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The First World War devastated the lives of a generation of young men. But the trauma of war didn't end when the guns stopped firing ...

Thousands of soldiers returned from the battlefields and trenches of the First World War reeling from the sheer horror of the conflict.

By the end of the war, 20,000 men were still suffering from shell shock. Thousands more had experienced its symptoms during their military service.

Inside Out Extra looks at the condition and visits Seale Haynes, a medical centre ahead of its time in dealing with the trauma of shell shock.

On the front line

Across the country, doctors were mystified by a condition that they hadn't seen before. Soldiers were returning from the trenches blind, deaf, mute or paralysed.

But doctors coudn't find any physical damage to explain the symptoms.

The term 'shell shock' was coined in 1917 by a Medical Officer called Charles Myers. It was also known as "war neurosis", "combat stress" and Post Traumatic Stress Disorder (PTSD).

At first shell shock was thought to be caused by soldiers being exposed to exploding shells.

Medical staff started to realise that there were deeper causes. Doctors soon found that many men suffering the symptoms of shell shock without having even been in the front lines.

A shock to the system

In the early years of World War One, shell shock was believed to be the result of a physical injury to the nerves and being exposed to heavy bombardment.

Shell shock victims often couldn't eat or sleep, whilst others continued to suffer physical symptoms.

Shell Shock - The symptoms

Hysteria and anxiety

Paralysis

Limping and muscle contractions

Blindnes and deafness

Nightmares and insomnia

Heart palpitations

Depression

Dizziness and disorientation

Loss of appetite

Many soldiers found themselves re-living their experiences of combat long after the war had ended.

Officers suffered some of the worst symptoms because they were called upon to repress their emotions to set an example for their men.

War neurosis was four times higher among officers than among the regular soldiers.

The war poet Siegfried Sassoon, himself a victim, describes the psychological pain of shell shock in his poem Survivors.

He writes of soldiers with "dreams that drip with murder" and their "stammering, disconnected talk".

Victims of shell shock

By 1916, over 40% of the casualties in fighting zones were victims of the condition.

At the end of the war over 80,000 cases of shell shock had passed through British Army medical facilities.

The huge number of shell shock cases was completely unexpected. By 1915 there was a shortage of hospital beds for sufferers.

Many county lunatic asylums, private mental institutions and disused spas were taken over and designated as hospitals for mental diseases and war neurosis. By 1918 there were over 20 such hospitals in the U.K.

Many shell shock victims served at the Battle of the Somme - official figures put the figure at 16,000 but military experts say that the true figure could be much higher.

No sympathy

At the time there was little sympathy for shell shock victims.

Shell shock was generally seen as a sign of emotional weakness or cowardice.

Many soldiers suffering from the condition were charged with desertion, cowardice, or insubordination.

The unlucky ones were subjected to a mock trial, charged, and convicted.

Some shell shocked soldiers were shot dead by their own side after being charged with cowardice. They were not given posthumous pardons.

The road to recovery

Shell shock victims found themselves at the mercy of the armed forces' medical officers.

Treatment was often harsh and included...

solitary confinement

disciplinary treatment

electric shock treatment

shaming and physical re-education

emotional deprivation

The "lucky" ones were treated with a variety of "cures" including hypnosis, massage, rest and dietary treatments.

A revolutionary treatment

But at Newton Abbott's Seale Hayne in Devon, the approach was very different.

Today the hospital is part of Plymouth University, but in its early days it was at the centre of a national crisis.

More than 80 years ago men arrived at the hospital nervous wrecks, seemingly destroyed by the terrors of the First World War

They were suffering from shell shock, and the hospital's treatment was revolutionary for its time.

Arthur Hurst, an army major, swept aside opposition to establish himself at Seale Hayne.

His miracle treatments meant that he was able to cure 90% of shell shocked soldiers in just one session.

Miracle cure

Soon Hurst was being acclaimed as a miracle worker, but how did he weave his magic on the sick soldiers?

Hurst made the only film in existence about how shell shock victims were treated in Britain. These rare recordings give an insight into Hurst's dramatic techniques.

One of the films follows Private Percy Meek who was driven almost mad during a massive bombardment of the Western Front.

When he first came under Hurst's care, he'd regressed into a babylike state and was sitting in a wheelchair.

Gradually Meek recovered the physical functions he'd lost, and returned to normality under Hurst's tutelage.

Taking the cure

Another of Hurst's techniques was to take the men to the peace and quiet of the rolling Devon countryside.

It was thought to be a place where the men could get over their hysteria through labouring on the land. The men toiled on the farm, and were encouraged to use their creative energies.

Arthur Hurst even encouraged his patients to shoot.

He also directed a reconstruction of the battlefields of Flanders on Dartmoor to help the men relive their experiences.

Back indoors, the men were encouraged to write and to produce a magazine with a gossip column called Ward Whispers.

Pioneering help

Arthur Hurst's son Christopher recalls his father's treatments, "The main work was occupational therapy. These soldiers, who had been shell shocked, had lost vital faculties, like walking, speaking and so on, were given jobs to do here.

"This was interspersed with intensive therapy sessions. My father... was head of a team, but he was the guiding genius here. He cured these cases by means of persuasion and hypnotism."

Hurst's pioneering methods were both humane and sympathetic. It was a miracle that literally saved the lives of dozens of shattered men.

At Seale Hayne the shell shocked soldiers were treated with humanity and dignity.

It remains a living testament to the men who survived the horrors of the First World War.

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The First World War devastated the lives of a generation of young men. But the trauma of war didn't end when the guns stopped firing ... Thousands of soldiers returned from the battlefields and trenches of the First World War reeling from the sheer horror of the conflict.

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The Shell-Shocked Soldier ↑

In 1916 a young Australian soldier was admitted to Seale Hayne hospital in Devon from where he wrote the following letter to his family:

You may be a little surprised to hear that I am in the hospital suffering from shell shock, which has taken away my speech and hearing. It is some sixteen days now since it happened [...] We were in the trenches and going for dear life, when two of us spotted a German machine-gunner in a hole, so we made up our minds to have him, and I just remember getting to him when a high explosive shell burst at my head; it seemed as if it burst inside my head; everything went black. I tried to call out and couldn't and I could not hear my mates - only just a terrible bursting in my head all the time. I never remembered anything more until I came onto the boat [...] The doctors have told me that I will get all right in time.

The soldier was suffering from shell shock. In his case the symptoms were hysterical deafness and loss of speech, conditions which were treated with a single dose of ether. Doctors told him in writing that it would restore his speech and hearing. He initially struggled but after a few whiffs he whispered "mother". He "then repeated it louder and louder until he shouted with a voice that would have filled the Albert Hall." Once his voice and his hearing returned the associated conditions - depression, headaches and insomnia - disappeared too.

Arthur Hurst (1879-1944), a neurologist and commanding officer at Seale Hayne told this story to demonstrate wartime psychiatry at its most successful. The soldier, an ordinary man from the ranks, had broken down during active combat and so he had nothing to be ashamed of. In addition he had faith in the doctors who were his social and military superiors and he responded well to treatment. Like many others in this situation his first words were indicative of his moral character: in doctors' descriptions men recovering their voices generally called for their mothers, sang the national anthem or declared "God Save the King!"

