The South African
By Ian B Copley
In September 2021 I gave a zoom talk on this subject for the Eastern Cape Branch of the Society referring to the Somme casualties as a serious situation due to the large number of cases reported and the army’s fear of ‘shell shock’ becoming an epidemic. In the time allowed this was just scratching the surface of a human problem prevalent since Homo sapiens congregated in ever larger numbers in subdivisions of locality and power.
In Homeric times there was no tolerance for weakness or unheroic traits that were regarded then as cowardice – [Finlay M I, The World of Odysseus, Folio Society 2002 p110]. The term ‘battle fatigue’ was used in the subsequent wars until ‘shell shock’ in WW I trauma became frequent enough to be thought of as an impending epidemic.
My experience comes from serving as a medical officer in the British Army posted to Kenya, Kuwait and Swaziland, then for the Volunteer Reserve of the Rhodesian Army Medical Service and lastly in the South African Army Medical Services.
I was privileged to start a Neurosurgical unit in the new 1 Military Hospital in Pretoria where our department happened to perform the first operation. The separate ward was for all ranks. Only children and those cases needing to be in Intensive Care were accommodated elsewhere.
Part of the old military hospital became a rehabilitation centre where there were weekly ‘ward rounds’ to review patients individually. The ward sister, social worker, physio and occupational therapists attended to give their input. Occasionally parents were invited after patients had been allowed home for weekends. There was a resident psychologist present. A buddy system was developed whereby a new patient was ‘adopted’ by another more experienced patient who had also had a brain injury.
Previously this type of mental stress was described as ‘cowardice’, dereliction of duty, inadequacy or stupidity in cases where abnormal behaviour required a court martial.
The battle of the Somme which lasted some 6 months brought to the fore a recognisable mental condition after soldiers had been exposed to continued stress in many forms for extended periods. There were so many cases of what was called ‘shell shock’ or ‘battle fatigue’ that there was a fear of the condition becoming epidemic. There was a feeling amongst higher ranks that the doctors were being too lenient and the court martial recommendation of clemency was not followed in some cases, so the ‘coward’ was put in front of a firing squad. In the army an additional stress for some, particularly amongst officers, was to not appear to be afraid.
Acute or Chronic Stress
Stress can be acute or chronic; both were applicable in the trenches. Acute stress is associated with battle conditions such as noise and concussion of explosions and especially when witnessing injuries to others and having to bury them or parts of them. There were many assaults on the sense of smell in the appalling muddy conditions in the trenches of putrefaction as well as the presence of rats, flies, fleas and lice and then the fear of the presence of gas, chlorine or phosgene, in addition to the suspense of waiting for something to happen.
Chronic stress included the constant fear of having to ‘go over the top’ with a strong chance of being struck by an exploding shell, or machine gun bullets. The ‘Tommies’ felt they preferred dodging bullets to shells. One may have been a naval gunner on a warship where the noise was intense, but of short duration. [I have been on a Royal Navy destroyer of the Mediterranean Fleet, 3 destroyers and 2 cruisers in line astern, shelling a French target range in the Bay of Arzew, North Africa]. If the ship was badly damaged and sinking a crew member, who may not have had the opportunity to learn to swim, though life jackets might have been worn or available, may have suffered acute stress, especially with the thought of the freezing water – the case in the Royal Navy in WWI in the North Sea winter with a survival time of 45 minutes. My grandfather was involved with the Boys Brigade and taught many boys how to swim before WWI. Some came back to thank him after the battle of Jutland, having survived by being able to swim until rescued.
Similarly, aircrew on repeated, prolonged bombing flights, sustained heightened stress levels after being damaged, or short of fuel, the limited chance of returning to base or a crash landing, would have had increased levels of acute anxiety.
In civilian life one may have been involved in a tall building on fire, a ship about to sink, a hijack flight emergency, or being stuck in a panicking crowd. The commonest condition seen today is after a road accident with an associated head injury when the brain is subjected to acceleration and deceleration forces and a diffuse neuronal [axonal] brain injury ensues. However, a complete loss of consciousness and amnesia may give exemption from PTSD.
In warfare the shock wave produced by a close shell burst can cause a traumatic brain injury due to inertial movement of the brain from the blast or shock wave and may result in subtle changes in mentation. Outwardly there may be no sign of injury; the classical ‘shell shock’. Memory may be affected. Some may have loss of smell and taste due to shearing of olfactory fibres passing through the cribriform plate at the top of the nasal cavity.
Similarly, a bullet travelling around the speed of sound, produces a shock wave at right angles to the path of the bullet which may cause a brain injury with only a minor ‘gutter wound’ of the scalp and no skull fracture, but local contusion of the brain cortex beneath; this sometimes may be the source of epilepsy at the time or later.
Nowadays the disorder can be diagnosed if certain criteria apply. For an example after a person is exposed to death directly as a witness, or after exposure in performing a service – such as that endured by emergency personnel. A speaker at a Society meeting held in Grahamstown who had served as an army medic in Vietnam and was still getting flashbacks although fortunately not during his talk! PTSD symptoms may become permanent in about 7% of cases.
