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and maintained by Chris Glass
Updated 11 July 2020
1821 Info11f4 for Walter John Thomas Blackman (Tom) |
A clinical analysis
Dr. Stephanie Linden, Clinical Lecturer, Institute of Psychological Medicine and Clinical Neurosciences Cardiff University and author of They called it Shell Shock, very kindly read Tom’s repatriation medical file and offered her considered opinion of Tom’s case relevant to her analysis of the World War 1 shell-shock records of the National Hospital, Queen Square, London (QS). 1 There are three initial considerations from this analysis:
These points would suggest Tom had a limited chance of avoiding shell shock.
She writes: 'Tom [being] buried following a shell explosion in France in September 1917 […] was not found for some time, [was a] typical trauma leading to shell shock symptoms; many soldiers from my sample eventually broke down after being buried by a shell explosion (a truly terrifying experience)'. Tom being dazed and confused ‘was most likely not a result from the physical trauma, but a reaction to the psychological trauma of being buried alive. He was probably in a so called "dissociative state", 6 […] detached from his surroundings, a reaction which might have protected him from further trauma.’ After the burial Tom was "in a dream state", he had a "dull expression and vacant look". 7 Linden wrote this was a 'description I have come across many times in the QS cases records.' Tom is also described as "mildly demented", which meant that he was not reacting to his surroundings, that he was not able to communicate and appeared "dull" and without emotional expression. It was very common to mention a "predisposition" or "constitutional weakness" which ultimately lead to mental breakdown (also in Tom's case; this was usually based on a family history of mental troubles, a past history of mental problems, or simply on personality traits e.g. being "highly strung" or gentle and soft).’
She continues: ‘It is interesting that Tom, after his burial, never really recovers. He loses interest in his surroundings, does not get up, or speak (indeed, for some time he does not seem to be able to speak). 8 This is an interesting phenomenon which was also described frequently at the time.’ Mott 9 (who would have treated Tom at the Maudsley), was particularly interested in these soldiers who:
'suddenly lost their speech, and he tried to understand why "these mutes, whose silent thoughts are perfect, [should] be unable to speak? They comprehend all that is said to them unless they are deaf; but it is quite clear that in these cases their internal language is unaffected, for they are able to express their thoughts and judgements perfectly well by writing, even if they are deaf. […] Many who are unable to speak voluntarily yet call out in their dreams expressions they have used in trench warfare and battle." Mott emphasised the symbolic meaning of these symptoms, which could not be explained by a direct trauma to the brain. The patient was merely unable to talk about his terrifying experiences; Mott reckoned that there were simply no words for the horrors he had gone through – soldiers were "dumb with fear"'. 10
Linden queried the reason for Tom’s repatriation from Egypt to Australia. He was hospitalised for two months, diagnosed with both enteric and pyrexia (fever) of unknown origin in Mudros, being transferred to Alexandria for five weeks. From there he was invalided to Australia, arriving on 13 March 1916. After three weeks ‘treatment’, Tom was returned to duty before proceeding overseas on 21 August 1916. 11
Linden continues. 'Later, Tom developed psychotic symptoms (delusions), but I am not sure of the nature of these experiences. It seems that Tom already struggled before his actual breakdown in 1917. On 28 October 1915, he suffered from headache, malaise and loss of appetite; this was attributed to an infection (which was not verified). After all, it was much easier to find a physical explanation for these symptoms.' 12 It is the author’s opinion that the Enteric Fever diagnosed at Anzac and Alexandria was an early sign of shell shock in a combat environment where doctors were unaware of the nature of Shell-shock. Enteric Fever/typhoid was rife and certain manifestations of the illness could be identical to Shell-shock: headaches, loss of appetite, general malaise but with no diarrhoea or evidence in Enteric in his urine. Certainly, the general malaise, loss of appetite and force-feeding was prevalent in Tom’s mental illness.
A historical perspective
The First World War marked a turning point in the history of neurological treatment. 13 Clinicians were provided with the opportunity and resources to treat and evaluate large numbers of patients with similar symptoms.
