Major Dowson, a barrister of considerable court-martial experience said: "Cowardice is showing signs of fear in the face of the enemy." Such a definition is not helpful to the medical officer who may be called on to decide between cowardice and shell-shock.  Cowardice, if regarded as a lack of or failure to show requisite courage, renders discussion more feasible and assists us in comprehending how the brave after much stress may temporarily fail to show their wonted courage without deserving to be called by an opprobrious term. Fear is the chief factor in both cowardice and emotional "shell-shock" and it was for this reason that cowardice in the military sense was made a subject of enquiry by the Committee.

Witnesses were agreed that cowardice should be regarded as a military crime to be punished when necessary by death. Fear is an emotion common to all and evidence was given of very brave men who frankly acknowledged to it. It is obvious then that fear alone does not constitute cowardice. 

Colonel Allison remarked that with second lieutenants it was their one fear, that they should show cowardice in front of their men.

Dr. Farquhar Buzzard said: "I quite see that fear passes to cowardice. But fear is really an unconscious thing and has a very definite physical manifestation." And again he remarked -" Cowardice is a voluntary attitude taken up by an individual; he adopts a certain attitude that he will not face a situation in which he believes certain things will take place. That is cowardice, if you like to apply the term, but the fact that my knees shake when I am looking over the side of a building is an absolute physical thing over which I have no control."

Prof. Roussy noted the difficulty of distinguishing between cowardice and emotional shell-shock. " Cowardice is lack of self-control of an individual over himself. In the presence of a situation in which there is an element of danger or in which there is an element likely to cause fear, any man who can control himself is a courageous man, but he who gives way, runs away or does certain other actions not esteemed worthy is defined as a coward."

It may then be accepted that neither feeling fear nor manifesting the physical signs of fear - pallor, shaking, tremors, quick pulse do not of themselves constitute cowardice though they are more or less essential to it.  If the individual exercises his self-control in facing the danger he is not guilty of cowardice, if, however, being capable of doing so, he will not face the situation, he is then a coward. It is here that difficulty arises in cases of war neurosis for it becomes necessary to decide whether the individual has or has not crossed that indefinite line which divides normal emotional reaction from neurosis with impairment of volitional control.

Dr. Mapother said: “Frankly, 1 am not prepared to make a decision between cowardice and shell-shock. Cowardice I take to mean action under the influence of fear and the ordinary type of 'shell-shock' was, to my mind, persistent and chronic “fear.”

Dr. Johnson thought that when the symptoms of fear, tremors, sweating, tachycardia persisted or revived on slight emotional stimulation a psycho-neurosis was present.

The subject of courts-martial held during the war received exhaustive investigation by Mr. Justice Darling's Committee immediately upon its conclusion. The report of that committee is before us, and having regard to its terms, the steps subsequently taken to carry out its recommendations, and the evidence which has been given before us, we anticipate that in any future war justice will be administered in a thoroughly satisfactory manner, if the same or a similar policy if followed.

Our conclusions are:

• That the military aspect of cowardice is justified.

• That seeming cowardice may be beyond the individual's control.

• That experienced and specialised medical opinion is required to decide in possible cases of war neurosis of doubtful character.

• That a man who has already proved his courage should receive special consideration in case of subsequent lapse.

MALINGERING AND SHELL-SHOCK.

On this subject the ample evidence heard by the Committee revealed some difference of opinion both as to the prevalence and the practicability of detection of malingered shell-shock.  When closely considered this divergence of views is found to be to some extent more apparent than real and the bulk of evidence is not much at variance. Such discrepancy as exists is partly explicable as arising from the use of the term malingering and as to whether it is interpreted in a limited or broad sense. Again, in those who have been exposed to the stress of battle with its danger, noise, and terrors, there is frequent difficulty in deciding how much of conscious and how much of unconscious motive there may be in the actions of the possible malingerer, since in either case the fundamental instinct of self-preservation is presumably present.

The dividing line between malingering and functional neurosis may be a very fine one and many "shell-shocks" are of hysterical nature; in most there is a halo of hysteria according to Sir F. Mott.   Hysteria was called " La Grande Simulatrice " by Charcot as quoted by Prof. Roussy so that simulation is common to both malingered “shell-shock” and to much genuine “shell-shock."  Further, if we bear in mind how the incidence of shell-shock varied with the morale of different units it may be comprehended how equally competent observers have arrived at different conclusions.

With these preliminary observations the deductions which the evidence appears to justify may now be formulated:
(1) True malingering, meaning the action of one who deliberately attempted imposition in pretending to be suffering from "shell-shock," was of rare occurrence or, as one witness expressed it, " absolute malingering was very common."

(2) Partial malingering, exaggeration of symptoms or prolongation of a condition no longer remaining was far from uncommon and frequently arose from a desire to avoid service or for a continuation of pension. Such form of malingering was found most difficult to deal with even by specialists owing to the doubt which often existed in their minds as to the degree of intention present.

(3) Quasi-malingering, skrimshanking, skulking.  In this group there are included those who, with little or no pretence decamped from the battle as opportunity arose, pleading "shell-shock" as the excuse for their evasion. Their numbers were great. For the most part they made but feeble if any attempt at deception and ultimately by persuasion or command returned to duty.

“Shell-shock” became recognized as a handy excuse, and, indeed, a suggestion also to the many who were ready to avail themselves of any subterfuge to escape from the terrors of the front. If this breaking away of men in small and large numbers is to be classed as malingering, then it must be allowed that malingering occurred in unprecedented proportions.  As a defence in court-martial cases "shell shock" was so frequently pleaded as to be spoken of as a "parrot cry" by a witness of much experience of courts-martial.

The Detection of Malingering.

