Medicine and multimedia: Shell shock patients: from cowards to victims
Authors: Derek Summerfield
Journal: BMJ (1998)

In 1980 I was a rural government medical officer in southeastern Zimbabwe when the civil war ended and Robert Mugabe’s guerrillas could show themselves and seek treatment. One of these lay unmoving but alert in his soiled bedclothes day after day on my ward, without wounds or obvious pathology. As my concern about an atypical encephalopathy subsided, I came to see him as a case of some sort of combat stress and eventually talked him back into life. 

An admirable three part television series on shell shock started this week with the first world war (Shell Shock, Channel 4, Sundays 8 00 pm). In fact, a better place might have been the American civil war, where military doctors were perplexed that men could die not just of wounds or disease but also of what they called “nostalgia”—a contagious condition associated with morbid homesickness. “Nostalgia” became an epidemic as the war dragged on, accounting for more cases than dysentery.

During the first world war, there were 13 000 cases of shell shock in the British army by 1915, and 200 000 over the entire war. An early article in the BMJ described a sergeant with a paralysis of his trigger finger preventing him from firing a rifle. The television series included telling footage of the man deaf to all sounds save the word “bomb,” whereupon he would scramble under his hospital bed. There was an outbreak of hysterical blindness, weird gaits, and intractable shaking, almost all in ordinary soldiers. It was interesting that officers tended to present (and to be handled) differently.


Worried by the loss of manpower, the army set up special hospitals. One of these, Craiglockhart in Edinburgh, was described by the poet Siegfried Sassoon, an inpatient, as “a mausoleum filled with the morbid slumbers of men haunted by self-lacerating failures to achieve the impossible.” Some psychiatrists drew on Freudian ideas of repressed trauma, ushering in the talking cure. Their French peers tried electric shocks to the affected part, soon to be adopted in Britain too (quicker than talking), and in Germany doctors used hypnosis. What they all shared was an ethical dilemma in that their efforts were directed to returning men to the trenches. 




Although the War Office recognised shell shock as a genuine war injury in June 1916, the imperative for the army remained that men should kill and be killed as commanded. We will never know how many of the 307 British soldiers executed for “cowardice” had indeed suffered acute medical incapacity beyond their control, and how many had made a rational decision in a murderously irrational situation. Fifteen thousand men were still in hospital with shell shock in 1921.

The second part of the series moves on to the second world war. The lessons of the first war were forgotten and the prevailing line was that men would not break down if they had good training and leadership. However, the army was staggered by the extent of hysterical symptoms in those evacuated from Dunkirk, and 200 psychiatrists were recruited. Gung ho pioneers such as William Sergeant, who saw psychoanalysis as useless talk, promoted physical treatments including amytal or insulin coma to open up the unconscious mind and release its demons. Electroconvulsive therapy without anaesthetic began to be deployed in an increasingly indiscriminate fashion.

However, there was resistance in high places to these trends. Churchill believed that psychiatrists could do harm “by asking odd questions” of ordinary men in interviews; some generals refused to have psychiatrists on their staff; and in north Africa, where there were high levels of what was now to be called “battle exhaustion,” there were calls for reinstatement of the right to shoot deserters. The air force remained determined to stigmatise those who could not cope, their diagnosis being LMF (lacking in moral fibre). None the less, advance planning for D-Day included provision for battle exhaustion, and an entire psychiatric hospital was established within a month of the first landings. It is telling that a quarter of all initial D-Day casualties were psychiatric.

Part three in the series deals with the Falklands and Gulf wars. It is interesting how much more “psychological” the modern soldier sounds than his predecessors. A victim identity, particularly if medically certificated, has taken a special place in contemporary society, inevitably shaping what a soldier thinks has happened to him. It is a pity that these sociological issues were not discussed in the programme.

The major conundrum now facing the British army is Gulf war syndrome, not mentioned in the series, and the extent to which it is psychosocially shaped. The politics and psychomorality of post-traumatic stress disorder, the diagnostic tag that has usurped its predecessors, is a story in itself. This term was first applied to US veterans of the Vietnam war by psychiatrists who were part of the anti-war movement. Together with the old bugbears—suspicion about malingering and a fear of contagion if the military climate was too permissive—this issue is as pertinent today as it was in 1918.