Taylor Downing reveals an official cover-up of mental illness in the later years of the war.

George Leroux’s depiction of Verdun was entitled simply; Hell. It captures well the dehumanising character of the modern industrialised battlefields of the Western Front that drove so many men mad.

It was not just the scale of the physical casualties that overwhelmed the British Army in the summer of 1916 on the Somme, terrible though these were – 38,000 wounded to be processed through medical facilities on the first day alone. A tsunami of men with shattered minds from a variety of war neuroses also threatened to overwhelm the system.

On the Somme, the generic term used to describe the problem was ‘shell shock’. This covered a multitude of reactions to the fighting ranging from bad cases of ‘the shakes’ and all sorts of physical disabilities, through loss of memory and appetite to pitiful cases of complete breakdown in which men could not walk, talk, or relate to others in any normal way.

But during the Third Battle of Ypres (better known as the Battle of Passchendaele), there were hardly any cases of shell shock diagnosed in the British Army.

How could this be, as the conditions of the battle were just as bad, if anything worse, than on the Somme? Had soldiers really learned to overcome the mental traumas that had afflicted them the year before? Or was there some form of cover-up by the medical authorities?

OFFICIAL DENIAL

Shellshocked soldier awaiting treatment during the Battle of the Somme.

In 1914, the Royal Army Medical Corps (RAMC) included not a single trained psychiatrist to treat war trauma.

Captain Frederick St John Steadman was typical of many doctors in the Corps. He ran a field ambulance unit on the Somme that within days of the start of the offensive was overrun with battle casualties.

He was astonished at the high proportion suffering from shell shock, for which he had received no training. He had never imagined such cases could be so terrible.

In a letter to his wife, Steadman wrote:

I have become fairly expert in diagnosing the degree of shell shock a man has, as I have seen so many cases now. I ‘spot’ them at once by the nervous twitching of their faces or hands; some frown when they are talked to, as though to answer the simplest question is too much mental exertion. Some have a curious dazed look about their eyes, quite different from anything else I have seen. Some recover rapidly, but others remain in the same state for days.

In another letter, he wrote:

We had another bad case of shell shock in. Poor man, he lost his friend near him, but the shell did not touch him – it knocked him down by the loud concussion. The man looks quite insane; it is fearful to watch him. I think he will eventually recover but it is very sad.

The high command feared that if this condition was allowed to spread it would undermine the ability of the Army to keep on fighting. The Official Medical History of the War described shell shock as ‘a flood-gate for wastage from the Army which no one was able to control’.

The assumption was that shell shock was contagious – in that a nervous man made all those around him nervous. In a unit with a high incidence of shell shock, it was believed, there was the possibility of a complete collapse in morale.

Also, there was a suspicion of malingering. The Army imagined that if men saw one of their mates being sent back behind the lines for rest and recuperation, they would try it on too.

ABUSING THE SICK

An advertisement for the Official Medical History of the War, published in the early 1920s, which described shell shock as ‘a flood-gate for wastage’.

The Army tried to make a stand, and units with high levels of shell shock were punished. The 11th Borders, a Pals Battalion known as ‘the Lonsdales’, failed to go over the top when ordered to a week after 1 July because so many were suffering from shell shock.

As punishment, they were humiliated in front of their peers and told by their divisional commander, ‘you have failed in your duty and you have brought disgrace not only on yourselves but also on the battalion to which you belong’. That speech was delivered to a unit that had suffered one of the highest casualty rates in the Army during the 1 July assault.

In addition, MOs (medical officers) thought to be too sympathetic to shell shock were reprimanded, and some were sent home in disgrace.

It is difficult to calculate from the official casualty figures exactly how many men were afflicted with shell shock. The evidence suggests that about 17-20% of all those wounded were suffering from psychiatric wounds of one sort or another. That makes for a total during the Battle of the Somme (July to November 1916) of between 53,000 and 63,000 shell shock cases – a colossal figure.

The official figures show shell shock casualties during the second half of 1916 as four times higher than during the previous six months. If the figure increased by only half of this level in the following year, then for 1917 the British Army might have been looking at an extraordinary 180,000 battle casualties from shell shock.

HIDDEN SHELL SHOCK

British casualties receive first aid during the Battle of the Somme.