With the 1915 Mental Treatment Bill, the British Army’s treatment in 1915 distinguished between 'neurological' and 'mental' cases. Neurological cases were affected by unexplained physical symptoms, and functional paralysis, with officers suffering from neurasthenia. 14 However, the symptoms of traumatised soldiers were diverse and could affect every system of the body. 'These confused, troubled souls, frozen with terror and frantic with fever, who had lost touch with the world, developed symptoms similar to long term inhabitants of asylums.' 15
Although soldiers showed few signs of obvious physical injury it was argued that the shell was 'the spark that released long pent up forces of a psychical kind [making] the soldier's central nervous system vulnerable to stress in the widest sense and rendered him susceptible to mental breakdown. […] Shell shock was […] a psychological reaction to stress. […] [A] soldier who ad previously suffered from [Enteric Fever] could develop a chronic state of physical and mental exhaustion.' 16
Debate about the causes of shell shock continued through 1916 to 1918. One looked at physiological changes to the normal function of organs being a cause. Another considered the emotion of fear producing changes to the cerebral cortex associated with higher brain function, voluntary movement and sensory information. 17 Initially, Mott thought that the symptoms were caused by the concussing of the shell explosion: the blood in the cerebral fluid and loss of proper blood supply to the brain. 18
Whatever the cause, very few truly Shell-Shocked patients 19 were sent back to the front. 20
End notes
Tom, through his Gallipoli experience, was an experienced veteran who merited a battlefield commission. His commotion shock was recorded in his medical records as being buried by a shell. Perhaps an enlightened Australian doctor in France recognised the seriousness of Tom’s case and evacuated him to 4th London General Hospital.
Report of the War Office Committee of Enquiry into "Shell-shock"
The War Office Committee of Enquiry into Shell Shock chaired by Lord Southborough reported in 1922. Evidence provided came from serving officers, War Office branches, the RAMC and neurologists from hospitals in which Shell-shock had been presented. Sir Frederick W. Mott, from The Maudsley Wing, which first opened in 1915 as the military psychiatric hospital of the 4th London General Hospital, served on this committee.
The writer, who has no psychiatric qualification or knowledge offers the following in an attempt to put Tom’s Shell-shock into the context of prevailing war and immediate post war thinking. It is:
The 1922 Report is the only official and contemporarily evidential document that the writer has been able to find. And based upon its content it is the writer’s 21st century assumption that Australian troops shared many of the same experiences reported in evidence. It is possible some Australian psychiatrists applied the same psychiatric treatments. However, there is only one reference to soldiers buried alive by debris from explosion.
Tom’s Gallipoli experiences are treated here as secondary evidence. Assumptions have been made as to how these experiences generated his possible battle fatigue, generally classified as enteric. Enteric or Enteric Fever is currently termed Typhoid.
The military perspective
Although medical research and the progress made in neurology in the treatment of Shell-shock, in 1920, much of the military reasoning was that of the '1914 model' of Shell-shock: victims were cowards who would disrupt the morale of their units. Major WJ Adie, neurologist to the Ministry of Pensions, argued that the manifestation of Shell-shock was a means of the soldier evading duties and avoiding punishment. Because the condition was nervous rather than physical, it did not merit a wound stripe. 1
The evidence given to the Committee by General Lord Horne, G.C.B., K.C.M.G. late GOC 1st Army France, is typical of the Army’s post-war perspective. He told the Committee that he first understood the term Shell-shock to apply to 'the immediate result of concussion' caused by 'close proximity to a violent explosions'; 2 a similar understanding to Mott's early clinical experiments. Horne was of the opinion that it applied 'to cases of loss of control of the mind or nervous system, as the result of battle, and to nervous breakdown due to strain'. Physical fitness, morale and home leave protected against Shell-shock. 3 This strain and the resultant Shell-shock, he suggested, was more likely in troops new to the line and their immediate battle experiences. However, he was unsympathetic to battalions with multiple cases of Shell-shock, which suggested low battalion morale. Morale and emotional stress was improved by 'training to the proper state of efficiency […] justice of cause, pride in regiment, and supremacy in the use of weapons, etc., [assisted by] good food and good care taken of the men'. Shell-shock, he believed, was encouraged by a stalemate war dominated by artillery and would not be a feature of mobile war. 4
In 1922, the Committee classified Shell-shock as concussion or commotion shock with loss of consciousness. '[E]vidence of organic lesion of the central nervous system or its adjacent organs (such as rupture of the membrana tympani), should be classified as a battle casualty'. However, 'no case of psycho-neurosis or of mental breakdown, even when attributed to a shell explosion or the effects thereof, should be classified as a battle casualty'. It was to be an illness regarded on par with any sickness or disease. The Committee officially recognised the importance of neurological hospitals to which doubtful cases should be referred. 5 The stiff upper lip of army tradition still prevailed and would prevail until 1939. The term Shell-shock and abbreviations such as N.Y.D. 6 and P.U.O 7 were to be eliminated in favour of the correct medical term.
