“They were very pathetic, these shell shocked boys.”
[The fifth of a series of essays about the gallant nurses of World War I commemorating the centennial of America’s entry into the war on April 6, 1917]
Every war has mental casualties, but each war has its own way of understanding them. Each war, that is, has its own nomenclature for what we now term “psychiatric diagnosis.” To Napoleon’s Surgeon in Chief, Dominique-Jean Larrey, we owe the diagnosis nostalgie (nostalgia); it characterized soldiers whose homesickness left them depressed and unable to fight. This was in 1815. During the American Civil War, nostalgia remained in vogue, but a new term, “irritable heart” (aka “soldier’s heart” or “Da Costa’s Syndrome”) was coined just after the war to label soldiers whose uncontrollable shivering and trembling had been accompanied by rapid heart beat and difficulty breathing. During the 10-week Spanish-American War of 1898, soldiers who broke down mentally amid heat, bugs, bullets, and rampant typhoid fever were diagnosed with “tropical weakness.”
And this brings us to World War I, the war that bequeathed the diagnosis of shell shock. At first, the nurses of WWI were no less baffled by variable expressions of shell shock – most cases of which, it was learned, arose some distance from the exploding shells at the Front – than the doctors. The term was coined in 1915 by the British physician and psychologist Charles Myers, then part of a volunteer medical unit in France. Myers immediately realized the term was a misnomer: he coined it after seeing three soldiers whose similar psychological symptoms followed the concussive impact of artillery shells bursting at close range, only to discover that many men with the same symptoms were no where near exploding shells. In May, 1917, the American psychiatrist Thomas Salmon, with the approval of the War Department, traveled to England to observe how the British treated their shell shocked soldiers; he returned home convinced that shell shock was a real disorder, not to be taken for malingering, and a disorder that was amenable to psychological treatment. Salmon was the Medical Director of the National Committee for Mental Hygiene, so his report to the Surgeon General carried weight, and the Army began making arrangements for treating the mental casualties that, he predicted, could flood overseas and stateside hospitals following America’s entry into the war.
Nurses were unconcerned with the animated debate among physicians on the nature of shell shock. Was it a kind of brain concussion that resulted from the blast force of exploding shells? A physiological response to prolonged fear? A psychological reaction to the impact of industrial warfare? A product of nervous shock analogous to that suffered by victims of railway accidents in the later nineteenth century? A Freudian-type “war neurosis” that plugged into earlier traumas that the soldier had suffered? They did not care. Theirs was the everyday world of distressed soldiers, whose florid symptoms overlaid profound anxiety and for whom the reliving of trauma and its aftermath occurred throughout the day. Theirs was the world, that is, of management and containment.
The management part could be bemused, good-naturedly patronizing, a tad irritated. Shell shock victims, after all, made unusual demands on nurses. The patients were always falling out of bed and otherwise “shaking and stammering and looking depressed and scared.” Simple tasks like serving meals could be a project, as attested to by the British nursing assistant Grace Bignold, who, prior to becoming a VAD in 1915, worked as an orderly at a London convalescent home. There, she recalled,
One of the things I was told was that when I was serving meals . . . always to put the plate down very carefully in front of them and to let them see me do it. If you so much as put a plate down in front of them in the ordinary way, when they weren’t looking, the noise made them almost jump through the roof – just the noise of a plate being put on a table with a cloth on it? 
Accommodation by the orderlies at mealtime paled alongside the constant burden on ward nurses who had to calm hospitalized shell shock soldiers when exploding shells and overhead bombs rocked the hospital, taking patients back to the Front and causing a recurrence of the anxiety attendant to what they had seen or done or had done to them or to others. And both, perhaps, paled alongside the burden of nurses in the ambulance trains that transported the shell shocked out of the trenches or off the battlefield. “It was a horrible thing,” wrote the British VAD and ambulance nurse, Clair Elise Tisdall,
because they sometimes used to get these attacks, rather like epileptic fits in a way. They became quite unconscious, with violent shivering and shaking, and you had to keep them from banging themselves about too much until they came round again. The great thing was to keep them from falling off the stretchers, and for that reason we used to take just one at a time in the ambulance. . . . these were the so-called milder cases; we didn’t carry the dangerous ones. They always tried to keep that away from us and they came in a separate part of the train.”
