Shell-shock

​Hello and welcome to post number five, this time about the condition known variously through time as war neurosis, combat hysteria, shell-shock, or PTSD.
 
Writing historical fiction involves a lot of research to uncover information which informs the novel but isn’t necessarily included in it. This blog is to share some of the interesting facts I’ve learnt during the course of my research.

One of the characters, Sarah’s brother, John, is seriously injured during the South African war, known at the time as the Boer War:

He draws an uneven breath. ‘I got a rifle shot in my thigh, so I dragged myself under a rock overhang to take cover from the pom-pom shells. Two of my comrades pegged out nearby, one with his face blasted off.’ He gives a humourless laugh. ‘He was the lucky one. The other bled dry from a belly wound. That’s a slow death, I can tell you.’ He shakes his head as though trying to rid himself of the memory. ‘Reckon I’ll hear his screams to my dying day.’
He strikes a match, cupping the flame with his undamaged hand, and lights his cigarette. I remain silent, not wishing to interrupt his flow.
‘Seemed like forever I lay there. Then I noticed the stretcher-bearers in the near distance and waved my handkerchief. That’s when a sniper blasted away the handkerchief, and my fingers with it.’ He holds out his right hand—a reptilian claw with the middle and ring fingers missing. ‘They’re hunters, you know, the Boers, used to aiming quick before their prey catches wind. They practise by firing at hens’ eggs a hundred yards away. Anyway, I was in no doubt of their skills.’

Invalided out of the army back to England, John goes to stay with Sarah and Ed after living with his father becomes intolerable. But he is disrupting their family life with his nightmares:
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‘Did you get back to sleep after the nightmare?’
He shrugs, clearly not wanting to talk. But I believe in talking things through.
‘How long have you been having them?’
‘Since the field hospital.’
‘What do you dream about? Whatever it is, it must be awful.’
‘Don’t want to talk about it.’
He spreads tobacco along a cigarette paper with the forefinger and thumb of his mangled hand. It still makes me shudder.
‘Talking may help,’ I say. ‘Like laying ghosts to rest.’ He shakes his head. ‘Please, John. What harm can it do?’
‘Dredging it all up when all I want is to forget.’


John is suffering from what we would nowadays term Post Traumatic Stress Disorder (PTSD), but that designation was unheard of in 1902. The term PTSD was first used in 1980 in connection with veterans of the Vietnam War.(1) Even the name shell-shock had not been coined in 1902. It was first applied by Charles Myers in an article in The Lancet in February 1915 to soldiers of WW1 suffering from loss of memory, vision, smell, and taste.

The condition itself has long been recognised as an effect of war, and there are descriptions of it in ancient literature. The character of Gilgamesh in the Epic of Gilgamesh (Mesopotamia c. 2100 BC) suffers recurrent nightmares after witnessing the death of his closest friend. The ancient Greek historian Herodotus in his account of the battle of Marathon (440 BC) tells of an Athenian warrior who suddenly went blind in the midst of the fighting, not because of a physical wound but from fear after seeing his comrades killed.

The symptoms of PTSD are many and varied but can be grouped into three basic types: recurrent re-experiencing of the trauma in nightmares, thoughts, flashbacks or hallucinations; emotional withdrawal and avoidance of stimuli; a permanent state of increased arousal, of being ‘on edge’. Victims of shell-shock could suddenly be unable to speak or hear, to stand or walk. They could lose their memory or even undergo ‘personality loss, as in the case of one man who seemed to develop an entirely new identity, including a different accent, after he had been hit by a shell.’ (2)  Sufferers may experience headaches, episodes of loss of consciousness, tremors or convulsions. They may have problems sleeping or concentrating, are easily irritated or angered, and engage in reckless or self-destructive behaviour. Symptoms can be brought on by a sudden trigger which reminds the victim of the trauma he has undergone.