Enlistment medical
The evidence presented to the Committee convinced them that not enough attention had been given to the mental history of potential recruits. The Committee recommend medical boards to reduce the risk of sending those predisposed to the possibilities of Shell-shock to the front. They were to weed-out those with ‘Emotional shock, acting on a predisposed nervous temperament’, as was recorded by Tom’s Royal Park, Melbourne, medical board. 8
Tom’s Attestation Papers were dated 19 August 1914, which was one of two generic date for the first rush of volunteers to the colours in Melbourne. The medical examiners, in the chaos of recruitment, examined 200 to 300 9 men a day and could only perform very superficial examinations. Consequently, many men were probably accepted as Category A for front line service who could have been unsuitable due to their nervous health and susceptibility to Shell-shock. 10
The Committee proposed medical boards of four members 11 giving thorough examinations to, at the most, five recruits an hour. The intention was to accept those of 'at least an average degree of mental and nervous health and stability […for…] the successful conduct of the war'. Recruits would now be required to confirm they had not suffered from insanity (schizophrenia) or a nervous breakdown. More thorough medical boards would avoid potential Shell-shock victims, prolonged and costly treatment, increased pension lists and the difficulty of assimilation back into civilian life: 12 all of which had been features of Tom’s post Polygon Wood life.
The Report is specific in its recommendation for dealing with recruits, like Tom, who, as his Royal Park medical records show, had a ‘constitution predisposed to psychosis on active service’ 13 caused by ‘a nervous breakdown when 21 years old and prior to enlistment from which he recovered’. 14
In action at Gallipoli
It is not as easy to explain Tom’s Gallipoli experiences and why he was evacuated to Mudros, Alexandria and then to Melbourne.
Colonel JFC Fuller 15 gave evidence to the committee related to the influence of chronic and persistent 'fear' on the emotions of the soldier. Sometimes this lead to a complete mental breakdown or a callousness against self- protection leading to a mental terror. In his experience Shell-shock was greater in troops who had been in dangerous situations. 17
These recommendations were possibly unhelpful to Tom’s apparent ‘predisposition’. At Anzac, raw troops dashed ashore in the wrong place, to a location with a rear area under artillery fire. The stretcher-bearers of 2/Australian Field Ambulance (2/AFA) were in action for a constant eighteen weeks. The strain of poor diet, sickness and lack of exercise took a heavy toll. 17 The stretcher-bearers also had to deal with the dangers, heavy infantry casualties and disturbing sights at the battles of Lone Pine and Second Krithia.
By being thrown into battle and his experience on Gallipoli, Tom became, in my opinion, an experienced soldier, later worthy of a commission.
Evacuation to Egypt
The October 1915 War Diary for 2/AFA notes that Tom and four other men left the unit. Tom was admitted to 2/AFA’s hospital at Sarpi Point, Mudros and then evacuated to Alexandria, where he remained for three months having been diagnosed with Enteric Fever, 19 before being repatriated to Australia.
Tom's Repatriation file contains an annotated medical record dated 15 December 1915. 20 which amongst the ‘enteric’, is a typed P.O.U.O.
