Cristóbal S. Berry-Cabán
Fort Liberty, North Carolina, United States

 

Shell shock. Upon suffering a head injury and the loss of his eardrum, this soldier developed shell shock and was put in the Sunshine Room at Chaumont Hospital, installed by the American Red Cross. The room contained absolute quiet, harmonious colors, and cheerful surroundings. Library of Congress.

The casualties suffered by the participants in World War I surpassed those of previous conflicts, as some 8.5 million soldiers died from wounds or disease.^1,2 Artillery caused most of the casualties, followed by small arms and poison gas. However, the war’s signature injury became known as shell shock, now recognized as posttraumatic stress disorder (PTSD).^3-6 The term “shell shock” entered the medical vocabulary in 1915 when Capt. Charles Samuel Myers, an English psychologist, published an article in The Lancet. Initially, the condition was believed to result from physical trauma, but doubts soon arose about the role of direct brain injury that lead some to propose that the symptoms had more psychological origins.^7,8

Several years after the war, Virginia Woolf’s 1925 novel Mrs. Dalloway^9,10 explored the heart-wrenching experiences of shell-shocked veteran Septimus Warren Smith. It depicts how soldiers returning from the battlefield struggled to readjust to civilian life. Septimus, once an idealistic young man, had become a shattered individual haunted by hallucinations and traumatic memories. His war-bride, Rezia, witnesses his mental deterioration and seeks medical help from Dr. Holmes, who dismisses Septimus’s condition as a minor issue, reassures the couple that nothing is seriously wrong. He accuses Septimus of talking nonsense to scare his wife.

Desperate for a solution, Rezia seeks a second opinion from Sir William Bradshaw, a renowned physician. Before the war, Septimus had been a promising poet who deeply admired Shakespeare’s works.^11,9 However, he now believes that the England he fought for holds little value for him. Despite Septimus expressing his concerns, Sir William also dismisses them and attributes them to “a lack of proportion.” Sir William decides to have Septimus committed to a mental institution.

Cover of Mrs. Dalloway, first ed. Jacket design by Vanessa Bell. Via Wikimedia.

That same evening in June 1923, the protagonist of Woolf’s novel, Mrs. Clarissa Dalloway, has organized a party for the British prime minister.^11,9 Sir William arrives and the guests learn that one of his patients, a young war veteran, had taken his own life earlier that afternoon. This news disturbs the meticulously orchestrated atmosphere of Mrs. Dalloway’s flawlessly planned evening. As the story unfolds, it reveals the fragmented nature of time and the interplay between perception and reality in the lives of individuals and society.¹² Clarissa, preoccupied with the superficial aspects of social norms and hosting a successful party, uses these distractions to shield herself from the harsh realities of the post-war world. Septimus, on the other hand, represents the disintegration of society and its restrictions, ultimately choosing to escape confinement through his suicide. Clarissa’s temporary identification with Septimus highlights her awareness of the limitations on her own freedom and momentarily relieves her disillusionment.

During and after World War I, shell shock was a significant problem among military personnel.⁶ Treatments included shock therapy, frontal lobotomies, institutionalization, and harsh disciplinary measures.¹³ While these methods are considered crude and inappropriate today, at that time they were the best options available based on the medical community’s understanding of the condition.^14,15

Understanding combat trauma has improved since World War I.¹³ While some World War II military leaders such as Gen. George S. Patton still attributed “battle fatigue” to cowardice, frontline medics recognized its complexity.^13,16,17 More compassionate treatments included rest, counseling, and medication. The Vietnam War, brought into homes by television, depicted returning veterans who often struggled with anger and PTSD. While the initial rates were low, toward the end of the war PTSD was diagnosed in around 30% of returning veterans. The exact reasons for this rise are unknown, but a lack of support and acceptance from the American public may have played a role.^3,18

Post-traumatic stress disorder (PTSD) was first included in the DSM-III (1980).¹⁹ The diagnosis distinguished a psychological response to traumatic events from other that of stressors that do not typically produce the same symptoms.^19,3 The diagnostic criteria for PTSD were subsequently revised to align with ongoing research. Today, PTSD is categorized under Trauma- and Stressor-Related Disorders rather than an anxiety disorder, as it can be associated with other mood states and behavioral patterns.^19,20

In the aftermath of World War I, writers and poets such as Ernest Hemingway, Robert Graves, and Siegfried Sassoon conveyed their emotions and anxieties through their writing and captured the shared sentiments of people worldwide.^21,22 Virginia Woolf also resonated with many people of this era, with Mrs. Dalloway offering profound insights into coping skills in the aftermath of the First World War.