By 1916, the military medical professions of all combatant armies were developing ways of managing mentally wounded soldiers. Men have long broken down in wars but it was not until the First World War that mental breakdown amongst troops presented a significant problem in terms of morale and manpower. Given the nature of war neurosis it is difficult to estimate accurately the numbers of men that were affected. There were over 80,000 recorded cases amongst the British armies on the western front; estimates amongst German troops range from 200,000-300,000 and the number of French troops affected was similar or possibly higher. The statistics identify horrific numbers of traumatised men but war neuroses accounted for only a relatively small percentage of battle casualties overall. Nevertheless medical officers at the time felt overwhelmed by the "extraordinary incidence of mental and functional nervous diseases": the numbers of mentally wounded were unprecedented by comparison with previous wars, and shell shock affected military morale and discipline "in a special way." It is this "special" nature of First World War shell shock that has provoked such widespread interest in the subject, as the treatment of military mental breakdown has provoked questions about madness, class, masculinity, medical progress and military discipline. As a result the history of First World War shell shock is broad and includes the history of mental trauma per se, the history of shell shock as a specific military medical condition and its social and economic consequences, and the history of shell shock as an emblem or a metaphor for the war and its aftermath.

Shell Shock and History ↑

There was much medical commentary on shell shock during and immediately after the war yet historians paid little attention to its history until the late 1970s when Eric Leed argued that shell shock was a soldier's flight from 'intolerable reality' and that neurosis provided men with a legitimate - if temporary - respite from the rigours of warfare. This was the first of numerous studies into military medicine and ethics. The recognition of Post-Traumatic Stress Disorder (PTSD) in 1980 prompted historians and medical experts to situate modern trauma in its historical context. This attention to the history of war neuroses was matched by a growth in the longer-term histories of shell-shocked men and their families, many of whom had to deal with the emotional impact of the war for years, or even decades, after the armistice.

In Britain there has long been an extensive historical, political and cultural interest in shell shock. The topic does not have the same popular resonance in Germany: nevertheless there is a substantial history of German wartime and post-war psychiatry. Paul Lerner's seminal work indicates the extent to which the history of modern German psychiatry has long been seen through the prism of the Third Reich. Yet to understand early 20 th century war psychiatry we need to abandon this teleological narrative and focus instead on the political, economic and cultural debates of Wilhelmine Germany because it was the social legislation of the Second Reich which meant that neurotic soldiers were treated in the same way as injured industrial workers. Turning to the post-war world, Jason Crouthamel highlights the tensions surrounding the treatment of war neurotics as rival political groups tried to appropriate mentally wounded veterans for their own causes. In France, Sophie Delaporte opened up the study of French shell shock, ensuring that trauma became crucial to the wider understanding of the First World War. Gregory Thomas' extensive history investigates the effect of war neuroses on soldiers, civilians, and medical professionals but shell shock is still a comparatively under-researched subject in France, despite a growing interest in the history of the war itself.

A number of historians have recently incorporated the psychologically wounded into the wider medical history of the First World War, yet there has been no European survey of the history of shell shock. In response, this article offers a brief synthesis of combatant trauma throughout Europe. The focus is on the soldiers of the primary combatant nations on the western front because although men were traumatised in all areas, the conditions on the western front were unique, being characterised by highly industrial, intensive and static trench warfare. In consequence, the type of "mental cases" seen on the western front were not replicated in all sectors.

Doctors and Shell Shock: Early Responses ↑

The first mental casualties appeared after the Battle on Mons in 1914 and they portrayed a baffling range of symptoms: tics, trembling, functional paralysis, hysterical blindness and deafness, speech disorders ranging from stuttering to mutism, confusion, extreme anxiety, headaches, amnesia, depression, unexplained cramps, fainting and vomiting. It had long been understood that strong nerves would be required to fight a modern industrial European war. Wilhelm II, German Emperor (1859-1941) had declared that victory would go to the nation with "strongest nerves" - yet many German doctors believed that war would provide "cathartic front experiences" that would actually strengthen enfeebled, degenerate modern men. Similarly, many French doctors believed that the war would revitalise individual Frenchmen as well as French science and medicine. The sense of war as a tonic was strongest amongst the German psychiatric profession but was also present in Britain where doctors routinely extolled the virtues of "character."

In retrospect doctors were able to argue that the First World War produced "no new symptoms". Yet doctors dealing with mentally traumatised soldiers often felt that they were facing completely unprecedented problems. Lieutenant Colonel Charles Myers (1873-1946) anthropologist and consulting psychologist to the British Expeditionary Force first publicly used the term "shell shock" in The Lancet in February 1915. The term implied a direct link between a bursting shell and trauma, a diagnosis that was as emotionally satisfying as it was medically imprecise, as Myers quickly recognised. Consequently, British medical and military authorities tried in vain to proscribe the term and to find a suitable alternative. In 1917 Medical Officers were instructed to label possibly traumatised men as NYDN (Not Yet Diagnosed Nervous) but throughout the war, and afterwards, men continued to be described as "shell-shocked" and a wide range of other terms were used too: hysteria, neurasthenia, hybrid hystero-neurasthenia, nerve shock, war shock, war neurosis, exhaustion. Closer to the front line, doctors' private papers sometimes simply refer to men as "mental cases" or even "dotty". There is no direct translation for the Anglo-Saxon "shell shock" but there was a similar variety of descriptions in other European armies. The French discussed commotion cerebrale, accidents nerveux, and obusite ("shellitis"). French commotionnés were most commonly diagnosed with hysteria and tended to be described as suffering from "mental confusion". German medics referred to Kriegneurosen and Krieghysterie, and sufferers were popularly referred to as Kriegszitterer (war quiverers) or Schüttler (shakers). The Italians referred to shock da esplosione emphasising the importance of the physical shock. Thomas Salmon, who had been commissioned to observe the British treatment of shell shock for the US army, commented that "it is doubtful if there is another group of diseases in which more confusion in terms exists."

War psychiatry does not develop in isolation from civilian psychiatry and throughout the war military psychiatry drew from concepts in the civilian world where there had been much medical investigation into mental trauma since the late 19 th century. Shell shock may have appeared to be a new condition, requiring a new language but responses to mentally traumatised, apparently hysterical soldiers were all rooted in the debates, cultural assumptions and practices of the pre-war period. The violence of the modern, industrial world was provoking anxiety long before the outbreak of the First World War. Passengers and workmen involved in railway accidents often suffered from odd symptoms such as partial paralysis, headaches, backache, dizziness and loss of memory, none of which seemed directly related to the initial impact or physical shock. While it was accepted that "railway spine" could be explained by damage to the central nervous system, there was also some debate about the extent to which it had been caused by "fright alone". "Neurasthenia" was also coined in this period. In 1869 George Beard (1839-1883), an American physician and neurologist, used the term to describe patients suffering from a range of physical and mental symptoms such as headaches, impotence, anxiety, paralysis, neuralgia, depression and loss of memory. He attributed neurasthenia to the nerve damage caused by the strain of modern, highly competitive, urban life. As a result of its association with modernisation sufferers were not stigmatised and were often treated with Silas Weir Mitchell's (1828-1914) "rest cure". A modified version of this cure was later adapted to treat British officers during the First World War.

Railway spine and neurasthenia affected men and women alike but hysteria has traditionally been considered a specifically female complaint. In France, the acclaimed neurologist Jean-Martin Charcot (1825-1893) published widely on traumatic hysteria, indicating that it was not a malady appertaining only to women and to effete men: his male patients were workers, artisans and peasants. However despite this nuanced understanding of male hysteria, the subject was barely mentioned in medical textbooks, encyclopaedias or dictionaries. On the whole hysteria remained "a female malady". Yet hysteria was also a class-bound diagnosis and since the late 19 th century German psychiatrists had used it to pathologise "work-shy" working-class men. In Britain the situation was similar and so during the war it became normal practice to categorise traumatised officers as neurasthenic and in need of rest and recuperation whereas men from the ranks were more likely to be labelled as hysterical and treated more harshly. Despite official proclamations insisting that these "unfortunate men would not be treated like ordinary lunatics", many men with hysterical symptoms did feel that they were punished and incarcerated rather than treated.

