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Shell-Shock
1911 Encyclopedia Britannica
or "SHELL-SHOCK, the popular name given during the World War to an obscure form of nervous disease which became rife among the armies. The term " shell-shock " appears to have been officially adopted in Great Britain in 1916, although cases to which this term might have been equally applicable had occurred in the English and French armies from the beginning of the war and onwards. It is probable, although it is not recorded, that similar cases occurred in previous bloody wars; but never before have such vast numbers of men been subjected to such terrific strain, dangers and horrors from forces generated by explosives. In consequence thereof the term " shell-shock," applied to all forms of war psycho-neurosis, found ready acceptance by the press and public, but by neurologists it was generally regarded as a misnomer - unless it were strictly limited to cases of concussion or commotion of the brain directly caused by the violence of the forces generated by the explosion.
Early in the war, and subsequently, cases of sudden death of groups of men without visible external signs of injury were recorded. They were particularly noted when the explosive forces were generated in confined spaces, where percussion and repercussion would be intensified in their effects upon the cerebrospinal fluid, which acts as a water-jacket to the central nervous system and especially protects the vital centres in the medulla from concussion. Carbon-monoxide poisoning was also considered a possible cause of such a death, and especially was this likely in the case of explosion of mines or the imperfect detonation of shells in closed spaces, such as dugouts, saps or ravines.
The great majority of cases diagnosed as " shell-shock " were not commotional in origin, but emotional, and due in most instances to the existence in the sufferer of an inborn timorous, neuropathic or psychopathic disposition; but in a certain number of cases an emotional instability was acquired by the prolonged strain and stress of war. Thus fatigue, insomnia, anxiety and infective disease frequently combined to cause a neuro-potentially sound individual, with an excellent record of service, to become emotive and to develop " shell-shock," the final breakdown having been precipitated by a shell bursting near to him. The present writer had the opportunity of examining post-mortem the brain in such a case, and it showed rupture of minute vessels and haemorrhages into the substance of the brain and cerebro-spinal fluid.
In the absence of objective signs during life, such as ruptured tympanum, and changes in the cerebro-spinal fluid - for example, the existence of blood - it would be impossible for the medical officers to decide whether such a case was primarily commotional or emotional. This is an important matter, for the former was classed as a battle casualty and entitled the sufferer to a gratuity. The large number of British cases claiming a gratuity for "shellshock" led to the promulgation of Army Form W 3436, which required circumstantial evidence by an eye-witness of the proximity of the soldier to the bursting shell. Even then great difficulties were experienced in coming to a just decision, for a purely commotional case, if not severe, usually recovered more rapidly than an emotional one; consequently,, a record of service and the severity, character and persistence of symptons had to be taken into account.
The diagnosis of " shell-shock " was made at the Casualty Clearing and Field Ambulance stations, and when a barrage was opened prior to the attack of the enemy, or other intense shell-fire, medical officers at the front-line stations had little time to investigate the numbers of casualties coming in, and until the later period of the war cases of " shell-shock " were sent to the base hospitals. The wish in a great number of these cases was not to go back to an intolerable situation; and fear, associated with the instinct of self-preservation, arose as an unconscious defence mechanism, and persisted in maintaining such hysterical manifestations as amnesia, tremors, paralyses, contractures, convulsive tics, aphonia, mutism, blindness, deafness and other functional sensori-motor disabilities. Whereas hysterical manifestations were extremely common in the ranks,they were relatively rare among the officers, who suffered from neurasthenia and anxiety neurosis instead. These two forms of psycho-neurosis in no essential manner differed from those affecting civilians of either sex (see 14.211 and 19.432).
Among the causes which led to the prevalence of cases diagnosed " shell-shock " was the neurological and psychological inexperience of medical officers in the diagnosis and treatment of psycho-neurosis. Another was the degree of discipline, moral and esprit de corps in a regiment; this largely depended upon the personality of the commanding officer, the medical officer and the quartermaster, their efficiency in performing their duties and their endeavours to supervise the welfare of their men so far as the emergencies of war permitted. Thus confidence and willpower were inspired in the men to face with them any situation, and " shell-shock " cases were relatively few in such regiments as compared with the number of cases in a regiment with poor moral and discipline, where suggestion played an important part.