John displays several of these symptoms, most notably nightmares and recurrent unwelcome memories of the war. In a scene where he is looking after his niece, Annie, he experiences a trigger which sends him back to the battlefield. Sarah returns from shopping to find him under the table:

When I let myself in a half-hour later, a starkly contrasting scene confronts me. Annie is whimpering in a corner while John crouches under the table, eyes closed, hands over ears.
I drop my basket and get down on the floor to cuddle Annie as I look at my brother.
‘John, it’s Sarah. Are you all right? Why are you under the table?’
He uncovers his eyes and stares at me. It takes a few seconds for comprehension to dawn.
‘Sorry. I was at Bakenlaagte with a sniper shooting me.’
 ‘But that’s one of your nightmares. Surely you weren’t asleep? Don’t tell me you dropped off while looking after Annie.’
He struggles to crawl out, breaking into a cold sweat as he manoeuvres into a chair.
‘Aargh. My leg’s gone into a spasm.’ He massages his thigh muscles. ‘I wasn’t asleep. We were playing with the bricks at the table. She got fed up, so we tidied them away, and I set her on her feet while I searched for my tobacco pouch. The next thing, I heard a rifle crack and leapt for cover.’
The box of bricks is lying on its side on the quarry-tiled floor. Annie must have pulled it off the table.

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Soldiers in WW1 being treated by medics in a trench. The man on the left of the picture is suffering from shell-shock.

PTSD is a syndrome specific to individuals who have experienced a major traumatic event. It is a chronic disorder which may worsen over time, and should be distinguished from acute stress disorder, caused by events such as divorce, financial hardship, or serious illness, which does not produce the same range of symptoms. PTSD is commonly the result of war trauma but can be caused by other traumatic events such as accidents or sexual abuse. Many Holocaust victims suffered PTSD, unsurprisingly. Perhaps more surprising are the symptoms of PTSD shown by survivors of railway accidents during the industrial revolution when rail travel became common. The condition was known at the time as ‘railway brain’. But shell-shock was a specific form of PTSD caused by high explosive artillery which prior to WW1 had not been used for such prolonged periods, and some doctors of the time believed the vibrations of shell explosions caused invisible physical damage to the brain.

So what is going on inside a person who develops PTSD? It seems to be caused by the stress hormones, adrenaline and norepinephrine, which put the person into the fight or flight mode. People with PTSD continue producing abnormally high amounts of these hormones even though they are no longer facing danger. Brain scans reveal that the amygdala, the part of the brain which deals with emotion, is more active than in people without the condition, while the hippocampus, which handles memory, is likely to have shrunk. A malfunctioning hippocampus may prevent nightmares from being properly processed so that the anxiety the nightmares produce never reduces. These changes in the brain can grow worse over time.

Nowadays, PTSD is treated by psychotherapies, such as cognitive therapy, and by medication, such as antidepressants. In John’s day, given that the condition was not even recognised, it is not surprising that there were few treatments available.

John’s father, George Crouch, has no sympathy and regards him as a weakling and a coward.
Most military doctors at the time would have agreed. They regarded the symptoms of PTSD as a sign of weakness or lack of will-power. The cure was often public ridicule.

During WW1 the condition of shell-shock was recognised but viewed with suspicion by army officers who were most likely to attribute it to emotional weakness or cowardice.  A British army order from 1915 illustrates the uncertainty with which shell shock was regarded. The letter W was to be prefixed to the patient’s report only if the damage was directly due to the enemy, in which case the soldier would be ranked as wounded. But if the man’s breakdown did not directly follow a shell explosion, it was not thought to be due to the enemy. He was to be labelled S for sickness and not entitled to a pension. Luckily for Arthur, he suffered physical injuries as well as psychological ones and so was granted a war pension.

WW1 firing squad

Many soldiers with shell shock were sent back to fight after just a few days’ rest. Those who couldn’t face it were charged with desertion or insubordination, court-marshalled and convicted. Many were executed for cowardice. The following is an account of one such execution during WW1 by Victor Silvester, a young soldier who joined up aged just fourteen:

“We marched to the quarry outside Staples at dawn. The victim was brought out from a shed and led struggling to a chair to which he was then bound and a white handkerchief placed over his heart as our target area. He was said to have fled in the face of the enemy.

 “Mortified by the sight of the poor wretch tugging at his bonds, twelve of us, on the order raised our rifles unsteadily. Some of the men, unable to face the ordeal, had got themselves drunk overnight. They could not have aimed straight if they tried, and, contrary to popular belief, all twelve rifles were loaded. The condemned man had also been plied with whisky during the night, but I remained sober through fear.
        