In both war and peace the psychiatrist's role remains the same, namely to diagnose and to treat the mentally disturbed patient and to further scientific knowledge through clinical observation. In addition, psychiatrists had their own political and professional aims, and many doctors were enthusiastic about the professional opportunities offered by the war. German doctors thought of the war as a great "experiment", similarly their French counterparts saw it as "a grandiose laboratory experiment". However, the comparison fell short because laboratory experimentation implies order and a level of control which was not always possible in wartime, especially close to the fighting zones. First, men were not always treated by mental-health specialists, especially in the early stages of the war. In addition, doctors continually complained about the difficulty of collecting statistics, monitoring cases and maintaining dialogue with colleagues. Doctors working at the Salpêtrière in Paris admitted that some of their methods were "makeshift", and some Italian medics even abandoned all correlation between diagnosis and treatment. At the same time, war psychiatrists were faced with more than just practical difficulties as the conditions of war served to deepen, rather than alleviate, some key pre-war anxieties. Fin de siècle psychiatry had developed amongst fierce concerns about national degeneracy and a strong belief in social Darwinism. Yet the belief that only fit societies would survive was combined with growing fears that relentless trench warfare was producing a dis-eugenic war, one in which the least fit were destined to survive. This provoked already entrenched fears of "pension neurosis" or even outright fraud. The belief that the financial security of a pension would encourage a man to maintain rather than discard his neurotic symptoms continued as a source of political friction and social resentment throughout the inter-war years.

The practical arrangements for shell-shocked casualties varied across sectors and developed in response to the exigencies of warfare and to the professional goals of the medical profession. British and German troops were initially sent home for treatment but the French - fighting on their own territory - were less able to send men away from the firing lines and so developed treatment centres closer to the front. By the summer of 1917 each French army had its own neurological centre, with approximately 200 beds, about fifteen miles from the front, and these were supported by regional neurological bases and psychiatric centres further to the rear. All neurological cases were directed to the forward centres in the first instance because specialists wanted to deal with mental complaints before they became intractable. Influenced by the French example, Myers insisted on forward centres in the British zones. The military command was initially hostile but forward treatment soon became standard practice amongst the western allies. The approach of the Central Powers was different. The German armies continued to send troops back to Germany where they were generally treated in large hospitals although work-based therapies were developed in Germany from 1915. In stark contrast, the Austro-Hungarian armies centralised their treatment in Vienna and by the end of the war there were approximately 120,000 shell-shocked soldiers in the capital. The Austro-Hungarian approach was unique as throughout Europe mentally wounded soldiers were generally hidden or dispersed - in Britain "mental cases" were often not unloaded with the physically wounded men but were held in separate railway carriages and quietly spirited away to remote locations, far from the gaze of onlookers or even ordinary nursing staff.

Shell Shock, Cowardice and Discipline: the Ethics of Military Mental-Medicine ↑

"Can war make any man a coward in time?" asked Charles McMoran (1881-1977), later Lord Moran, a renowned physician who served in both world wars. This question lay behind much military medical treatment because doctors were dealing with men who would not or could not fight, despite the lack of an obvious physical wound. Moran eventually concluded that all men had a limited stock of courage and that "men wear out in war like clothes" but not all medics agreed. Frederick Walker Mott (1853-1926) dismissed some of the shell-shocked as simply "shell-shy", a term every bit as disparaging and dismissive as the "work-shy" label which had been applied to the pre-war working class, and many doctors would have concurred with Marc Bloch's (1886-1944) rather contemptuous dismissal of a French corporal as a "neurasthenic man of the world, not much of a warrior". Most doctors wholeheartedly supported the war aims of their respective nations and also accepted that self-respecting, healthy males should make effective soldiers.

The relationship between serving soldiers and their medical officers is not always straightforward. Doctors can be seen as the humane, civilising face of warfare: the International Red Cross had organised medical care so as to humanise warfare and some pacifists, while eschewing military combat, accepted military medical service. Yet the belief that doctors were primarily committed to their own armed services - and to their own career advancement - often provoked antagonism from ordinary soldiers. In the doctor-patient relationship the power is tilted towards the doctor and during wartime this asymmetrical power relationship was weighted even more heavily in the doctor's favour because doctors were medical officers and therefore senior in rank - and also in class - to most soldier patients. As a result, soldiers from the other ranks were often hostile to medical officers and this hostility was especially rife in cases of war neuroses where a neurologist, psychiatrist or even a doctor without specialist training could withhold treatment rights, deny a pension or sanction disciplinary action. For these reasons men in the trenches often tried to avoid sending a mentally wounded man to see a doctor. In 1916 a British soldier in the trenches was stricken dumb with fear. Recognising the loss of speech as an hysterical symptom, his comrades slapped him, tickled him and poured boiling tea over him to make him shriek. This ad hoc treatment may seem absurd but its purpose was to restore the man's speech and spare him from the medical professionals: it tells us much about the ordinary soldier's faith in wartime psychiatry.

The language of cowardice permeates the wartime discourse and even in its absence doctors assumed that war neurosis arose in men who were predisposed to some kind of mental breakdown and were therefore flawed, if not culpable. Yet although doctors shared these basic assumptions the range of treatments was diverse. First responses often encouraged rest on account of the links between shell shock and physical and mental exhaustion. A British stationary hospital in France simply encouraged men to stay in bed for three or four days and German soldiers were also given "soft" therapy in the form of spruce needle baths, good food and valerian. More focused or active therapies could include re-education, hypnosis, intensive massage or hydrotherapy. These treatments were all designed to re-awaken the afflicted senses and demonstrate to the patient that he still had control of his physical faculties. The ether given to the young Australian at Seale Hayne was to relax him so that he would be more suggestible, and ether often accompanied light hypnotism. Re-education could be benign - it included singing lessons for men with speech disorders - but it could also appear harsh. Hurst describes trying to awaken a man suffering from hysterical deafness by banging a poker on a coal scuttle at his bedside - a type of treatment very similar to that carried out by the ordinary Tommies in the trenches. In contrast, a limited range of practices were inspired by psycho-analytic theory. William Rivers (1864-1922) has become famous for the "talking-cure" at Craiglockhart, a British hospital for officers, and there were also attempts to promote dream therapy in men from the other ranks in the Red Cross hospital at Maghull. Men resisted the dream therapy, which they perceived as intrusive, but they were most visibly opposed to harsh physical treatments which seemed little short of punitive.

It is electro-shock therapy, known as the Kaufmann treatment in Germany and Austria, which has become the most notorious of shell-shock treatments. The Hamburg neurologist and wartime psychiatrist Professor Max Nonne (1861-1959) required his patients to be naked during treatment to increase their vulnerability, as did many doctors in France. In Britain Lewis Yealland's (1884-1954) electrotherapy evoked disquiet not just from ordinary soldiers but from other doctors who worried that the over-use of simple electrotherapy would condemn patients to the care of untrained "medical electricians". Proponents of electric shock therapy argued that it worked and that it was not necessarily inhumane. Yet whatever its merits, soldiers were frightened of it and protests demonstrate the extent to which patients and the general public wanted to curtail the excessive power of wartime psychiatrists. In May 1916, Baptiste Deschamps (1881-1953), an ordinary soldier in the French army, was sent to Dr Clovis Vincent's (1879-1947) neurological centre for treatment. As the electric treatment was beginning, a clearly terrified, and possibly furious, Deschamps punched Vincent, an action punishable by death. Deschamps was tried and found guilty of having assaulted a superior officer but was only given a suspended sentence of six months in prison. The case provoked a great public outcry in Deschamps' favour and, despite the power of the military medical profession, the tribunal was forced to treat him leniently.

Not all doctors were quick to brand shell-shocked men as cowards or to treat them as criminals. In July 1916, a party from an infantry battalion failed to carry out a raid on their sector of the western front. The officer in charge called for the medical officer, Lieutenant George Kirkwood (1879-1931), who later issued a certificate testifying to collective mental breakdown amongst the men:

In view of the bombing attack to be carried out by 11 th Border Regiment, I must hereby testify to their unfitness for such an operation as few, if any, are not suffering from some degree of shell shock.