It is generally accepted by medical authorities in England and abroad that the stress and strain of war, including exposure to shell-fire, does not produce psychoses such as epilepsy, manic depressive insanity, dementia-praecox, obsessional psychasthenia, or an organic disease like general paralysis, but it may excite or reveal them. It is, however, admitted that exhaustion or toxic psychoses with mental confusion of a temporary character are often due solely to the stress and strain of war.
Relation of " Shell-shock" to Court-Martial Procedure
As a result of questions in Parliament and a debate opened on April 28 1920 by Lord Southborough, a War Office committee, with Lord Southborough as president, was constituted July 1920 with the following terms of reference: " To consider the different types of hysteria and traumatic neurosis called ` shell-shock'; to collate the expert knowledge of the service medical authorities and the medical profession from the experience of the war, with a view of recording for future use the ascertained facts as to its crisis, nature and remedial treatment and to advise whether, by military training or education, some scientific method of guarding against its occurrence can be devised." In the House of Lords debate, in which Lord Home, Viscount Peel and Lord Haldane took part, a good deal of attention was devoted to court-martial procedure, and especially in relation to ." shell-shock " and to death sentences in connexion with cowardice and desertion. From what was said it seems probable that in the early days of the war, before " shell-shock " was fully understood, a few men were shot who, in the light of further knowledge and experience, could not have been held responsible for their actions. The question arises, When is a man who has pleaded " shell-shock" (taken in its widest acceptance) to be held responsible for and conscious of the quality of his acts? The psychology of the emotion of fear in relation to the instinct of self-preservation and the will-power to control supplies a basis upon which to answer this question. The emotion of fear is associated with three instinctive reactions, as we see in animals: (1) flight; (2) immobility; (3) concealment. In war practically every man, even the bravest, before a battle may experience fear; but a soldier should, by suitable training and confidence in his superior officers, overcome this by will-power, and thus convert the primary reaction of fear into that of anger. How can a medical officer differentiate between cowardice and fear causing an irresponsible lack of will-power in a man to control his actions in the face of difficulties and dangers? The doctor should know the man's personality, his previous record and what his comrades thought of him. It is not so much what he says as what he did, or what he has done, which will help towards a decision. There are, however, certain signs in a man who refuses to go forward in action or who runs away, that show he cannot be held altogether responsible for his action. He may be dazed in consequence of " shell-shock " and be the subject of mental confusion; there may be physical signs of fear over which he has no voluntary control, namely rapid action of the heart, dilatation of the pupils, sweating, blueness and coldness of the hands, often protrusion of the eyeballs, and an expression on the face which is hard to simulate. These conditions, associated with trembling, are sufficient indications of true fear inhibiting the will.
Out of the psychology of fear arises the question whether in recruiting there is any test by which the unfitness for active service on account of a nervous disposition can be ascertained. And, if so, whether it would be desirable to eliminate from the army such a man without probation. It is a fact that many highly intelligent men with nervous instability may, if suitably trained, develop into most efficient officers and non-commissioned officers. Much depends upon the method of training and on those who undertake the training. A sensitive nature with self-esteem must not be broken by harshness or injustice, which produces a mental conflict ending in an anxiety-neurosis or neurasthenia. It is generally admitted that under no circumstances should an imbecile, an epileptic or an individual who has suffered with a previous attack of insanity be recruited.
For further information the reader is referred to Parliamentary Debates, House of Lords, Wed. April 28 1920, vol. xxxix., No. 29. See also Sir F. W. Mott, Shell Shock and War Neurosis (1919).
(F. W. Mo.)
These files are public domain.
Chisholm, Hugh, General Editor. Entry for 'Shell-Shock'. 1911 Encyclopedia Britanica. https://www.studylight.org/encyclopedias/eng/bri/s/shell-shock.html. 1910.
