Discuss the Psychological Effects of the Great War on Soldiers, and How Medical Professionals Attempted to Treat ‘Shell Shock.’

This essay by 17 year old Rose Halls of Brighton College was one of the 2023 Colin Hardy Memorial Prize runners up. 

On 19th June 1879, Union Army General William Tecumseh Sherman forebodingly exclaimed that “war is hell” when addressing a group of cadets. It took a mere thirty-five years before this statement became a reality for the 250,000 men who suffered what Charles Myer coined as ‘shell shock’ during The Great War (National Archives, 1916). The psychological condition dates back to Ancient Greek times, where it was called ‘persistent nightmares,’ and was seen, too, in the American Civil War, when it was known as ‘soldier’s heart.’  Yet it was not until the First World War, when the prevalence of the condition revealed damaging effects on military performance, that medical professions decided that treatment was a necessity. The war essentially acted as a catalyst for the move towards the acceptance of purely psychological causes of mental symptoms. Prior to the emergence of shell-shock in the Great War, not enough attention had been paid to the mental and psychological aspects and impacts of undergoing military service (Howorth, 2000). Captain C F Tisdall, of the College Military Hospital in Canada, found that when labourers became soldiers, albeit doing similar manual work, they shifted from being an “asset to the country” to a “liability” as a result of the emotional turmoil developing due to the persistent fears and anxieties experienced during trench warfare. This was likely due to the undeniable fact that ‘the primitive instinct of self-preservation is more prominent in warfare than in civil life’ as the brutality of the Great War forced soldiers to confront the reality of seemingly inescapable death (Tisdall, 1919).

Shell shock was an unfamiliar condition, attributed initially to repetitive shelling and concussive bodily damage, as understanding of cognitive psychology related to the human mind was limited in the early 20th century.  Medical professionals have now related shell shock to the emotional disturbances imposed on soldiers during trench warfare.  The rat and fly infestations, close proximity and unhygienic conditions meant that infectious diseases such as cholera and typhoid fever spread rapidly, contributing towards the uncertainty felt by all. These anxieties co-existed with the fact that these soldiers spent a long duration under frequent artillery bombardment, further enhancing their fears and contributing to what Sherman described as “hell.”  Yet, trench warfare also involved long periods of inactivity permeated with uncertainty, meaning that their natural fears couldn’t be reduced by the release of purposive action (Howorth, 2000).  There was an evident conflict between these emotions, as their genuine, humane fear collided with their feelings of patriotism as they had a desire to fulfil their ‘masculine’ duties as soldiers. Additionally, soldiers felt disconnected from their family and friends during the Great War, which subsequently resulted in feelings of isolation and loneliness permeating their every day.  In the case of Private W, aged 20 at the time of a report on 20th July 1918, he had never spent time away from his father’s farm prior to enlistment.  He was showing evident signs of shell-shock, including catatonia, dizzy attacks and poor appetite, highlighting why isolation from his earlier existence had such a profound impact on his mental stability (Tisdall, 1919).  The traumatic experiences of brutality certainly catalysed these innate, natural psychological reactions, as seen with the epidemic rise in shell-shock cases during the Battle of the Somme from July to December 1916, with 16,000 additional cases diagnosed in the British Army (Howorth, 2000).  These cases hindered the British military greatly, as these men were removed immediately from the front line as part of their treatment.

Shell shock would be categorised into two groups; hysterical manifestations, which were more likely to affect private soldiers, and traumatic neurasthenia, which was more likely to affect officers (Howorth, 2000).  The former was characterised by hysterical outbursts, nightmares and tremors.  With the latter condition, one would experience the co-existence of headaches, which were believed to be worsened by thundery weather, a mild degree of catatonia, mental depression, insomnia, aphonia, fatigue without exertion, localised pain, loss of appetite, wasting, paralysis of limbs and muscles, loss of memory and nervousness (Garton, 1916).  It was deemed likely that sufferers had a lower average ‘nerve stamina’ when compared to the ‘mentally stable,’ suggesting that they were unable to hide their trauma and anxiety whilst engaging in their duties, hence their immediate removal from the front-line (Tisdall, 1919).  William Collins of the Royal Army Medical Corps explained how it was dealt with on the frontline, describing cases as “gibbering idiots.” He stated that “as a rule they were either charged with malingering or sent down to hospital, and it depended on what the officers were dealing with (Imperial War Museum - Online , n.d.).”  This statement reveals how treatment for cases of shell shock was not necessarily prioritised.  Physical fitness was a necessity for war, and due to resource constraints, this overruled mental diseases.  For those who were fortunate enough to be treated, the first stage was to be removed from direct fighting, with those showing severe symptoms sent to one of the 20 hospitals dedicated to the treatment of ‘mental diseases’.  These facilities were converted into hospitals from disused spas, private mental institutions, and country mental asylums.  Patients were often treated poorly and sent to hospitals a substantial distance from their homes, yet they had no rights to appeal their placements, hence why many soldiers suffered in silence and allowed their illness to develop in complexity (Combat Stress , 2023 ).  Many attempted to cure their ‘wounded minds’ using a cocktail of self-medication, involving alcohol and drug use to relieve themselves of immediate symptoms, as prevalent stigmas obstructed legitimate treatments.  Yet, this simply exacerbated untreated cognitive symptoms, such as flashbacks and nightmares and subsequently worsened their experiences (Butterworth, 2018).