But during the Battle of Passchendaele, the official figures record only 5,346 cases of men diagnosed with shell shock, less than 3.5% of the wounded. This defies all belief.

The terrible nature of the battle, with artillery barrages that lasted hours and sometimes days, the static nature of trench warfare from which there was nowhere to escape, and the dreadful, sucking mud that provided a constant risk of drowning for a soldier who missed his step – these were just the sort of conditions liable to induce shell shock.

Even the uncritical Official Medical History concluded, ‘Considering the nature of the conditions in this battle area and the nerve- racking character of the struggle, this must be regarded as a very low figure.’

The reasons why the official figure was so low are not difficult to find. On 21 November 1916, three days after the guns fell silent at the end of the long Somme battle, the Director General of Medical Services announced that ‘the expression shell shock’ should no longer be used, and all cases displaying nervous symptoms of any sort were to be classed as ‘nervousness’ and ‘under no circumstances to be recorded as a battle casualty’.

This directive also introduced a new term ‘NYDN – Not Yet Diagnosed Nervous’. Possible cases of shell shock were no longer to be diagnosed by MOs in forward dressing-stations but were to be sent back to specialist centres. Only here could a man be accurately diagnosed. The centre then sent a form, not to his MO, but to a man’s commanding officer.

As if front-line officers did not already have enough to do, they now had to complete a form verifying a man’s mental state before he had been sent back for medical aid.

This medical case sheet from the First World War records the soldier-patient as suffering from ‘Nervousness’ and comments that he was ‘Probably just a little used-up’.

Predictably, this led to long delays. Officers filled out the forms as and when they could. Meanwhile, potentially serious victims of war trauma had to wait for days in hospital wards before being officially diagnosed, let alone treated.

Outwardly, the Army could congratulate itself that the crisis of shell shock had been resolved. In reality, they simply refused to count such cases any longer. But massaging the numbers did not solve the problem. The simple fact is that there was an official cover-up during Passchendaele of the scale of shell shock.

POST-WAR PENSIONS

Otto Dix’s Dead Sentry in an Observation Post (undated) shows a deranged soldier who has shot himself.

By 1921, 65,000 men were still receiving pensions for what by then was generically termed ‘neurasthenia and other forms of psychiatric disease’. There was a complex structure for calculating war pensions based on the scale of a man’s disability.

The flat rate for a weekly disabled war pension was 1 pound and 13 shillings (roughly equivalent to £90 today). The loss of two or more limbs entitled a man to 100% of the pension. On the other hand, the percentage payable for the amputation of a leg depended on whether it was above (60%) or below (50%) the knee.

Payment for the loss of a thumb or four fingers depended on whether they were from the right (40%) or the left hand (30%). And payments were increased proportionately as a consequence of the claimant’s final rank and number of dependents.

The whole question of pensions for those with mental diseases, however, was the subject of intense debate during the 1920s. The loss of a limb was clearly a permanent sign of bravery, a badge of courage, and everyone agreed the state should offer compensation. But how should a man be assessed for suffering from the mental scars of war?

Claimants had to go before a medical board. If the board decided that his shell shock or neurasthenia was wholly the consequence of his military service, it was classed as ‘attributed’ and could be paid for some years. But if the board thought it derived from an existing condition that had been made worse by wartime service, it was called ‘aggravated’ and could only be temporary.

How could it be decided when and if the shell shock had passed and the pension could cease? This would be left up to individual doctors to determine. There was still a stigma surrounding all forms of mental illness, and some doctors took a hard line, suspecting that many claimants were malingerers and should ‘pull themselves together’ now the war was over. Others, often those with military service in the war, were more sympathetic and tended to be generous to claimants.

POST-WAR ILLNESS

Paul Nash’s After the Battle (1918), as well as depicting the alien character of the battlefield, appears to show an isolated shell-shocked man cowering in a trench.

We now understand that many of the symptoms of war trauma manifest themselves only after the event, in some cases many years afterwards.
The medical boards calculating pensions were faced with thousands of cases of men who had returned home apparently fit and well, and had settled back into civilian life, but then started to behave erratically.

Robert Dent, a tough Northumberland miner before the war, was one of many. He suffered from minor shell shock on the Somme but soon recovered. He left the Army at the end of the war and returned to work as a hewer at the local pit.