Kirkwood was promptly disciplined and removed from his post because his sympathy with the men ran counter to military discipline. Doctors had constantly to balance clinical and military requirements and could be punished either for excessive harshness or excessive leniency. In Kirkwood's case the question of discipline was overt but it could be subsumed into more complex clinical debates. This was especially notable in Germany where battles within the medical profession led to the diagnosis of traumatic neuroses being replaced with that of hysteria.

In Wilhelmine Germany, Hermann Oppenheim (1858-1919) had demonstrated that traumatic events were pathogenic and could provoke post-traumatic neuroses. This thesis had been accepted by the Imperial Insurance Office in 1889 and German workers were entitled to compensation if they developed neurotic symptoms after an accident. Yet some medical professionals suspected "pension neurosis" amongst the feckless working class and preferred instead to diagnose "hysteria", a label implying both predisposition and weakness of will. Conflict continued until the 1916 War Neurology Congress in Munich when Oppenheim was isolated and roundly defeated. Elite psychiatrists and neurologists rejected Oppenheim's diagnosis of neuroses but non-specialists - and certainly the lay public - accepted the notion that the war caused nervous or mental illness. This medical debate had significant political implications. Military psychiatrists were firmly of the belief that war neurotics were malingerers, degenerates or frauds and that awarding them a pension would only encourage their symptoms. In consequence the psychiatric profession - already aligned with the establishment before the war - became closely associated with the highly punitive military state and the old elites. It was therefore firmly at odds with the Social Democratic state of the early Weimar years and mentally wounded soldiers' efforts to win effective pensions became politically contentious and remained so throughout the Weimar Republic. War psychiatrists became targets for fierce anger, especially from working-class veterans and their families.

Shell Shock after the War: Pensions and Politics ↑

The problem of shell shock did not end with the armistice. Some men succumbed to nervous collapse after hostilities had ceased; some appeared to get better and then suffered from relapses. Moreover, the war wounded and their families, in both victor and combatant nations, wanted some kind of recompense. Notions of citizenship varied across Europe but the men who had fought in the Great War believed that they had a right to state support: the "thanks of the fatherland" meant little without money and access to health care. The British government introduced a statutory pension scheme for veterans in 1915 and did award pensions for neuroses, however the bureaucratic process was cumbersome, the final awards were meagre and there were many complaints about care and conditions in Ministry of Pension Hospitals. The situation was similar in Germany where veterans with nervous disorders accounted for almost half of all military pension claimants. The 1920 National Pension Law did accord pension rights to psychologically disabled veterans whose injuries were directly attributable to war service, although a 1926 ruling removed these rights on the basis that men who were still disturbed so long after the war were clearly not suffering from a war-related wound. In France war hysterics received no pension unless they were so incapacitated that they required internment, at which point they had to use their paltry pensions to pay asylum fees. Interned, mentally wounded veterans, known as " les morts-vivants", had little political support and were often deeply isolated. As if to emphasise this metaphorical death the wives of aliénés received the equivalent of a widow's pension. The disparity between physically and mentally wounded veterans generated much anger, and although French pension rates were revised in 1929, the psychologically wounded veteran remained far worse off than his physically wounded counterpart. Impoverished war neurotics remained a standard feature of daily life throughout inter-war Europe. Paintings by Otto Dix (1891-1969) and George Grosz (1893-1959) are characterised by Kriegszitterer on street corners; George Orwell (1903-1950) noted the tormented shrieks of shell-shocked men in tramps' hostels in the 1930s. More obliquely, the trauma of the war looms large in post-war film and in the avant-garde art world, notably in Dada, German expressionism and Surrealism.

In addition to this underlying discontent, the treatment of war neurotics continued to provoke high-profile political scandals in the post-war years. In Britain concerns about shell shock were dominated by two issues: lunatic asylums and courts-martial. Soldiers suffering from shell shock should not have been labelled as insane and should not have been sent to lunatic asylums, nevertheless many of them were and they were often placed some distance from their homes, making family support difficult, if not impossible. In addition, lunatic asylums were popularly known as pauper lunatic asylums because they were traditionally populated by those unable to afford a private clinic. That the government later agreed to pay for service patients to be treated as private patients was largely irrelevant: ex-servicemen and their families deeply resented the twin stigmas of insanity and poverty. In response, the Ex-Services' Welfare Society (ESWS), initially established by the wives of shell-shocked men, campaigned on behalf of veterans in asylums throughout the 1920s. The ESWS provoked government ire by insisting that veterans languished in asylums but also attracted popular support by providing dignified, non-institutional care for mentally wounded men.

Concerns about courts-martial were based on the fear that "through inadvertence and want of knowledge, dreadful things may have happened to unfortunate men who had in fact become irresponsible for their actions". In response, Francis Hopwood, Lord Southborough (1860-1947) was charged with chairing the official Government Committee of Enquiry into Shell Shock in 1920. The committee did not re-open any courts-martial cases, rather it focused on identifying the causes of shell shock and on highlighting appropriate responses. The outcome, after two years of enquiry, was ambiguous. While acknowledging that men could suffer mental collapse as a result of the strains of war it also insisted upon the importance of predisposition; while recognising that shell-shocked men should be properly treated, contributors concluded that treatment should be based on military experience and common sense rather than medical knowledge, as the following comments attest:

I would rather have an experienced man about 35 years of age, a man of the world rather than a youthful medical officer with some special bee in his bonnet. (Dr Wilson)

He should get to know the soldier and to live with him. He need not know much medicine - a smattering of neurology would be useful. He should not be a peacetime psychologist, this would be a great disadvantage. (Major Adie)

Wartime mental-health specialists had clearly not made themselves appear indispensable in the British army. Moreover, the belief that war could regenerate weak men endured. Emanuel Miller (1892-1970) described a previously "timid" man who had become a respected soldier on the western front and noted that "several instances have come under observation of decorations for bravery that have been won under the occurrence of 'shell shock'". The conviction that a shell-shocked man could go to fight another day could lead to a lack of sympathy for a man suffering from a relapse yet the belief in recovery also ensured that shell shock was not necessarily shameful, especially if the man had "done his bit". In consequence, British post-war images of shell-shocked men could successfully present them as both hard-working and respectable.

The Southborough committee did not manage to allay concerns about the mental health of servicemen who had been executed and the issue resurfaced at the end of the 20 th century when their families demanded an official pardon. Central to their argument was that the medical profession should have recognised the symptoms of shell shock and that men had been unjustly punished for the failures of wartime psychiatry. In contrast, public concern about the French fusillés was not expressed in the same medicalised discourse. For those on the political left, the fusillés were "martyrs to the radical pacifist position": they had died because they had taken the honourable stance and had refused to fight, not because they had lost their reason. The French fusillés were heroic in a way that the shell-shocked was not; in Britain these two identities converged and the shell-shocked soldier became a very particular sort of hero, namely the hero-victim, best exemplified by the fictional Harry Penrose, a young officer shot for cowardice. The character of Penrose in the novel The Secret Battle was a clear indictment of the military system that destroyed men's nerves and then punished them for it. Moreover, it was a characterisation that provoked widespread sympathy even amongst conservative political elites, with Winston Churchill (1874-1965) describing Penrose as a "gallant soldier" who had been "caught in the teeth of the military machine".