To provide a real-world example of shell shock, one may examine the case of Jay Milner, documented on 1st June 1916, when he was 25 years of age.  Milner had been serving in the army for six years.  In 1914, he deployed to France and was almost captured in the retreat from Mons on 27th August.  His battalion was forced to retreat as the German infantry surrounded them.  Then, at Ypres in April 1915, a high explosive shell reportedly ‘threw him backwards and knocked him semi-conscious and dazed.’  Afterwards, he discovered that he was suffering from aphonia (the inability to speak) and his limbs were weak and weary.  He was sent to England, and during the crossing developed a persistent, worsening tremor. Medical reports stated that Milner had lost weight, was unable to stand, could not eat nor drink, his tongue became coated, his tremor fluctuated, and when at its worst he was unable to urinate for over 24 hours.  His arms and legs were ‘quiet’ until inspection, and his head violently jerked to the right when inspected.  His abnormal jerks were increasing in frequency and were most common on the left side (National Archives, 1916).  This all provided clear evidence of a mental disorder, namely ‘shell shock’, from direct exposure to combat.  The medical report continued to look for a physical cause of these symptoms, where modern-day medical professionals would turn towards a psychological cause.  

Soldiers were exposed to harsh treatments, such as the commonly used electroshock therapy, or brutal physical conditioning to alleviate the physical conditions, but the psychological impacts were ignored.  These solutions were evidently ineffective, with 80% of those treated in this manner unable to serve again (Butterworth, 2018).  Nevertheless, other treatments applied in cases of shell shock during the First World War did achieve some success.  Where one suffered from aphonia, chloroform hypnosis was regarded as the most effective contemporary treatment.  The patient would go under a general anaesthetic and have a ‘laryngeal spatula inserted into the larynx and moved gently from side to side to stimulate sensitive laryngeal reflexes’ (Milligan, 1916).  Upon regaining consciousness, the patient would then be asked to shout, and it was reported that they would always have the ability to do so.  Medical professionals during the war attributed the aphonia to the ‘temporary suspension of neuron impulses from the higher cortical cells of the central nervous system to the peripheral nervous system’ (Milligan, 1916).  There was only one case of relapse reported by the Royal Society of Medicine in this 1916 report.  These findings are actually supported by modern medical discoveries, whereby ‘Post-Traumatic Stress Disorder’ or ‘PTSD’ is now known to cause negative neurobiological impacts upon the body.  Neurons become overexposed to glutamate (a neurotransmitter which is vital to memory, cognition, and mood regulation), which is known to cause an excitotoxic effect, and can contribute to the loss of neurons and neural integrity (Sherin, 2011).  Therefore, it is evident that the medical discoveries of the Great War have had a profound impact on our current abilities and discoveries.  Many medical professionals doubt whether contemporary advancements would have been possible without the early developments in the First World War.

Developing this theme, a treatment of cerebro-spinal galvanism was commonly given to those suffering from the neurasthenic condition of shell-shock, as it was believed to be ‘an organic disorder of the central nervous system, due to a disarrangement of metabolism’ alongside a ‘paralysis of the nerves regulating nutrition’ (Garton, 1916).  This was viewed as rather simple to treat via galvanism, which was the generation of electricity using chemical means, which would stimulate muscle contraction.  There was evidence to suggest that this method was effective, for example, in the case of Private H, aged 30.  He was buried under debris from a mine explosion in 1915 and was subsequently left unconscious for a number of hours after being rescued.  Later, whilst on duty near a railway, he was reported to feel nervous and distressed, and began to feel sick and show signs of mental depression. Upon examination, it was evident that he was severely sleep-deprived and fatigued, experiencing vivid nightmares, loss of memory, headaches, and a loss of appetite.  After a mere four treatments of cerebro-spinal galvanism he was deemed fit for duty and put on a precautionary light duty by his medical officer.  However, he relapsed once he heard news of the death of his child and underwent another round of treatment.  Despite this episode, he was deemed fit once again and appeared to be in perfect health afterwards (Garton, 1916).  It was claimed that this treatment would allow soldiers to be cleared for duty after a mere three months, contributing greatly to military effectiveness.

