regimental hospitals displayed little to no superficial injuries but were clearly not combat fit; suffering from all manner of symptoms ranging from loss of speech, insomnia, chronic fatigue, impaired sight and hearing to outright hysteria. By modern medical knowledge these symptoms would instantly be recognised as post-traumatic stress disorder (PTSD) but the colloquial term surgeons and soldiers alike adopted for what they were trying to comprehend was “shell shock”. An official report on the medical statistics of the war published in 1931 claimed that ten percent of all British combat casualties were found to have had or still have a variation of shell shock. Because RAMC doctors saw shell shock being characterized by a wide range of common symptoms, they formulated several etiological explanations. Initially, compression and decompression on the body from a soldier being nearby an exploding artillery shell were thought to be the cause. It was also speculated that the disorder resulted from damage to the central nervous system from carbon monoxide released by the explosion of the same. The introduction and use of chemical weapons was also suspected to have played a role. Ultimately, shell shock was formulated as an organic problem even though the pathology remained a complete mystery.
Efforts to reach a clinical consensus on the new condition began soon enough. Research conducted in 1915 by Dr. Charles Myers, a consultant psychologist to the BEF, led to a new hypothesis. Based on his observations he presented to the Lancet medical journal Dr Myers found that the increasing and consistent stress of trench warfare led to the nervous breakdown of soldiers. Myers suggested a psychological explanation he called ‘traumatic neuroses’. Myers findings were supported by the similar findings of a commissioned surgeon, Dr. Harold Wiltshire. Wiltshire likewise published an article in the Lancet where he claimed to disprove the ongoing belief that shell shock was caused by the physical effects of artillery shells. His evidence was that he observed one-hundred and fifty shell-shocked soldiers who had been nowhere near an explosion yet had ‘traumatic neurotic symptoms’ while those that had been near an explosion exhibited little to none of the symptoms. One psychologist, Dr. Peter Cooper even suggested hypnosis as a form of treatment for shell-shocked soldiers. Myers and Wiltshire’s hypothesis was collaborated by the colonel-commandant of the RAMC, William Macpherson who wrote in a post-war memoir that ‘the artillery preparation of the attacking force called for an artillery reply from the opposing side. This duel frequently lasted for several hours or days, and during this period the nerves of all were kept on edge. Little by little the men became worn down from this such experience’. This psychological explanation was favoured over the alternative of a neurological explanation because it offered the BEF an open opportunity to return shell-shocked soldiers to active duty. Since the BEF was fast running short of fighting men any excuse that enabled officers to return soldiers to the front line was considered attractive.
Medical historians tend to favour patient dialogues and like to focus on doctor-patient interactions and assess information one can discern but the case study of shell shock demonstrates the merits of assessing the interaction between doctors themselves. The professional make-up of the RAMC at this point in its history demonstrates what can happen when medical professionals from vastly differing backgrounds are made to work together, or in cases like this one against each other. This study has already established that the RAMC had been made to recruit civilian doctors out of necessity, partially through the relative youth of its organisation and partially through necessity for the war effort. However, accounts from military and civilian doctors demonstrate that their working relations with each other were seldom civil. Two accounts that provide evidence of this disconnect between civilian doctors, military doctors and military officers comes from the work of medical historian Peter Leese. The two figures Leese depicts are those of Lieutenant Kirkwood and Captain Kaye. MO Kirkwood was ordered by a senior officer to assess the capability of his battalion to launch an incursion into enemy territory but upon seeing his men Kirkwood was left with no doubt that because of prolonged expose to combat stress they had all succumbed to shell shock. Kirkwood’s superior officer, General Hubert Gough, stripped Kirkwood of his rank and dismissed him from the RAMC following this tirade: ‘It is inconceivable how men, who pledged themselves to fight and uphold the honour of their country, could degrade themselves in such a manner, and show an utter want of manly spirit and courage which, at least, is expected of every soldier and Briton. The conduct of Lieutenant Kirkwood RAMC shows him to be totally unfit to hold a commission in the army’. Captain Kaye’s account is one more directed at the ‘antiquated attitudes’ of the RAMC and draws a lot of comparisons with comments historians would make decades after his passing. Kaye’s criticism is levied at the enlisted officers of the RAMC and the BEF in general, specifically targeting their stubbornness and resistance to the professional input of civilian doctors who had joined the RAMC when duty called. As historian Fiona Reid explains, although psychological explanations for shell shock developed during the war large swathes of the RAMC and military elite remained hostile to any changes to long-standing ideals. Up until the end of the First World War the RAMC, under the control of doctors and officers who were essentially laymen dictating to proven professionals, would operate under its previously infamous and now deposed of mantra of ‘NBR: No Bloody Research’. In the eyes of the military elite coming under pressure would turn raw recruits, young boys, into men who would be worthy Britons. The entire state of inertia from the RAMC during this period is best summarised by a symposium article which stated ‘the British army struggled to define shell shock in the same manner it struggled to define what it itself should do to combat it, it failed to produce a clear understanding of what it constituted and failed produce a coherent management plan’.