Post-war anger also motivated a committee of investigation into shell-shock treatment in Austria, in this case, the specific use of electrotherapy. In the autumn of 1920 Julius Wagner-Jauregg (1883-1940), Professor of Psychiatry at the University of Vienna, was accused of treating soldier patients brutally with electric currents. Individual patients had resisted treatment during the war and there were even patient revolts in some hospitals. As a result, Wagner-Jauregg and six others had to justify their use of electrotherapy in court. Here there are clear parallels with the case of Vincent and Deschamps in France but there are also important racial differences. The German-speaking medical elite was often suspicious of the "foreign-speaking" soldier patients in the multi-ethnic Austro-Hungarian armies. Unlike hypnosis or suggestion therapy, electric treatment was a way of exposing malingerers with only limited recourse to language: it could be a virtually "speechless therapy". Of course ethnic-focused psychiatry was not limited to the Austro-Hungarian Empire. The British authorities insisted that troops from southern Ireland were especially prone to mental weakness; the German authorities had similar attitudes towards Jews in the German army; French specialists perceived black troops, especially those from Senegal, as especially prone to psychiatric disorders.

High-profile anxieties about patient treatment existed alongside a growing suspicion of shell-shocked men in the post-war period. The wartime belief that war neurotics were faking, malingering or exaggerating was never fully dispelled, rather it became more pronounced as time went by and it grew more difficult to make direct links between a man's wartime experience and his post-war mental state. "Are you a potential post-war criminal?" a popular magazine asked its readers, before going on to list the crimes and anti-social behaviour associated with shell shock. The politicised nature of military medicine and the diverse and paradoxical attitudes towards shell shock ensured that the condition - and shell-shocked veterans - became a politically potent tool in post-war Europe. This was most obvious in the new Weimar Republic which was scarred by the defeat of war and continually marred by political violence. The fledgling welfare state, initially established by the Social Democratic Party (SPD), should have ensured adequate health care and pensions for psychologically damaged veterans. In the early 1920s the SPD saw war neurosis as a universal experience that was shared by all German citizens and so could unite the post-war Volksstaat. Yet this unity was far from realised. Men who had fought resented being categorised alongside women and civilians whose wartime stresses had been limited to the home front; the welfare system was administered by cost-cutting officials in the Labour Ministry; the whole process relied upon the advice of psychiatrists, most of whom were highly conservative nationalists who blamed weak or degenerate men for losing their nerve in 1918 and bringing Germany to defeat and revolution. As a result men did not find it easy to access support and the situation grew worse as pensions were cut throughout the 1920s.

The SPD failed the psychologically damaged veterans they sought to protect and state welfare was inadequate. Their opponents further to the left - the German Communists (KPD) - had never believed that the bourgeois state could serve the needs of the working-class soldier and was most vocal in attacking the highly conservative psychiatric establishment. As far as the KPD was concerned, the state-hired psychiatrist was no more than "a businessman disguised as a doctor" and, like all members of the ruling class, it was in his interest to deny the trauma of the last war so as to prepare the proletariat for yet another one. Where did the shell-shocked veteran fit into these political arguments? While many shared the KPD's hostility to doctors, they could draw little comfort from its solutions. KPD activists were opposed to state-sponsored welfare measures which they saw as turning men into helpless dependants, and they argued that neurotic men needed to "find healing in active class struggle and revolution", not handouts from the bourgeois state. There is a peculiar parallel between KPD opposition to pensions and the approach of the conservative and the extreme right. Conservative doctors castigated the Weimar welfare state for "coddling" neurotics with pensions, and Nazis were similarly hostile because the very existence of war neurotics challenged the Nazi glorification of the war experience. In consequence, the National Pension Law of 1934 cut off all pensions for mentally disabled veterans. Throughout these battles - and against the odds - German veterans of all political persuasions continued to petition for pension rights and insisted that they should be treated with the same dignity as their physically wounded comrades.

Conclusions: Hero-Victims and Patient Protest ↑

The history of wartime and post-war shell shock is both ambiguous and paradoxical. During the war medical officers, soldiers and civilians displayed sympathy and understanding to shell-shock victims in all combatant armies. At the same time the military code prevailed, as did the medical belief in predisposition and the importance of will; some military medics were hostile to the very idea of war neurosis. As a result wartime medicine was often found wanting and could be described as more disciplinary than therapeutic. After the war many shell-shocked men were forgotten or discredited, or - in Britain - became idealised hero-victims. The political issues provoked by shell shock varied across Europe but all of the issues which made shell shock politically important - courts-martial, lunatic asylums, electrotherapy, pension disputes - indicate the extent to which shell-shock treatment was constantly entwined with discipline. Yet shell-shocked men were not simply victims of total war, mental collapse and punitive treatment regimes. Both during the war and afterwards, formally and informally, patients and their families consistently demanded proper treatment and adequate pensions. They did not always succeed but men refused to be stigmatised by a mental war wound: the history of shell shock is a history of trauma and psychiatry but it is also history of patient protest.

Fiona Reid, University of South Wales

Section Editors: Michael Neiberg; Sophie De Schaepdrijver

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During the First World War soldiers from all combatant nations suffered from a wide range of debilitating nervous complaints as a result of the stresses and strains of modern warfare. War psychiatrists struggled to manage these complaints and shell-shocked men struggled to ensure that they had decent treatment and proper pensions.

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Abstract

Almost every major war in the last century involving western nations has seen combatants diagnosed with a form of post-combat disorder. Some took a psychological form (exhaustion, combat fatigue, combat stress reaction and post-traumatic stress disorder), while others were characterized by medically unexplained symptoms (soldier's heart, effort syndrome, shell shock, non-ulcer dyspepsia, effects of Agent Orange and Gulf War Syndrome). Although many of these disorders have common symptoms, the explanations attached to them showed considerable diversity often reflected in the labels themselves. These causal hypotheses ranged from the effects of climate, compressive forces released by shell explosions, side effects of vaccinations, changes in diet, toxic effects of organophosphates, oil-well fires or depleted-uranium munitions. Military history suggests that these disorders, which coexisted in the civilian population, reflected popular health fears and emerged in the gaps left by the advance of medical science. While the current Iraq conflict has yet to produce a syndrome typified by medically unexplained symptoms, it is unlikely that we have seen the last of post-combat disorders as past experience suggests that they have the capacity to catch both military planners and doctors by surprise.

Keywords: post-combat disorders, shell shock, post-traumatic stress disorder, disordered action of the heart, Gulf War Syndrome

1. Introduction

Over the last century, post-combat disorders have been a significant health feature of major wars between western nations. On the surface, they appear to exhibit marked differences in their nature and the explanations attached to them. The South African War (1899-1902), for example, saw large numbers of British servicemen discharged from the armed forces with a diagnosis of disordered action of the heart (DAH), thought to be the effect of exertion on a soldier's chest constricted by tight webbing and equipment. Shell shock was the pre-eminent functional disorder of the First World War, characterized by tremor, restricted movement and nervous exhaustion. At first, it was thought to be the result of the concussive or toxic effects of exploding shells. During the Second World War, when physicians were concerned by an epidemic of gastro-intestinal disorders, explanations attached to medically unexplained symptoms often referred to diet or the stress of a novel military environment. By contrast, the symptoms of so-called Gulf War Syndrome (GWS) were ascribed to an immune or central nervous system damaged by a variety of toxins.

It has been argued that GWS is a unique disorder, a discrete illness related solely to exposures in the Gulf War, and as such has nothing in common with earlier post-combat disorders. There are three possibilities. Firstly, post-combat disorders arising in the twentieth century were in essence the same phenomenon and any apparent distinctions occurred because both doctors and patients emphasized symptoms that interested them or reflected popular health fears. Secondly, these disorders had much in common with each other but their differences were sufficient to designate them as varieties of a species. Thirdly, each one was quite distinct with unique causes and pathological mechanisms. This paper addresses this nosological question but also explores why war syndromes recur, why they attract popular attention and what factors determine their form.