Notwithstanding these successes in treatment, a diagnosis of shell-shock often produced stigmatisation and poor opinions of the individual affected.  In the British Medical Journal of 1922, General Lord Horne stated that he agreed with the usual regimental opinion that the majority of shell shock cases in a battalion were a direct result of poor morale and defective training (The British Medical Journal, 1922).  Soldiers attempted to conceal their trauma, due to fears of being shunned or stigmatised by fellow comrades for their ‘moral failings and weaknesses,’ which resulted in these mental illnesses growing in complexity and severity. Upon average, due to these feelings of apprehension, it took a veteran 14 years before they sought help after leaving the military, which is, unfortunately, still widely applicable in the modern day (Combat Stress , 2023 ).  Evidence of these negative stigmas could be seen in the Ypres salient, where the Guards battalions were so repulsed by shell shock cases that they regarded it as a ‘catching’ complaint, and refused to go into the line with a certain battalion next to them due to fears of ‘catching’ this disease (The British Medical Journal, 1922).  Additionally, some cases were accused of malingering to excuse themselves from the brutality of trench fighting, and as a consequence a number of men suffering from ‘shell-shock’ were executed for cowardice or desertion.  The emotional shock of having this condition was sometimes belittled by the chain of command, as it was believed that all one needed to treat it was ‘an intimate knowledge of human nature’ and ‘simple methods of persuasion and explanation’ to overcome it.  Many found it hard to distinguish shell shock cases, where visible symptoms had diminished, from ‘partial malingering’ (The British Medical Journal, 1922).  Furthermore, many doctors were still unconvinced by its legitimacy.  Dr Stanford Reade stated that he believed that the majority of the patients sent to mental asylums were simply suffering from dementia praecox, which is modern day schizophrenia (The British Medical Journal, 1922).

Treatments for ‘shell-shock’ have had a profound impact on modern treatment of PTSD, having moved away from the Freudian analysis of childhood experiences and innate sexual desires, to focus on recent trauma and impactful experiences.  Charles Myers, William McDougall and William Brown were examples of contemporary practitioners who worked along these psychotherapeutic lines, and their treatments correlate to current treatment of PTSD.  They aimed to treat the illness promptly, ideally close to the front line, acknowledge recent traumatic events, undergo individual, personal psychological analysis, as well as use cognitive restructuring alongside assessment of soldiers’ previous experiences to calculate the likelihood of a severe breakdown (Howorth, 2000).  In 1983, Bulman and Frieze proposed that problems arise due to someone’s ‘cognitive baggage.’  These refer to an individual’s thoughts and expectations about reality, which become highlighted and questioned when trauma arises, as their innocent and peaceful assumptions are shattered, hence leading them to the view that they themselves are weak and vulnerable.  Many soldiers in the First World War began to see the war as senseless genocide as they became segregated from the civilian world, which shattered their prior beliefs and added to their ‘cognitive baggage’ (Howorth, 2000).  More recently, individuals undergoing treatment have been able to express their trauma, and acknowledge that there is no distinction between the ‘sane’ and the ‘insane’ as all humans have the innate ability to breakdown.  Early realisation of this concept resulted in the Labour government removing the death penalty for cowardice and desertion in 1930, considerably reducing anxieties and contributing to the upsurge in the popularity of individualistic psychotherapeutic methods (Howorth, 2000).   As a direct result of the suffering of early shell-shock patients, current PTSD patients benefit from the growth in out-patient clinics and voluntary treatment in the growing industry of mental hospitals. 