On 26 January 1916, three members of 3rd Auxiliary Hospital medical board in Alexandria, recorded on Form C.M. Form D.2.: ‘Headaches, loss of appetite, general malaise, no diarrhoea, no epistaxis (nose bleed), no complications. Excreta no (sic) examined’. His urine and excrete were later examined in Alexandria in March 1916 and proved negative [for enteritis]. 21 On 27 January 1916 a Medical Board declared the ‘enteric’ was contracted on active service and Tom was totally incapacitated for a full livelihood: a statement indicating the serious nature of his case. 22
It could be argued the incapacitating symptoms of enteric were mis-diagnosed for an early case of Shell-shock generated by the environment of Gallipoli (qv). This, at a time when Shell-shock was not fully recognised. Enteric is initially typified by prolonged fever and abdominal pain include headache, chills, cough, sweating, muscle and joint pains and malaise. Gastrointestinal symptoms include anorexia, abdominal pain, nausea, vomiting, and constipation/diarrhoea. 23
In 1915 Charles Myres 24 recorded Shell-shock cases exhibiting physical symptoms of 'reduced visual fields, loss of smell and taste, and some loss of memory'. By 1916 symptoms had expanded to 'rather like a jelly shaking; headache; tinnitus […]; dizziness; poor concentration; confusion; loss of memory; and disorders of sleep' 25.
Sir Frederick Mott, in the evidence to the Committee, stated 'Once their nature [war neurosis] had been determined it was possible for the medical man who was previously familiar with the handling of cases of nervous and mental diseases to place each case under its proper caption'. But, as Sir Frederick pointed out, 'only a comparatively few medical men prior to the war had had an opportunity of becoming thoroughly familiar with this very distinct branch of medicine'. It is unlikely these specialists were to be found in Mudros and Alexandria in 1915 where field doctors diagnosed a more understood physical cause rather than a mental disorder. 26
Treatment
It was deemed uncommon for Shell-shock patients 'to become insane except very temporarily' and therefore they were not certified. 27 The Committee concluded that most Shell-shocked soldiers were effectively treated in the field, at one of six Charles Myres' specialist neurological centres. Only those deemed exceptional cases should be returned to the UK with the equivalent of a 'Blighty' wound. These Myres' centres were apparently successful as many Shell-shock victims were returned to their units. By 1917, medical officers were instructed to avoid the term Shell-shock and classifications such as ' Not Yet Diagnosed (Nervous)' (NYD) 28 as they became, in times of pressure, very loose or harmful labels. Doctors were encouraged to give more precise clinical diagnosis, which would return men to the front more quickly. 29 Passed to a Myers’ psychiatric units, the soldier was assessed by a RAMC specialist as either ‘shell-shock (wound)’ or ‘shell-shock (sick)’, the latter diagnosis being given if the soldier had not been close to an explosion. To deter 'malingers' the Committee added 'This policy should be widely known throughout the Force'. 30
Treatment in the manner of that used by Mott at The Maudsley, was accepted and recommended. The personality of the physician was of the greatest importance. The majority of patients responded to the simplest forms of psycho-therapy care of mind and body. Treatments included explanation, persuasion and suggestion, aided by such physical methods as baths, electricity, massage, though deep hypnotic sleep may even aggravate the symptoms for a time. An interest in nature and occupational therapy, for re-education and post-military employment, was employed. This was very much the approach advocated by Ernest Jones at Mont Park and Bundoora. Perhaps Tom’s benefited from it.
Tom’s medical record in France notes both NYD and PUO, but in late 1917 it is highly improbable Tom would receive a clinical psychiatric diagnosis in France. Had he received a diagnosis of his condition in a Myres' hospital, the symptoms could have been obvious to the specialists. In the experience of Dr Bernard Hart 'only cases which required certification were sent from shell-shock to mental hospitals'. 31
On 27 October 1917, Tom was returned to the UK after ten days of treatment in the 2nd General Hospital, Le Harve, diagnosed with PUO (qv). When Mott’s treatment at The Maudsley failed, Tom was certified as ‘insane’ and spent thirteen months in Latchmere House for Insane Officers. 32 In Australia, the Repatriation Department described him as never likely to recover suggesting it was officially accepted that he was seriously incapacitated. The Committee noted that the mutism Tom showed, developed in a place of safety: his home or the hospital.