The aforementioned drive to seemingly uphold values of masculinity has prompted gender historians to become involved in the debate on the topic of shell shock with the belief that it ‘threatened the entire construction of madness as a feminine malady. It can be seen as the body language of a masculine complaint due to the heightened code of masculinity that dominated in wartime’. Another argument from a similar perspective claims that ‘war was the supreme test of manliness, and those who were the victims of shell shock had failed this test. These late 19th century notions went into constructing the societal view of shell shock, transforming it from a battlefield disease to a social indicator’. While the arguments presented here from a perspective have some potential basis in truth the more likely reason behind the military elite acting in the manner they did was more due to fearing a potential breakdown of military discipline. This is the view put forward by other historians who draw attention to the widespread belief that civilian doctors recruited into the RAMC were used by the military to ‘rubber stamp disciplinary decisions’ and that neurologists in particular were called upon to sit on court martial hearings for accusations of cowardice and desertion. This is a view further supported by military historians claiming that the problem was that the traditional stance of the military establishment, one that proved notoriously difficult to dislodge, was to consider psychiatric disorders as disciplinary issues rather than medical issues as medical historians proved them to be.
These sources from civilian doctors, military doctors and the military elite they both served demonstrate that all three parties held a fractious working relationship at best with civilian doctors exasperated with the ‘dregs of medical schools’ they had to work with, military doctors being resentful for civilian doctors bringing foreign concepts such as psychiatry into the RAMC and the military elite seeking results but refusing to not recognise a psychology issue instead of a disciplinary one. The aim of this study is to prove that the First World War was a seminal event for medical history and the final proof of such, for this section of the argument, comes in the form of the post-war Report of the War Office Committee. Published in 1922 this is a document that has generated the most historiographical debate as to the purposes and circumstances surrounding its establishment and publication. Medical historians point to the very specific mention in the report that the military must introduce more stringent recruitment criteria and that ‘only men physically and organically sound should be enlisted’ and that ‘thorough psychiatric tests should be performed on recruits’ as the British military recognising the necessity for psychiatry being an official branch of the RAMC. Collaborating this argument and indicating that the lessons of the First World War were learned is another primary source, appearing over a decade later, in the form of the 1936 medical manual issued to the BEF by Lieutenant-Colonel Nichols where he writes, ‘there is a divergence of opinion, chiefly based on experience during the Great War as to the likelihood or not of the occurrence of a large number of patients, or soldiers, who are suffering from neuroses in various forms. These may occur after intensive air raids or from active hostilities. Care must be taken during recruitment to ensure that predispositions do not provoke neuroses to emerge in times of war.’ The counter argument comes from historians who instead point to the sixty-five thousand ex-servicemen still drawing disability pensions for ‘neurasthenia’, nine-thousand of which were at the date of publication undergoing hospital treatment, implying that the publication is either a vindication of the claimants or otherwise a means of drawing a line under the entire ordeal. British society remained hostile to the idea of apparently mental defections not being hereditary and therefore capable of befalling any individual. The contemporary reaction to the report from the professional medical community seemed to agree with the former belief as a symposium article in the British Medical Journal which stated ‘whatever may have been the immediate motives that led the government to institute the enquiry, there can be no doubt that the most influential was the fact that a feeling of dissatisfaction had been expressed in certain quarters with regards to the treatment of mental disorders amongst ex-servicemen where the disorder was caused by shell shock’. The fact that this article is both anonymous and a symposium article leads one to the suspicion that it was composed by a group of enlisted civilian doctors and psychiatrists who were dissatisfied with their experience with the RAMC. The collective experience of doctors in the First World War proved to a seminal event for the history of medicine and for the history of psychiatry as it brought what was previously a civilian field of work and medicine into the fold of the military and gave it a practical usage in service to the nation.