Moreover, the impact for the military has been profound, with the screening of service personnel before and after deployment becoming a necessity (Butterworth, 2018).  This is to check for prior traumas to allow medical professionals to identify issues early to reduce the risk of developing PTSD – a substantial alteration from the way that shell-shock was treated, which only commenced as the symptoms became severe.  Furthermore, ‘talking cures’ have been developed, and individuals such as Arthur Hurst contributed greatly to their implementation.  Hurst led the neurology department at Netley Hospital and would film cases of shell shock before and after therapy.  He wanted to encourage patients to reconstruct their trauma and confront their memories, emphasising the cognitive and behavioural symptoms which individuals experience (Butterworth, 2018).  He named the mental struggle ‘War Neuroses’ instead of ‘shell shock’ to reduce the stigma and allow veterans to come forward confidently, despite not being physically harmed during wartime.  In 1918, he claimed that he would be “disappointed if complete recovery [from shell shock] does not occur within 24 hours of commencing treatment, even in cases which have been in other hospitals for over a year” (BBC, n.d.).  Additional aid to soldiers suffering after the First World War was provided through charitable schemes such as ‘Combat Stress.’  This was set up in 1919 by a group of revolutionary women striving to end the stigma around psychological damage caused by warfare.  Donations and fundraising events helped to provide recuperative residential homes where veterans could live and work to rebuild their lives in a humane manner (Combat Stress , 2023 ).  The organisation is still vital to upholding the mental health of soldiers in the modern day, a memorable legacy of the profound developments and impacts made during the Great War. 

In conclusion, it is evident that the exclamation made by Union Army General William Tecumseh Sherman in 1879, claiming that “war is hell”, holds myriad possible interpretations, in this case referring to the psychological trauma inflicted upon the soldiers of the Great War.  It appears that this developed due to the brutal conditions to which they were continually subjected, namely the dangers and uncertainty involved in trench warfare. The stigmatisation made by fellow comrades, and accusations of malingering meant that shell shock was concealed by soldiers, until their conditions held a deep complexity and severity.  They would be removed from the front line, whereby soldiers were sent to hospitals and subjected to a variety of treatments, and no individual medical decision was made as to how to treat this disorder.  Arguably, the most effective treatment was developed by Arthur Hurst, called ‘talking therapy’, whereby the cognitive and behavioural characteristics of their trauma would come to the surface, but due to resource constraints this was rarely used during wartime (Butterworth, 2018).  However, progressive steps were taken by the women of ‘Combat Stress’ in 1919 to de-stigmatise shell shock and provide veterans with the suitable conditions to rebuild healthy lives and confront their trauma. Service personnel must now be screened before and after deployment to identify any signs of possible PTSD, which is a huge development catalysed by the ‘hellish’ nature of the Great War.

References:

BBC, n.d. Arthur Hurst - the man who filmed shell shock. [Online]
Available at: https://www.bbc.co.uk/programmes/articles/4VqPtrjsgcPKtgmYc2M5vXz/arthur-hurst-the-man-who-filmed-shell-shock
[Accessed 9 August 2023 ].

Butterworth, B. R., 2018. [Online]
Available at: https://theconversation.com/what-world-war-i-taught-us-about-ptsd-105613#:~:text=Psychological%20trauma%20experienced%20during%20the,when%20reminded%20of%20their%20trauma.
[Accessed 9 August 2023].

Combat Stress , 2023 . Combating stigma, mental health problems. [Online]
Available at: https://combatstress.org.uk/combating-stigma-mental-health-problems
[Accessed 10 August 2023].

Garton, W., 1916. Shell Shock And Its Treatment By Cerebro-Spinal Galvanism. The British Medical Journal, 2(2913), pp. 584-86.

Howorth, P., 2000. The treatment of shell-shock: Cognitive therapy before its time. Cambridge University Press , pp. 225-227.

Imperial War Museum - Online , n.d. IWM - Voices of the first world war. [Online]
Available at: https://www.iwm.org.uk/history/voices-of-the-first-world-war-shell-shock
[Accessed 8 August 2023].

Milligan, W., 1916. Treatment Of 'Shell Shock.'. The British Medical Journal, 2(2902), pp. 242-43.

National Archives, 1916. Medicine on the Western Front Part Two, Shell-Shock Cases. [Online]
Available at: https://www.nationalarchives.gov.uk/education/resources/medicine-on-the-western-front-part-two/shell-shock-cases/
[Accessed 8 August 2023 ].

Sherin, J. &. N. C., 2011. Post-traumatic stress disorder: the neurobiological impact of psychological trauma. Dialogues in clinical neuroscience , pp. 263-278.

The British Medical Journal, 1922. Shell Shock. The British Medical Journal, 2(3216), pp. 322-23.

Tisdall, C. F., 1919. Shell Shock. The Public Health Journal, 10(1), pp. 6-12.

Article by Rose Halls – Brighton College (Aged 17)