In the summer of 1924, he began to show signs of intense emotional upset. His wife, Hannah, testified that he was ‘strong and healthy before enlistment’, but that he was now ‘a total wreck’. He was taken into Morpeth Mental Hospital, where the doctors put in a pension claim on the basis that he was suffering from a recurrence of the shell shock from eight years before.

But the Ministry of Pensions refused to countenance this, arguing there was ‘no evidence to connect the shell shock with his present disability’. In Dent’s case, his local vicar, an ex-serviceman, took up the story and convinced the Ministry that his ‘ravings’ were a consequence of post-traumatic shell shock. He was eventually, but reluctantly, granted a pension.

The issue of shell shock and a sense that a great injustice was being done towards its victims grew stronger as a consequence of the complaints about war pensions in the years after the war. In 1920, Lord Southborough said in Parliament,

All would desire to forget shell shock – to forget… the roll of insanity, suicide, and death; to bury our recollections of the horrible disorder… But we cannot do this, because a great number of cases are still upon our hands and they deserve our sympathy and care.

Southborough chaired a major Committee of Enquiry that reported in 1922 that it was not just ‘cowards’ and the ‘weak and feeble’ who might suffer from shell shock, but that any soldier could be disabled by trauma in modern, industrialised warfare. But they still recommended avoiding the words ‘shell shock’ and insisted that most victims of neurasthenia would recover quickly.

SHELL SHOCK IN LITERATURE

Nearly all the great writers who fought on the Western Front include painful descriptions of men who had succumbed to nervous breakdowns. Robert Graves in Goodbye to All That (1929) repeatedly describes friends and colleagues as being ‘played out’, or ‘done in’, or of having ‘lost his head’.

Graves recounts how, after six months of continuous front-line duty, officers ‘began gradually to decline in usefulness as neurasthenia developed’, and those who had been at the front for more than 15 months were ‘often worse than useless’, and even a danger to the rest of their company.

Popular fiction of the 1920s is full of stories of shell-shock victims struggling to cope with the post-war world. The novels of Rebecca West, A P Herbert, Agatha

Christie, and Virginia Wolf all feature central characters with shell shock, and Dorothy Sayers created Lord Peter Wimsey, a fit and elegant aristocratic detective, who appeared in a series of immensely successful detective thrillers.

He repeatedly suffers from haunting ‘flashbacks’ to wartime horrors. He is described in Whose Body? (1923) as having been ‘dreadfully bad in 1918’, and, the reader is informed, ‘we can’t expect him to forget all about a great war in a year or two’.

Ian Carmichael as the Dorothy L Sayers character Lord Peter Wimsey – who suffered from shell shock following the First World War.

Lord Wimsey relies on his valet, Bunter, to sort him out. It turns out that Bunter had been his sergeant in the war and knew how to deal with the problem.

MILITARY PSYCHIATRY

In 1939, official figures showed that there were still 35,000 ex-servicemen receiving war disability pensions for neurasthenia and mental conditions. But by then the Army had cut back its medical services and many of the lessons painfully learned in the Great War about dealing with war trauma had been forgotten. The link established between the RAMC and the world of psychiatry had been broken.

Dr Charles Myers, one of the pioneers of the treatment of shell shock in the First World War, felt compelled to write a book containing some of the key factors in treating wartime psycho-neuroses in order to prevent the Army Medical Corps from ‘repeating the same mistakes’ as in 1914- 1918. When the Second World War began, the military medical services had to relearn what had been lost over the previous 20 years.

What today is called ‘military psychiatry’ goes hand in hand with more general developments in clinical psychiatry. War provides a great learning opportunity for medical practitioners, as with so many other fields.

Studying how the human body and mind respond to the extreme wounds of war has given a great boost to medical science in the last hundred years. War can open up a sort of laboratory into the mind.

Hopefully, Britain has now come to the end of a decade and more of continuous conflict in Iraq and Afghanistan. Much more is now understood about what is today classed as ‘Post-Traumatic Stress Disorder’ (PTSD). Let us hope that this will not all be forgotten, as after 1918, in the years ahead.

Taylor Downing’s book Breakdown: the crisis of shell shock on the Somme, 1916 is available as an Abacus paperback.



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