The latter were the “hopeless mental cases” destined, Tisdall recalled, for “a special place,” i.e., a mental hospital, in England a “neurasthenic centre.” But how to tell the difference? The line between “milder” and “severe” cases of shell shock was subjectively drawn and constantly fluctuating; soldiers who arrived in the hospital with some combination of headaches, tremors, a stutter, memory loss, and vivid flashback dreams might become psychosomatically blind, deaf or mute or develop paralyzed or spastic limbs after settling into base hospitals and the care of nurses. In their diaries and letters home, the nurses’ characterizations were not only patronizing but sometimes unkind: shock patients, often incontinent, were “very pathetic”; they formed “one of the most pitiful groups” of soldiers. Dorothea Crewdson referred to them as “dithery shell shocks” and “old doddering shell shocks.” A patient who without warning got out of bed and raced down the hall clad only in his nightshirt was a “dotty poor dear.” “It is sad to see them,” wrote Edith Appleton. “They dither like palsied old men, and talk all the time about their mates who were blown to bits, or their mates who were wounded and never brought in. The whole scene is burnt into their brains and they can’t get rid of the sight of it.”
It is in the containment aspects of their care of the shell shocked that the nurses evinced the same caring acceptance they brought to all their patients. After, all, shell shocked patients, however they presented, were wounded soldiers, and their suffering was as real and intense as that of comrades with bodily wounds. The nursing historian Christine Hallett, who writes of the WWI nurses with great sympathy and insight, credits nurses working with the shell shocked with an almost preternatural psychoanalytic sensibility in containing the trauma that underlay their symptoms. The nurses, she claims, aligned themselves with the patients, however disruptive their outbursts and enactments, since they “sensed that insanity would be a ‘normal’ response for any man who fully realized the deliberateness of the destruction that had been unleashed on him.” Hence, she continues,
Nurses conspired with their patients to ‘ignore’ or ‘forget’ the reality of warfare until it was safe to remember. In this way they ameliorated the effect of the ‘psychic splintering’ caused by trauma. They contained the effects of this defensive fragmentation – the ‘forgetting’ and the ‘denial’ – until patients were able to confront their memories, incorporate them as part of themselves and become ‘whole’ beings again.
I follow Hallett in her insistence that nurses usually ignored the directive not to “spoil” shell shocked patients. All too often, they let themselves get involved with them at the expense of maintaining professional distance.
But then the nurses were equally caring and equally prone to personal connection with all their patients, mental or not. They were not psychotherapists, and the dizzying demands of their long days and nights did not permit empathic engagement in the psychoanalytic sense, beyond the all-too-human realization that the shell shocked had experienced something so horrible as to require a gentleness, a lightness of touch, a willingness to accept strange adaptive defenses that, with the right kind of nursing, might peel away slowly over time. Here, for example, is one of Hallett’s examples of “emotional containment” on the part of the Australian army nurse Elsie Steadman:
It was very interesting work, some of course could not move, others could not speak, some had lost their memory, and did not even know their own names, others again had very bad jerks and twitching. Very careful handling these poor lads needed, for supposing a man was just finding his voice, to be spoken to in any way that was not gentle and quiet the man ‘was done,’ and you would have to start all over again to teach him to talk, the same things applied to walking, they must be allowed to take their time.”
This sensitivity, this “very careful handling” of the shell shocked, was no different than the sensitivity of the mealtime orderlies, who knew to “put the plate down very carefully in front of them,” always making sure that the shell shocked saw them do it. And of course there were accommodations out of the ordinary, a remarkable example of which comes from Julia Stimson, the American chief nurse of British Base Hospital 21 (and amateur violinist). Writing to her parents in late November, 1917, she related “an interesting little incident” that began when a patient knocked on her door and asked for the Matron:
He was so wobbly he almost had to lean up against the wall. “Somebody told me,” he said, “that you had a violin. I am a professional violinist and I have not touched a violin for five months, and today I couldn’t stand it any longer, so I got up out of bed to come and find you.” I made him come in and sit down. As it happened I had a new violin and bow, which had been bound for our embryo orchestra, here in my office. The violin was not tuned up, but that didn’t matter. The man had it in shape in no time and then he began to play and how he could play! We let him take the violin down to his tent, and later sent him some of my music. He was a shell shock, and all the evening and the next few days until he was sent to England he played to rapt audiences of fellow patients.