2. Definitions

Groups of medically unexplained symptoms arising in servicemen during times of conflict have recently been given the generic terms: 'war syndromes' ( Hyams et al. 1996) or 'post-combat disorders' ( Coker et al. 1999). The former is more accurate since many of those who experience these disorders have not been engaged in fighting but found themselves unable to function normally when training, deployed to rear areas or faced with the prospect of battle. Based on their effects, they can be divided into short and long term, the latter persisting beyond a month. Neither group necessarily implies anything about severity ().

Table 1

Combat is probably the most intense stressor known to human beings: the imminent, enduring but unpredictable threat to life. Its effects are heightened by the fact that servicemen are usually in the prime of life, while some may have wives and small children. The traumatic experience of war can lead to acute disorders, which have been given a variety of labels and range from shell shock to combat stress reaction (CSR). These were suffered either by inexperienced soldiers cast into battle without time to acclimatize or by replacements sent to units where they were not welcomed or wanted. Alternatively, experienced and hitherto successful soldiers could be worn down by prolonged exposure to combat, finding themselves no longer able to cope with the omnipresent threat of death or serious injury, so-called 'old sergeant syndrome' ( Shephard 2000).

Many of the symptoms that characterize short-term disorders are psychological, though not exclusively so, and they have one feature in common: an inability to perform tasks. In 1995, for example, the Israel Defence Forces defined CSR as 'a normal and transitional crisis stemming from exposure to the stress of combat in unfavourable external circumstances, such as the lack of social support from fellow soldiers or officers, physical deprivation such as lack of food or sleep' ( Shalom et al. 1995, p. 260). This causal definition focused on the situation in which the serviceman found himself rather than on any pre-dispositional psychology. Subsequently, Solomon wrote:

A CSR occurs when a soldier is stripped of his psychological defences and feels so overwhelmed by the threat that he or she becomes powerless to counteract or distance himself or herself from it and is inundated by feelings of utter helplessness and anxiety. In this state, the soldier is a danger to self and unit and is no longer able to perform military duties ( Solomon 2001, p. 11).

Treatment in so-called 'forward psychiatric' centres involved rest and reassurance and graduated exercise, the 'PIE' method, the acronym being based on proximity to battle, immediacy and expectation of recovery. Experience from the First and Second World Wars showed that few (possibly less than 20%) were able to return to combatant roles and, though most remained in the armed forces, they went to combat-support or base duties ( Jones & Wessely 2003). What remains uncertain about acute presentations was the extent to which they predisposed servicemen to more chronic psychological disorders, such as post-traumatic stress disorder (PTSD) and neurasthenia or to disorders that featured medically unexplained symptoms. An important study conducted in the aftermath of the Lebanon War of 1982 suggested that patients who had been treated for CSR in forward units were less likely to develop PTSD than those referred to base hospitals ( Solomon & Benbenishty 1986). However, an inherent bias in the selection of soldiers for immediate treatment undoubtedly influenced these findings; men with a better prognosis were sent to forward units. An opposite bias could have resulted from the observation that commanders have traditionally used medical referrals as a way of getting rid of disruptive servicemen, those who might be expected to have a poor outcome. Furthermore, soldiers in one of the non-PIE groups had been flown to base hospitals in Israel. It is possible that a higher threshold for CSR was required for a commander to request an evacuation by air.

3. Early war syndromes

Because of changes to the meaning of words and the ways that emotions were conceptualized, it is difficult to know what clinical phenomena were being described by military physicians any earlier than in the mid-nineteenth century. Despite this etymological problem, some have speculated that PTSD can be detected in Homer's Iliad ( Shay 1991), the diaries of Samuel Pepys ( Dally 1983), in an account of Italian avalanche victims of 1755 ( Parry-Jones & Parry-Jones 1994) or in veterans of the American Civil War ( Dean 1997). These observations are predicated by the belief that PTSD is a universal trauma reaction, a timeless disorder that has only recently been identified. As a result, it has been suggested that the disorder has masqueraded under other labels such as 'railway spine' and even 'shell shock' ( Trimble 1985). By contrast, Young argued that PTSD was a culturally conditioned response to trauma, one that is

glued together by the practices, technologies and narratives with which it is diagnosed, studied, treated and represented and by the various interests, institutions and moral arguments that mobilized these efforts and resources ( Young 1995, p. 5).

Furthermore, a study of flashbacks experienced by veterans from 1900 to the present showed a significant increase in the incidence of the symptom after the Vietnam War (), lending support to the hypothesis that soldiers respond to trauma in a variety of ways.

Because so many soldiers and sailors died of disease, accidents or the effects of wounds, concern about psychological effects was scarcely on the agenda for the eighteenth-century soldier. Nevertheless, during the Napoleonic Wars cases of 'cerebro-spinal shock', typified by tingling, twitching and even partial paralysis, were described in soldiers who had been close to the passage of a projectile or its explosion but not suffered a physical wound. Termed 'wind contusions', cases were treated with scepticism by military physicians ( Anonymous 1914). It is possible that the description 'windy' (meaning lack of courage) derived from this phenomenon. However, it would have been strange, indeed, if British soldiers exposed to the stress of battle during the Napoleonic Wars had not found physical outlets for their fears in ways that would avoid an accusation of cowardice. At present, we do not know what form the post-combat disorders of the eighteenth century took.

Of older provenance was the disorder termed nostalgia. Described in various Swiss and Spanish accounts of the seventeenth century, sufferers exhibited a state of deep despair found in conscripted troops sent to foreign territories, where they had little prospect of leave ( Rosen 1975). Writing in 1678, Johannes Hofer believed it was due to pathological processes in those parts of the mind where images of desired persons and places were stored. Treatment, in the form of purges, was designed to improve digestion thereby freeing up vital spirits. Patients were also encouraged by the promise of leave and the provision of diverting company, while chronic cases were sent home as this was shown in most cases to produce a cure. A novel explanation was proposed by J. J. Scheuchzer to explain the incidence of nostalgia among Swiss troops. As mountain people, he argued, they inhale refined air, which is also carried into the body by food and drink. When they descend to the lowlands, the delicate fibres of the skin are compressed, the blood forced into the heart and brain, its circulation is slowed. If a soldier was unable to resist these deleterious effects then anxiety and homesickness were thought to have resulted ( McCann 1941). Treatment principally involved moving the soldier back to the mountains or the administration of youthful wine and saltpetre to increase internal body pressure.

Yet cases of nostalgia were not confined to the Swiss and found in French and German eighteenth-century accounts and even among sailors of the Royal Navy. By 1800, it had become a recognized hazard of troops on campaign, and was increasingly categorized as a form of melancholy. Nostalgia came to prominence during the American Civil War when rates of 2.3 per thousand and 3.3 per thousand were recorded among northern troops in 1861 and 1862, respectively. Assistant Surgeon De Witt C. Peters observed that it was particularly prevalent among inexperienced troops serving in the far south where mail was irregular. J. T. Calhoun, an army surgeon, believed that the main cause was the recruitment of poorly motivated soldiers with unrealistic expectations of what war involved. Calhoun advocated a generous furlough system in place of the existing system by which leave was granted only as a reward for re-enlistment or to deal with emergencies at home.

The diagnosis of nostalgia did not find favour with doctors in the British army, who in the nineteenth century at least preferred the diagnosis melancholia. An analysis of over 6200 cases of Chelsea Hospital pensions dating from the late 1880s showed that 37 (0.6%) were for melancholia or mania, while no cases of nostalgia were recorded ().

4. Disordered action of the heart

Also known as irritable heart, soldier's heart, cardiac neurosis, Da Costa's syndrome, neurocirculatory asthenia and effort syndrome, DAH was one of the most common and enduring post-combat disorders ( Jones & Wessely 2005a). First recorded by the British in the Crimea, when termed 'palpitation', and by the Americans as 'cardiac muscular exhaustion' during the Civil War ( Hartshorne 1864), it was a consistent feature of military medicine from the late nineteenth century to the Second World War.