"The tears were rolling down my cheeks as he went on attempting to free himself from the ropes attaching him to the chair. I aimed blindly and when the gun-smoke had cleared away we were further horrified to see that, although wounded, the intended victim was still alive. Still blindfolded, he was attempting to make a run for it still strapped to the chair. The blood was running freely from a chest wound. An officer in charge stepped forward to put the finishing touch with a revolver held to the poor man's temple. He had only once cried out and that was when he shouted the one word 'mother'. He could not have been much older than me. We were told later that he had in fact been suffering from shell-shock, a condition not recognised by the army at the time." (3)

For those soldiers given treatments, the range on offer was varied. The lucky ones might receive massage or special diets, treatments which were unlikely to have cured the patients but at least caused no harm. Others might be given hydro- or electrotherapy. It was thought that the pain caused by electric shocks would jolt the patient out of his hysteria. Many sufferers were simply disciplined or put into solitary confinement. But two medical practitioners of the time stand out for their more sympathetic approach: Arthur Hurst and WHR Rivers.

Electrotherapy

Hypnosis being used on a shell-shocked patient

In a hospital which today is part of Plymouth university in Devon, Arthur Hurst, an army major, offered psychotherapies, notably hypnosis and occupational therapy, revolutionary treatments for the time. The men were given work to do, such as farming or basket-making, and were provided the opportunity to be creative by writing or painting. But they were also encouraged to re-live their experiences by reconstructing the Flanders battlefields on Dartmoor. Hurst made films to show the success of his techniques, the only footage of how shell-shocked victims were treated in Britain, and they appear to show some dramatic improvements. When Private Percy Meek arrived at the hospital he was in a wheelchair, having lost most of his physical functions. He is described as being in a babylike state. Under Hurst’s care he appears to have regained normality. Unfortunately, there are no studies of what happened to these men after their therapies finished but at least they were treated humanely.

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WHR Rivers

 
​Officers were four times likely to suffer from shell-shock than the ordinary ranks, perhaps because they were expected to repress their emotions to set an example for their troops. Anthropologist and psychologist, William Halse Rivers Rivers (yes, he has two Rivers in his name), pioneered humane treatments for officers suffering from shell-shock at Craiglockhart War Hospital, near Edinburgh. The war poets, Siegfried Sassoon, Robert Graves and Wilfred Owen were all patients there. 

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Siegfried Sassoon

Rivers believed it was necessary to bring repressed memories into a patient’s consciousness to bring about a sort of catharsis and rid the memories of their potency. He pioneered a treatment based on talking to his patients to help them understand the nature of their illness, a process he referred to as autognosis. At a time when men were encouraged to keep a stiff upper lip, Rivers encouraged his patients to express their emotions. Many of his patients were ‘cured’ enough to be sent back to the front to fight again. The life of W. H. R. Rivers and his encounter with Sassoon is the subject of British novelist Pat Barker’s Regeneration Trilogy, made into a film in 1997 with Jonathan Pryce starring as Rivers.
 
My character, John, is offered no treatment for his psychological problems and fears he is going mad. The last thing he wants is to end up in an asylum:

'Nightmares I understand—we all have them. But how do you explain it if it wasn’t a nightmare?’
‘I can’t.’ He rubs his eyes with his forefingers. ‘Look, don’t worry. I’ll be out of your hair soon.’
‘That’s not what I meant. I’m concerned for you.’
He stares at me. ‘You think I’m going mad.’
‘Shouldn’t you consult a doctor?’
‘And end up an inmate at Chartham? I suppose it would be a roof over my head.’

By the end of WW1 there were roughly 80,000 cases of shell shock in the British army. It was not until 1930 that the British government removed the death penalty for desertion and cowardice.

Survivors, by Siegfried Sassoon

No doubt they’ll soon get well; the shock and strain
Have caused their stammering, disconnected talk.
Of course they’re ‘longing to go out again,’--
These boys with old, scared faces, learning to walk.
They’ll soon forget their haunted nights; their cowed
Subjection to the ghosts of friends who died,--
Their dreams that drip with murder; and they’ll be proud
Of glorious war that shatter’d all their pride...
Men who went out to battle, grim and glad;
Children, with eyes that hate you, broken and mad.
 
Craiglockart. October, 1917
                                                                                                     

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Footnotes:
1. The Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, published by the American Psychiatric Association.
2. Shell-shock by Tracy Loughran, November 2018, British Library.
3. WHR Rivers: Healing minds beyond his time.
 
Sources:
1.Dialogues in clinical neuroscience, March 2000, US National Library of Medicine
2.NHS
3.Mayo Clinic
4.The History website
5.University of Oxford JISC
6.WebMD
7.Wikipedia
8.BBC Inside Out Extra: March 2004