With the shell shocked, the therapeutic gift of the WWI nurses resided less in their ability to empathize than in their acceptance that their patients had experienced horrors that could not be empathized with. Their duty, their calling, was simply to stay with these soldiers in an accepting manner that coaxed them toward commonality among the wounded, the sense that their symptoms and the underlying terror were not only understandable but unexceptional and well within the realm of nursing care. In this sense – in the sense of a daily willingness to be with these soldiers in all their bodily dysfunction, mental confusion, and florid symptomatic displays – the nurses strove to normalize shell shock for the shell shocked. After all, the shell shocked, however dithery, shaking, and stammering, were depressed and scared “only at times.” Otherwise, continued Dorothea Crewdson, “they are very cheery and willing.” Mary Stollard, a British nurse working with shell shocked soldiers at a military hospital in Leeds, noted that many of the boys were very sensitive to being incontinent.
They’d say, ‘‘I’m terribly sorry about it, Sister, it’s shaken me all over and I can’t control it. Just imagine, to wet the bed at my age!” I’d say, “We’ll see to that. Don’t worry about it.” I used to give them a bedpan in the locker beside them and keep it as quiet as possible. Poor fellows, they were so embarrassed – especially the better-class men.”
But such embarrassment was a relic of civilian life. It had no place among battle-hardened nurses who coped daily with the sensory overload of trench warfare: the overpowering stench of gangrenous infections and decaying flesh; the sight of mutilated soldiers without faces or portions of torso, not to mention missing arms and legs; the screams of gassed soldiers, blind and on fire and dying in unspeakable pain. Alongside such things, how off-putting could incontinence be? The fact is that shell shocked soldiers, no less than the nurses themselves, were warriors. Warriors are wounded and scarred in many ways; nurses themselves fell victim to shell shock, even if they were not officially diagnosed as such. Knowing full well that shell shocked soldiers declared physically unfit and shipped back home were often subject to stigma and humiliation, Ellen La Motte offered this dismal prognosis for one who had lost the ability to walk and could no longer serve the nation: “For many months he had faced death under the guns, a glorious death. Now he was to face death in another form. Not glorious, shameful.”
 Earl D. Bond, Thomas W. Salmon – Psychiatrist (NY: Norton, 1950), 83-84.
 Julia C. Stimson, Finding Themselves: The Letters of an American Army Chief Nurse in a British Hospital in France (NY: Macmillan, 1918), 41; Dorothea Crewdson, Dorothea’s War: A First World War Nurse Tells her Story, ed. Richard Crewdson (London: Weidenfeld & Nicolson, 2013), loc 4383; Grace Bignold, in Lyn MacDonald, The Roses of No Man’s Land (London: Penguin, 1993), 233.
 Claire Elise Tisdall, in MacDonald, Roses of No Man’s Land, 233-34.
 Mary Stollard, in MacDonald, Roses of No Man’s Land, 231-32; Stimson, Finding Themselves, 41; Crewdson, Dorothea’s War, loc 967; Edith Appleton, A Nurse at the Front: The First World War Diaries, ed. R. Cowen (London: Simon & Schuster UK, 2012), 184.
 Christine Hallett, Containing Trauma: Nursing Work in the First World War (Manchester: Manchester University Press, 2009), 163.
 Hallett, Containing Trauma, 165, 177.
 Hallett, Containing Trauma, 172-73.
 Stimson, Finding Themselves, 163.
 Crewdson, Dorothea’s War, loc 4383; Stollard, in MacDonald, Roses of No Man’s Land, 232.
 E.g., Crewdson, Dorothea’s War, loc 4914; In “Blind,” Mary Borden writes of herself as “jerk[ing] like a machine out of order. I was away now, and I seemed to be breaking to pieces.” She was sent home as “tired.” Mary Borden, The Forbidden Zone (London: Hesperus, 2008, 103). On the military’s unwillingness to diagnose women as “shell shocked,” see Hannah Groch-Begley, “The Forgotten Female Shell-Shock Victims of World War I,” The Atlantic, September 8, 2014 (https://www.theatlantic.com/health/archive/2014/09/world-war-ones-forgotten-female-shell-shock-victims/378995).
 Ellen N. La Motte, The Backwash of War: The Human Wreckage of the Battlefield as Witnessed by an American Hospital Nurse (NY: Putnam’s, 1916), 239.
Copyright © 2017 by Paul E. Stepansky. All rights reserved. The author kindly requests that educators using his blog essays in their courses and seminars let him know via info[at]keynote-books.com.