Discharges from the British Army for 'diseases of the circulatory system' became a serious cause for concern in 1864 following a presentation at the Royal United Services Institute by Maclean (1811-1898), Professor of military medicine at the Army Medical School, Netley ( Maclean 1864). Although Britain was not then at war, such soldiers broke down either under the rigours of training or as a result of earlier overseas service in the Crimea and India. To shed light on this problem, Maclean investigated 5500 soldiers admitted to the medical division of the Royal Victoria Hospital, Netley, who had served abroad between 1863 and 1866, and found that 8% had been invalided from the forces with what appeared to be heart disease. At Fort Pitt, where invalids serving in the UK were treated, he estimated that 15% were discharged with heart disease ( Maclean 1867). Having excluded rheumatism, excessive alcohol consumption, heavy smoking or over exertion as causes, Maclean considered that the weight and distribution of the soldier's equipment were responsible:

The pack-straps press on important muscles, arteries, veins and nerves to a degree which only those who have carried the loaded pack can appreciate. The weight, especially when the greatcoat... is strapped on, falls, to a great extent, without the line of the centre of gravity... You can well imagine how impossible it must be to make severe exertion under so many disadvantages without suffering ( Maclean 1867, p. 162).

He considered that webbing supporting a pack constricted the major blood vessels supplying the heart forcing it to pump excessively hard to maintain circulation. Having reached a similar conclusion, the 1865 War Office inquiry recommended the redesign of equipment affecting the chest ( Anonymous 1865). The marked differences in incidence between units, Maclean believed, related to morale: 'in well-disciplined regiments the practice of falling out at drill or on the line of march is discouraged, and men will bear and suffer much, rather than incur the imputation of being 'soft'' ( Maclean 1864, p. 111).

A further survey of 1635 cardiac admissions to Netley between 1863 and 1869 by A. B. R. Myers, assistant surgeon to the Coldstream Guards, found that 1322 (80.9%) were discharged from the forces and only 276 (16.9%) returned to duty ( Myers 1870, p. 4). Having observed that heart disorders were 'more prevalent in the army than the civil population', Myers concluded that three factors accounted for this difference: rheumatic fever, Bright's disease and violent manual labour. He, too, pointed a finger at the soldier's equipment:

His waist-belt adds to the constriction below the chest, and his tunic collar above it... and then, to complete the artificial chest case, the knapsack straps supply all that is requisite, whilst the pouch-belt adds its share to the general compression. The chest, thus fixed as it were in a vice, has little or no power of expansion, and the circulation through the heart, lungs and great vessels is proportionately impeded ( Myers 1870, p. 81).

Concern in the UK mounted in 1876 when re-designed equipment failed to prevent new cases of irritable heart. Despite clear evidence that there was an association with combat, Surgeon Arthur Davy suggested that the setting-up drill caused an over expansion the chest, which in turn produced dilatation of the heart thereby inducing 'irritability' ( Wilson 1916, pp. 119-120). Hence, late-nineteenth century investigations of DAH identified a mechanical pathology, whether hypertrophy, valvular lesion or aortic dilatation and proposed mechanical causes, commonly an obstruction of the heart's outflow ( Howell 1998). Because there was no effective treatment of these supposed organic conditions, servicemen were simply discharged, while military physicians sought ways to prevent new cases.

Evidence gathered from the American Civil War failed to clarify the situation. Jacob Da Costa (1833-1900), who had studied the phenomenon during the American Civil War ( Wooley 1982), concluded that there was no clear-cut cause, though his analysis of 200 cases (selection criteria were not stated) showed that 38.5% had been subject to 'hard field service and excessive marching', and a further 30.5% had previously suffered from diarrhoea ( Da Costa 1871, p. 37; Wooley 2002). Since 'irritable heart', as Da Costa termed the disorder, was not confined to the infantry but affected the cavalry and artillery, he argued that the webbing and packs, which varied between these arms, could not have been the primary cause. Although this was widely regarded as a disorder suffered by soldiers in wartime, Da Costa made the important observation that the same cluster of symptoms could also be seen in civilians.

DAH was a major cause of invalidity during the South African campaign. According to official statistics, 3631 servicemen were hospitalized with DAH, and of these 41% were invalided to the UK, where they were generally discharged ( Mitchell & Smith 1931, p. 273). The highest incidence of DAH was reported in orderlies of the Royal Army Medical Corps, explained by the great distances that field units were required to march to support fighting battalions ( Wilson 1904). In the latter stages of the war, a large number of small columns were deployed against the Boers so that medical units had long periods of continuous marching to keep up with the widely spread engagements. It was concluded that the prolonged strain of carrying heavy weights and the pressure of straps on the chest had damaged the heart. An official report also argued that 'cardiac exhaustion cases were much more frequent among men of volunteer companies than the regulars, probably due to the great difference of their usual daily occupation from the life of a soldier on active service' ( Wilson 1904, p. 73)-an observation that would be repeated during the next century. Once a soldier had succumbed to DAH, it was noticed that the symptoms returned if he had to 'undergo any extra exertion or from the excitement or nervousness of going under fire'. The incidence of such disorders also increased 'if the physical strength of the men cannot be kept up by good and sufficient food and the necessary amount of sleep and rest'. Thus, the finite resources of soldiers under fire had been observed but their implications not fully understood ( Jones & Wessely 2001).

Although shell shock was the quintessential war syndrome of 1914-1918, soldier's heart or DAH was, in fact, equally common. Because of the need to return as many soldiers as possible to some form of duty, much concerted investigation was directed towards the disorder. Traditional explanations of improper drill and faulty equipment were rapidly abandoned in favour of more sophisticated medical hypotheses such as excessive glandular secretions or infectious micro-organisms. Early in 1916, Sir James Mackenzie argued that the privations of trench warfare not only weakened men's constitutions but also provided a suitable habitat for toxic bacteria ( Mackenzie 1916). The net result, he believed, was a state of general exhaustion and that heart abnormalities were not cardiac in origin, but the outcome of injury to the central nervous system ( Wooley 1986a). This interpretation had parallels in the late-nineteenth century idea that neurasthenia was a consequence of influenza or typhoid infection. Despite the existence of toxic or post-infective explanatory models these did not achieve widespread popularity, in contrast to the latter part of the twentieth century when they were used to account for the effects of Agent Orange and GWS.

Specialist military hospitals were set up at Mount Vernon, Hampstead and Colchester under Thomas Lewis to find more effective treatments ( Wooley 1986b). Lewis redefined the disorder as 'effort syndrome' in a way that reflected 'the transformation of the concept of heart disease from static and anatomical to dynamic and physiological' ( Howell 1998, p. 85). This re-evaluation allowed military physicians to think of remedial interventions, such as graduated exercise, rather than discharge to a life of invalidity. Although he was unable to discover the cause of DAH, Lewis ruled out a number of organic factors, including valvular lesions. By the end of the war, he had identified three possible pathological mechanisms: decreased buffer salts in the blood, an increased leucocyte count and abnormalities in urinary constituents ( Christophers 1997). However, none of these hypotheses were mentioned in the 1940 edition of Lewis's The Soldier's Heart and the Effort Syndrome, which suggests that further investigation had failed to establish a connection. Nevertheless, Lewis continued to believe that this was a disorder of functional capacity and that the symptoms represented 'exaggerated manifestations of the healthy responses to effort' ( Lewis 1917, p. 7).