In 1940, Myers wrote in the second paragraph of the preface to his book Shell-Shock in France 1914-1918,
It is a long time since any book has been written about so called shell-shock that the present volume may well serve to re-enlighten members of the general public as to its nature, and to convince them how dependent it is on previous psycho-neurotic history and inherited predisposition, on inadequate examination and selection of soldiers fitted for the front line … 33
Finally
The writer opines that under different and enlightened circumstances Tom would not have passed his medical when joining up, would not have gone to war and would not have suffer the life changing consequences.
Acknowledgement
Professor Howard Ward for his advice on the structure and content of this text.
End notes
12. War Office pp.172-4
13. NAA Repatriation p.197 Tom’s Royal Park medical board
14. ibid pp.223-4 Tom’s Royal Park medical board. It is not known how this information was
obtained. Perhaps his family, who lived 120km away, was involved in the process
15. Late General Staff Officer, Tank Corps
16. War Office p.29
17. ibid pp.151-3
18. In eighteen weeks on Gallipoli 2/AFA suffered 20% of their total fatalities - Austin,
Ron, Wounds & Scars – from Gallipoli to France, the history of the 2nd Australian Field
Ambulance, 1914-1919, Slouched Hat, McCrae, 2012
19. Also known as typhoid
20. NAA Repatriation p.245
21. NAA Repatriation p.209
22. ibid p.208
23. IDA
24. Dr Charles S Myres CBE, FRS, RAMC, Consultant Psychologist to the Forces in France on
Shell-shock, whose first centre was at le Touquet
25. Smithsonian web site
26. War Office p.5
27. ibid p.144
28 ibid p.192
29. ibid p.149
30. ibid p.192
31. ibid p.146 Bernard Hard MD, Physician, University College Hospital
32. NAA Service Record p.24
33. Myers p.ix
Did soldiers of the First World War suffer from post-traumatic stress disorder? (PTSD)
Linden discusses the comparison between World War 1 Shell-Shock and modern PTSD.
Each armed conflict from the late 19th century to today had its own particular functional disorder: rheumatism and heart problems in the Crimea, Shell-shock in the First World War, bowel problems in the Second World War and PTSD in Vietnam. Today classical shell shock has been superseded by mental complaints: low mood, anxiety, intrusive imagery and flashbacks of battle scenes, avoidance of potential danger, and states of 'high alert' and suspiciousness; all components of today's PTSD. 1
Linden argues there are striking similarities between Shell-Shock sufferers re-living combat experiences in a fully conscious, confusional or dreamlike state, and the modern concepts of post-traumatic reactions (in particular, PTSD). Very vivid memories and intrusive ‘flashback’ images of the traumatising event are the hallmark of PTSD, as described in traumatised soldiers many decades before PTSD was officially recognised as a psychiatric disorder after the Vietnam War.
She asks if Shell-Shock was simply another term for PTSD and argues that it is not straight forward as trauma changed from war to war. PTSD today is probably more frequently encountered in victims of traffic accidents than in war veterans. PTSD is just one of a range of historically developing psychological reactions to the fears and stress associated with combat and certain aspects of it can be observed in Shell-Shock victims. 2
End notes
Conclusion
Major General Harold ‘Pompey’ Elliott 1 wrote on soldiers being buried alive: The men seem to fear this fate more than anything, and men who are ordinarily quite brave and steady are often quite hysterical when dug out of a place like that. They seem to imagine that another shell will come and land on them while they are imprisoned and helpless. Then there is the fear of being suffocated before they can be got out and I suppose the dread that the others might not have courage to come and dig them out. (Un-recorded source)
End notes
Sources:
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| This page was created by Richard Crompton and maintained by Chris Glass |
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Version A4 Updated 11 July 2020 |
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