(a) In the Front Line.  The pronounced case of acute shock cannot be doubted, and mild “shell shock.” cases are best dealt with as being simple exhaustion. It is patent that an exhaustive neurological examination, even if the medical officer were capable of'conducting it, is impracticable. The medical officer, however, may discriminate, and if he knows the character and personality of the man, observes in how far his behaviour appears to be voluntary or involuntary, and makes use of such further observation as circumstances permit of,  he will be assisted in deciding the false from the true.

(b) Away from the Front Line. Though the clumsy malingerer may be easily detected, the able one or the mental defective may occasion considerable difficulty to the medical officer in arriving at a conclusion completely free from doubt. In all cases of consequence the examiner should be specially versed in nervous diseases.

The presence of fine tremors, quick pulse and sweating, if persistent or readily excited by slight emotional stress, may, according to some authorities, be accepted as indicative of psycho-neurosis.  Space does not permit of considering all the details in making a differential diagnosis, but Dr. Mapother, who is quoted below, mentions many, and suggests that cases which show none of the signs of emotion impossible of simulation are very suspicious.

Reviewing the evidence, which was ample, on the subject of malingering and "shell-shock" it is evident that close and often prolonged observation may be necessary, that occasionally doubt may still remain and that in all important cases the decision should be made by a specially trained physician well acquainted with functional nervous disorders.

SUMMARY of the more important evidence on which the above report on Malingering is based.

Dr. Mapother. There was not a hard and fast distinction between either of the common types of Neurosis and simulation. The degree of awareness of intention and motive to deceive might vary even in the same cases at different times. I think most cases of Anxiety Neurosis were wholly genuine to start with. Many remained so throughout but some were consciously protracted and exaggerated later. A few added features not to be explained as effects of fear; more settled down to emphasis of one feature of the original syindrome. Most cases of " Conversion Hysteria " were consciously simulating or exaggerating at first. Eventually the production of symptoms became automatic and some achieved belief in their own symptoms. None of the so-called trophic changes were proof of genuineness.

In Dr. Mapother's opinion any case showing none of those signs of emotion impossible of simulation was suspicious.

The following were such signs of emotional disturbance as could be accepted as excluding conscious simulation:  Tachycardia; Arrhythmia; Diffuse and forceable cardiac impulse. Vasomotor changes, sweating, flushing. Enlargement of thyroid; Fine tremor of face and tongue; Fine tremor of hands of a quality only distinguishable by experience; Stammer only distinguishable by experience;  "Increased tendon jerks only distinguishable by experience;  Increase of supinator and triceps jerks much more important than of knee jerks; Insomnia and evidence of nightmares;  Polyuria;  Diarrhoea confirmed by observation. 

Specially suspicious points were profusion and alleged intensity of subjective symptoms with absence of the above.  Intensification of those signs of emotion produced by voluntary muscles with disappearance of those impossible of imitation; especially condensation of the general reaction of fear into one such feature as stammer and an exaggeration of this. Discrepancy of subjective symptoms with conduct; Variation of symptoms when unaware of observation; Variation in accordance with interests.

Other points were - Attitude, towards symptoms, e.g., emphatic repudiation of “mental origin;”  Attitude towards treatment and towards recovery;  Attitude towards discipline and occupation;  Evidence of moral sense in other relations, e.g.,  general untruthfulness, financial dishonesty, the meaner kinds of sexual misdemeanour, etc.

Dr. Hurst : After much investigation of the subject I came to the conclusion that the signs of genuine neuroses and simulation are identical, and that simulation can only be diagnosed with certainty in the very cases in which a malingerer has been detected in flagrante delicto, or when he confesses that he is shamming.

Dr. Johnson. Simulation was rare, but exaggeration of symptoms common. In the forward areas a valuable combination of symptoms indicating Neurosis was:
Fine tremors.  Sweating. Tachycardia.  A full experience and knowledge of men combined with adequate training in the subject of Psycho-neuroses forms the surest safeguard against being imposed on by the malingerer.

Dr. Gordon Hoinies considered that experienced and properly trained officers could usually detect simulation. There was great difficulty in accurate diagnosis in those who exaggerated or prolonged symptoms. During the battle of the Somme a large number of men deserted from the line on the claim that; they had "shell-shock."

Dr. Farquhar Buzzard : I think there were very few people  I should like to say were, absolutely inalingering.

Dr. W. Brown stated that in 1,000 cases he had found 28 cases of serious malingering, all of whom had confessed to him. Most with malingering had loss of memory, and he considered feigned amnesia was easily detected.

Squadron Leader Tyrrell, referring to his front line experiences, said he depended on his knowledge of the man, observation, judgment as to whether his behaviour, etc., was voluntary or involuntary, and in the exercise of common sense in distinguishing the genuine from the feigned shell-shock case.

Dr. Hampton: Many cases were on the border line between conscious and unconscious malingering.

Lieut-Colonel Scott Jackson:  Many cases of neurasthenia and 'shell-shock ' were skrimshanking of the worst type.

Major Adie: " We did not see much malingering."

Dr. Wilson,  in speaking of men who took advantage of an attack to get away, said:  "I do not know how much malingering there is in these cases; it is almost impossible to tell."

Colonel Campbell considered " shell-shock " a favourite method which malingerers employed to get away from the battle front; in a unit with poor morals this form of skrimshanking becomes contagious.

Dr. Dunn said: " In acute shock a man abandons himself to his terror. 1 have not seen an attempt to simulate it, and I cannot imagine such an attempt deceiving anyone."

Colonel Jervis considered the number of emotional breakdowns was slight as compared to the number " swinging the lead."

Colonel Soltau thought information in a suspect case could be obtained by observation during sleep and also by suddenly awakening the case. He had only detected two malingerers himself.

Major Longmore remarked that in court-martial cases "ShellShock " became a. parrot cry as a defence.