Recurrence of symptoms may be from unpleasant memories with or without emotional distress; there may be nightmares, flashbacks of the scene, and unpleasant reminiscences. Negative thoughts or feelings may increase after the trauma. Alternatively there may be memory blanks, self-blame, a sense of isolation and loss of interest in one’s usual activities. Survivors after war’s end tend not to mention or want to discuss their experiences.
Symptoms seen in chronic battle conditions which were diagnosed as ‘neurasthenia’ included exhaustion, mutism, facial twitching and shaking of the hands with or without an insane appearance; crying, stammering and being disturbed by noise, tinnitus and headache. Hallucinations, insomnia and nightmares were common, concentration may be poor. Change in behaviour could be dangerous – ignoring or disobeying orders, wandering off and being found AWOL could be labelled as ‘cowardice in the face of the enemy’ leading to the court martial. Many were sent back into the line after a rest period in the support area since they were not ‘wounded’ – ‘shell shock sick’ rather than ‘shell shock wounded’.
Other symptoms, especially if associated with head injury, could be irritability and aggression, destructive behaviour, hyper-vigilance and startle reactions, hypersensitivity to noise, poor concentration and often with poor sleep and nightmares. To be rescued from burial in a tunnel or collapsed trench wall with associated partial asphyxia and global brain damage could produce similar symptoms.
Chronic stress was described as ‘battle fatigue’ with exposure to the continuous noise of gunfire and shell explosions, little or no sleep, poor food and appalling living conditions in mud with rats and lice. The officer in the front line may also have had the stress of his responsibilities. The time spent in the front line was variable from as little as 2 days or up to 7, depending on enemy activity.
In civilian life the psychological aftermath of child abuse and rape situations is not uncommon. It has even been seen in abattoir workers. Those with a timid personality, a psychological condition or the mentally challenged may be amongst those more prone to the effects of stress.
Symptoms of post-traumatic stress after head injury occur with a memory of the events immediately prior to the loss of consciousness and/or the site of the accident, which may occur later as flashbacks and avoidance of passing the accident site. However, there may be antegrade amnesia when the memory trace is lacking, especially if there is brain injury which may or may not be visible on routine CT Brain scan and termed ‘diffuse neuronal brain injury’ where axons to brain cells are sheared and the cortical cell dies. There is a possibility of some improvement over 2 years post brain injury as surviving brain cells can make new connections, especially if the brain is stimulated, but these never reach 100%. Post–traumatic stress tends to subside with time, but has been seen to persist indefinitely.
Complications and sequelae in severe cases, include anxiety, panic attacks, flash backs and chronic pain [fibromyalgia] that may be increased on touch or in cold weather. Labile emotions occur with depression proportional to the amount of insight into the person’s present status compared to their pre injury life.
Treatment during WWI at first was the common sense of rest and quiet in the support areas; more severe cases might have been fortunate enough to do work on a farm at a distance with the object of distracting their attention to think of other things than themselves. Officers tended to end up in specialised country houses in England. More severe cases were sent to various hospitals in ‘blighty’ where various treatments were tried including electric shock and hypnotism. Rest, quiet and psychotherapy seemed to be the most effective in the long term, though medication from a psychiatrist for mood changes, such as anxiety, could also be needed.
The National Hospital for Paralysis and Epilepsy was a referral hospital in London for neurological cases. Records have been studied for the years 1914 – 1918 as well as those of pensioners beyond that date. There were problems with employment and compensation for those affected and later families unable to cope with the victim’s behaviour.
Up to now, if the head injured patient has a driving licence there is no legislation to stop him from driving again. We had a case where a family bought him a new car whilst he was still in Intensive Care.
We are fortunate that the diagnosis of PTSD is now well recognised and that a compassionate attitude is adopted towards a once stigmatised condition that may occur in military as well as civilian situations.
References
Downing T. Breakdown: The Crisis of Shell Shock on the Somme, 1916. Little, Brown, 2016
Copley I B. Remarkable recovery after a cranio-cerebral injury produced by an impacted hot missile fragment. British Journal of Neurosurgery [1990] 4, 23-27.
Copley I B. Cranial tangential gunshot wounds. British Journal of Neurosurgery, [1991] 5, 43-53.
Corrigan G. Mud, Blood and Poppycock, Britain and the First World War. Cassell, 2004
Sassoon, Siegfried. Memoirs of an Infantry Officer. Faber & Faber, 1920
Internet:
Caroline Alexander. The shock of war.
Lindon S C. National. Hospital records, London Queens Square
Recommended reading:-
Faulks S. Birdsong. Vintage, 1994
About the Author
Ian B Copley has served in various medical capacities in no fewer than three armies British, Rhodesian and South African. His professional recognition as a physician and surgeon extends beyond SA to England and Ireland.
He was Chairman of the SA Military History Society in 1990-1992 and has delivered lectures and written papers for the Journal on several occasions.
As a Rtd Head Neurosurgery, MEDUNSA, and of Neurosurgery at 1 Military Hospital in Pretoria with the rank of Lieut-Col for the SA Defence Force, he is eminently qualified to have shared this paper with the Society.
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