 

References

1. Royde-Smith JG et al. World War I: Killed, wounded, and missing. Encyclopedia Britannica. https://www.britannica.com/event/World-War-I/Killed-wounded-and-missing. Accessed May 26, 2023.
2. Stone N. World War One. Basic Books; 2009.
3. Jones E, Wessely S. Shell Shock to PTSD: Military Psychiatry from 1900 to the Gulf War. Psychology Press; 2005.
4. Stephens S. The Wounded Warrior. Multnomah Publishers; 2006.
5. Jones E, Fear NT, Wessely S. Shell shock and mild traumatic brain injury: a historical review. American Journal of Psychiatry. 2007.
6. Reid F. Broken men: Shell Shock, Treatment and Recovery in Britain 1914-30. A&C Black; 2014.
7. Mott FW. The Chadwicklecture on mental hygiene in shell shock during and after the war. The British Medical Journal. July 14 1917;2:39-42.
8. Mott FW. War Neuroses and Shell Shock. H. Frowde; Hodder & Stoughton; 1919: 348.
9. Woolf V. Dalloway. Harcourt; 1925:296.
10. Lehrman L. Presentation on Mrs. Dalloway by Lisa Lehrman. Shell Shock, Septimus Smith, and WWI. Dec 6, 2010. http://mrsdallowaypresentation.blogspot.com/2010/12.
11. Dalloway: Full Book Summary. SparkNotes. https://www.sparknotes.com/lit/dalloway/summary/.
12. Lohnes K. Mrs. Dalloway. Encyclopaedia Britannica. Last updated Jan 26, 2022. Accessed May 26, 2023. https://www.britannica.com/topic/Mrs-Dalloway-novel-by-Woolf.
13. Moore BA and Falke K. A century after ‘shell shock,’ struggle to address post-combat trauma continues. MilitaryTimes. April 19, 2017. https://www.militarytimes.com/military-honor/world-war-i/2017/04/19/a-century-after-shell-shock-struggle-to-address-post-combat-trauma-continues/.
14. Salmon TW. The care and treatment of mental diseases and war neuroses (“shell shock”) in the British Army. Mental Hygiene War Work Committee of the National Committee for Mental Hygiene; 1917.
15. Binneveld JMW. From Shell Shock to Combat Stress : A Comparative History of Military Psychiatry. Amsterdam University Press; 1997.
16. Chermol BH. Wounds without scars: treatment of battle fatigue in the US Armed Forces in the Second World War. Military Affairs. 1985:9-12. https://doi.org/10.2307/1988270.
17. Lovelace AG. “Slap Heard around the World”: George Patton and shell shock. The US Army War College Quarterly: Parameters. 2019;49(3):9. doi:10.55540/0031-1723.2776
18. Pary R, Lippmann SB, Turns DM, Tobias CR. Post-traumatic stress disorder in Vietnam veterans. Am Fam Physician. Feb 1988;37(2):145-50.
19. PTSD and shell shock. Last updated Mar 28, 2023. Accessed May 26, 2023. https://www.history.com/topics/inventions/history-of-ptsd-and-shell-shock.
20. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). 5th ed. 2022.
21. Hemingway E. A Farewell to Arms. 1st Scribner classic/Collier ed. Collier Books; 1986:332.
22. Silkin J. The Penguin Book of First World War Poetry. 2nd ed. Penguin Books; 1985:287.

 

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CRISTÓBAL S. BERRY-CABÁN, PhD, a graduate of the University of Wisconsin-Milwaukee, has over 30 years’ experience conducting research in military health. He is an epidemiologist at Womack Army Medical Center and an associate professor at Campbell University. He is the author of over 100 research articles, including several on the history of medicine. He lives in Fayetteville with his cat Solo, who enjoys sleeping in the library.

 

Spring 2023  |  Sections  |  Psychiatry & Psychology