Much of this study has been focussed on the perspective of the doctor, of the military and upon historical theory in relation to the topic at large but this final section will delve into a poignant area that completes the argument of this study. Literary works from the poets and storytellers of the First World War are practically mandatory reading for any British child in school and this alone is indicative of their cultural impact and legacy. The authors of these timeless classics were soldiers, but they were also patients. The censoring of wartime correspondence between soldiers and the home front was well known and has been well documented by a plethora of historians. The use of patient dialogues in lieu of medical data is one of the methodologies employed by medical historians and in the case of the First World War it is a methodology that works exceptionally well for the conflict produced some of the most evocative works of literature history has produced, from the likes of Wilfred Owen, Siegfried Sassoon and Alan Herbert. Historian Jay Winter makes a very good point when he writes that ‘the literary works of Owen and Sassoon have lasted. They are part of the history of the condition [shell shock] because they have informed later generations what it was. Individual memories fade away, but cultural representation endures’. To add an addendum to Winter’s argument: the fact that Owen, Sassoon and Herbert were able to retain their dialogues until they returned to Britain, where they would not be at the mercy of an army censor, to tell their stories is an astounding achievement and their contribution not only to the cultural legacy of Britain but to the understanding of the psychiatric condition that is shell shock.
Wilfred Owen is often attributed with the most striking poetry to have come out of the First World War but for the purposes of this study his most suitable poem is Mental Cases. The title of the poem itself is a direct reference to the derogatory label bestowed to shell shock victims and the prose aims to shock the reader as it describes in stark detail the physical effects a psychological breakdown has on a young soldier, ‘snatching after us who smote them brother; pawing us who dealt them war and madness’. Owen wrote this, arguably his darkest poem, while admitted to the Craiglockheart Hydropathic Hospital on account of shell shock and from this context it becomes easier to understand not only how he himself could have written a personal patient dialogue but also how he could have looked at his fellow patients and used their visible suffering as additional inspiration. Another patient of the Craiglockheart Hospital and a man who came to know Owen albeit briefly was Siegfried Sassoon. Sassoon likewise has a number of poems to his name but his most striking work on the subject of shell shock is actually in the form of a semi-autobiographical novel. Sherston’s Progress was written long after the war in 1936 but nevertheless says a great deal about the condition. Sassoon was inspired to write Sherston’s Progress following his tenure at Craiglockheart but specifically by the inspirational and innovative therapy and treatment he received from the psychiatrist William Halse Rivers who appears as a main character in the story. The most striking passage from the book depicts a ward of shell-shocked men at night: ‘One became conscious that the place was full of men whose slumbers were morbid and terrifying – men uttering uneasily or suddenly crying out in their sleep. Around me was that underworld of dreams haunted by submerged memories of warfare’. Other authors like Alan Herbert had similar successes in communicating their experiences, Herbert depicting the court martial trial of a soldier accused of cowardice but who in actuality ‘lost his nerve’ and was subsequently executed by firing squad; shedding light on an all-too-common eventuality for many of the court martial cases pertaining to shell-shocked soldiers. The works of these writers are as much a part of literary and cultural history as they are medical history. Regardless of whether they are poems, stories or testimonies these sources demonstrate that soldier-patient dialogues are voices that are very difficult to lose as subsequent generations past on the histories of those who came before.
Questions remain over whether shell shock, or traumatic neuroses was necessarily a product of the First World War or whether the size and scale of the conflict made it the largest example until that point in time. Traumatic neuroses brought on by exposure to prolonged warfare was not necessarily an innovation exclusively of the First World War as one could make a sound argument that the American Civil War was the first industrialised war with the means to precipitate death and destruction on a large scale. However, given the relatively larger scale of the First World War and the number of combatants that fought it this study concludes that the First World War was the seminal event for medical history because it accelerated innovations both in the practice of medicine as a means of prevention and in the way it enabled new forms of doctor-patient dialogues to emerge and survive in the cultural consciousness of nations. In the same vein that the First World War itself was the seminal event for military technology and the weapons of war which brought about the modern concept of shell shock as a psychiatric disorder. Since its discovery and subsequent diffusion shell shock has become an iconic symbol of the human cost of the First World War and has become a cultural landmark for British society. Primary source accounts from civilian and military doctors detail how the psychiatric discipline was gradually, after overcoming institutional conservatism, incorporated into the fabric of the military tapestry where it could serve a practical purpose and gain recognition for its merits on its own terms
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Watson, Alexander. Enduring the Great War: Combat, Morale and Collapse in the German and British Armies, 1914-1918 (Cambridge, 2008).
Wiltshire, Harold. ‘A Contribution to the Etiology of Shell Shock’, Lancet (June, 1916).
 George Kennan, The Decline of Bismarck’s European Order: Franco-Russian Relations, 1914-1917 (Princeton, 1979), p.3.
 Juan Fernandez, ‘Messianic Times: The Great War as a Trigger of World History’ in Alexios Alecou (ed), Acceleration of History: War, Conflict and Politics (Maryland, 2016), p.79.
 Ben Shepherd, A War of Nerves (London, 2000), p.2.
 Harold Merskey, ‘Shell Shock’ in German Berrois & Hugh Freeman (eds), 150 Years of British Psychiatry: 1841-1991 (London, 1991), p.261.
 John Blair, In Arduis Fidelis: Centenary History of the Royal Army Medical Corps (London, 2001), p.20.
 Taylor Downing, Breakdown: The Crisis of Shell Shock on the Somme (Abingdon, 2016), p.55.
 Richard Gabriel, No More Heroes: Madness and Psychiatry in War (New York, 1988), p.43.
 Wendy Holden, Shell Shock (Kent, 1998), p.7.
 T. J. Mitchell & G. M. Smith, Medical Services, Casualties and Medical Statistics of the Great War (London, HMSO, 1931), pp.15-16.
 Charles Myers, ‘A contribution to the study of shell shock’, Lancet (February, 1915), p.317.
 Harold Wiltshire, ‘A Contribution to the Etiology of Shell Shock’, Lancet (June, 1916), pp.1207-08.
 Peter Cooper, ‘Treatment of Shell Shock’, The British Medical Journal, Vol.2, No.2901 (August, 1916), p.201.
 William Grant Macpherson, Medical Services: Diseases of the War (London, 1923), p.15.
 Shepherd, A War of Nerves, p.25.
 Ana Carden-Coyne, The Politics of Wounds: Military Patients and Medical Power in the First World War (Oxford, 2014), p.43.
 Peter Leese, Shell Shock: Traumatic Neuroses and the British Soldiers of the First World War (London, 2012), pp.28-38.
 Anthony Babington, Shell Shock: A History of the Changing Attitudes to War Neuroses (London, 1990), p.80.
 Leese, Traumatic Neuroses, p.38.
 Fiona Reid, Broken Men: Shell Shock, Treatment and Recovery in Britain, 1914-1930 (London, 2010), p.21.
 Ibid, p.43.
 Edgar Jones; Nicola Fear; Simon Wessely, ‘Shell Shock and Mild Traumatic Brain Injury: A Historical Review’, American Journal of Psychiatry, Vol.164 (November, 2007), p.1644.
 Elaine Showalter, The Female Malady: Women, Madness and English Culture, 1830-1980 (London, 1980), p.168.
 George Mosse, ‘Shell-Shock as a Social Disease’, Journal of Contemporary History, Vol.35, No.1 (January, 2000), p.104.
 Holden, Shell Shock, pp.25-28.
 Alexander Watson, Enduring the Great War: Combat, Morale and Collapse in the German and British Armies, 1914-1918 (Cambridge, 2008), p.289.
 Shepherd, A War of Nerves, p.23.
 Peter Barnham, Forgotten Lunatics of the Great War (London, 2007), p.233.
 Anthony Richards, Report of the War Office Committee into “Shell Shock” (London, Imperial War Museum, 2004) (First Published in 1922), p.43.
 T. B. Nichols, Organisation, Strategy and Tactics of the Army Medical Services in War (London, 1936), p.325.
 Ted Bogaz, ‘War Neurosis and Cultural Change in England, 1914-22: The Work of the Committee of Enquiry into Shell Shock’, Journal of Contemporary History, Vol.23, No.2 (April, 1989), pp.227-28.
 Anonymous (Symposium), ‘Shell Shock’, The British Medical Journal, Vol.2, No.3217 (August, 1922), p.392.
 Jay Winter, ‘Shell-Shock and the Cultural History of the Great War’, Journal of Contemporary History, Vol.35, No.1 (January, 2000), p.10.
 Wilfred Owen, Mental Cases (Edinburgh, 1917).
http://www.poemhunter.com/poem/mental-cases/ (Last Accessed: 28/11/2016)
 Daniel Hipp, The Poetry of Shell Shock: Wartime Trauma and Healing in Wilfred Owen, Ivor Gurney and Siegfried Sassoon (North Carolina, 2005), p.54.
 Ibid, p.168
 Siegfried Sassoon, Sherston’s Progress (London, 1936), p.67.
 Alan Patrick Herbert, The Secret Battle (London, 1919), pp.119-204.