5. Rheumatism

During the Boer War, rheumatism or muscle and joint pain associated with fatigue became a prominent cause of invalidity. 'Among the symptoms we find prominently', recalled Anthony Bowlby (1855-1929), a civil surgeon who had worked at the Portland Hospital in Rondebosch and Bloemfontein during 1900, were 'pain, in the form of headache, generally posterior, pains in the neck, pains in the back and limbs, so that these cases are generally sent back as cases of rheumatism; general feebleness of the muscular system amounting to paralysis more or less pronounced' ( Bowlby et al. 1901, p. 129). The Boer War saw 24 460 troops admitted to hospital with rheumatic fever or rheumatism, of whom 4305 were evacuated home. Although today rheumatic fever, a disease that can cause heart failure, is differentiated from non-articular rheumatism (a disorder characterized by subjective symptoms such as joint pain, stiffness and tenderness), physicians in the nineteenth century were unable or unwilling to draw such a distinction.

A systematic investigation of surviving war pension files administered by the Royal Hospital, Chelsea, has shown that most veterans who had been awarded a pension for rheumatism showed no objective signs of disease within a few years of discharge (,). Dr J. W. Washbourn, who ran the Imperial Yeomanry Hospital at Pretoria in the latter stages of the war, treated 296 cases of chronic muscular rheumatism (the fourth most common medical disorder there) but was unable to establish an association with rheumatic fever. At a loss to explain the phenomenon, Washbourn considered that the joint and muscle pain was the result of 'the men's food and especially the want of fresh vegetables' ( Washbourn 1901, p. 394). An explanation offered by both veterans and Royal Army Medical Corps doctors was that exposure to cold and wet on the veldt had caused their rheumatic pains. Because the cardiac complications of rheumatic fever were then untreatable and often led to invalidity and premature death, pains in muscles and joints were a contemporary focus of concern for both patients and physicians.

6. Shell shock

Shell shock caught the popular imagination and has become a synonym for the hardships and trauma of trench warfare ( Feudtner 1993; Shephard 1996). There is no accepted definition, though the Southborough Committee, appointed in 1920 to prevent any future epidemic of shell shock, came the closest:

emotional shock, either acute in men with a neuropathic predisposition, or developing as a result of prolonged strain and terrifying experience, the final breakdown being sometimes brought about by some relatively trivial cause. [Or] nervous and mental exhaustion, the result of prolonged strain and hardship ( Southborough 1922, p. 92).

In practice, the chronic form of shell shock was expressed by medically unexplained symptoms, in particular tics, paresis, tremor, contractures, fatigue, headache, difficulty sleeping, nightmares, memory loss, poor concentration together with aches and pains. In addition, sufferers felt fatigued and were often unable to complete routine tasks. As such, it bore little resemblance to the modern definition of PTSD.

As has been seen, the cluster of symptoms expressed by any post-combat disorder usually has a civilian equivalent; effort syndrome and neurasthenia, for example, were not confined to the military. Some severe cases of shell shock bore a resemblance to Ganser's syndrome ( ICD-10 1992). Characterized by 'approximate answers' and other dissociative symptoms, it was first observed in prisoners awaiting capital punishment. Soldiers about to go into battle plausibly entertained similar fears and resorted to similar defences, both conscious and unconscious.

Contemporaries were sharply divided over causation. Psychologically minded doctors believed that in some cases shell shock was the inevitable result of the sustained and intense stress of combat. W. H. R. Rivers, a medical anthropologist who treated cases of shell shock at Craiglockhart, believed that war neuroses arose when an adaptive form of repression failed. Because most troops were not regulars but had volunteered or been conscripted into the army and trained in great haste, they had not had time to build up an effective mechanism to deal with fear and anxiety. Faced with 'strains such as have never previously been known in the history of mankind', Rivers wrote, it was 'small wonder that the failures of adaptation should have been so numerous and severe' ( Rivers 1918, p. 173). T. R. Elliott said that during his time as consultant physician to the British army in France he had come to the conclusion that shell shock was a result of persistent or recurring fear, which overrode the soldier's self control. Others, such as Gordon Holmes, consultant neurologist to the British Expeditionary Force, thought it was simply malingering or cowardice, while a number of military commanders thought the disorder preventable by the careful selection of recruits and training.

In essence, the report of the Southborough Committee sidestepped the contentious issue of causation by proposing a series of recommendations that were designed to prevent a re-occurrence of the shell shock epidemic. Firstly, the term was to be

eliminated from official nomenclature... 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 any more than sickness or disease is so regarded ( Southborough 1922, p. 190).

Such was the appeal of the term shell-shock, concluded the committee 'that this class of case excited more general interest, attention and sympathy than any other, so much so that it became a most desirable complaint from which to suffer' ( Southborough 1922, p. 6).

Secondly, the committee concluded that the incidence of shell shock would have been far lower if proper attention had been paid to the mental state of recruits. They were told by the chief recruiting officer for London District that during the early phases of the war, when volunteers enlisted in their droves, medical inspections had been conducted in 'a most haphazard manner'. Between 20 and 30% had never seen a doctor and for the remainder the examination was usually cursory. One physician saw 400 men a day for 10 days. Hence, it appeared that the judicious selection of recruits could dramatically reduce those vulnerable to war neuroses. Furthermore, it was asserted that well-trained troops, properly led, would not suffer from shell shock and that the many servicemen who had succumbed to the disorder were either members of Kitchener's hastily assembled Pals' battalions or the unwilling conscripts that followed.

The report left the core dilemma unsolved: how to compensate the truly deserving (courageous men traumatized by combat) without rewarding those for whom psychological injury merely offered an escape from military duty ( Shephard 1999). Its publication represented a high-water mark in the history of shell shock and henceforth the term disappeared from official medical and military vocabularies. This represented a remarkable paradox. Just at the time when the cultural significance of shell shock was beginning to gain ground, most particularly in its literary expression, it fell from use in psychiatric and medical texts until revived in the 1970s as an historical introduction to PTSD ( Trimble 1981).

Reflected throughout the report was the fundamental ambivalence felt by the military to psychiatry, an unease that remains to this day. These ambiguities were revealed in the testimony of Charles Wilson, later Lord Moran and author of the Anatomy of Courage ( 1945). While Wilson conceded that in modern industrial wars every man had his breaking point, he had little sympathy for battalions in which shell shock was prevalent, regarding them as 'a disgrace' ( Southborough 1922, p. 76). He thought shell shock 'very infectious, like measels'. In essence, the military can be compassionate and understanding provided it is considered that the sufferer has 'earned' his breakdown or spent sufficient time in danger. Alternatively, the armed forces can appear cold or rejecting if it is felt that the soldier has not done anything that might permit him to escape his responsibilities.

7. Non-ulcer dyspepsia

Roy Grinker and John Spiegel, US military psychiatrists based in Algiers during 1943, observed that 'gastrointestinal symptoms flourish in an abundance and variety', in contrast with 'the frequent cardiac syndromes observed in the last war' ( 1945, pp. 254-255). From the outbreak of war the incidence of non-ulcer dyspepsia had become a 'major medical problem' for British armed forces ( Hutchison 1941). In May 1942, digestive disorders accounted for 17% of all discharges for diseases from the army and RAF ( Anonymous 1944). At first, it was hypothesized that dyspepsia represented a new entity akin to shell shock, while others suggested that it was due to an acute type of peptic ulceration. Yet studies soon showed that the incidence of ulcer in the civilian population had been growing steadily during the inter-war period and that the gastric symptoms suffered by some servicemen pre-dated their enlistment ( Anonymous 1940).

At a time when diagnostic tools were at best unreliable, gastroenterologists and radiologists tended to err on the side of caution. Estimates of those with peptic ulcer among the vast numbers of soldiers with chronic dyspepsia ranged from 89% in 201 cases invalided from France to 45.5% in 88 consecutive UK admissions ( Payne & Newman 1940; Hutchison 1941). A 1941 study, which included veterans of Dunkirk and the Lofoten raid, found an incidence of 64.2% in 246 servicemen admitted to a military hospital with gastrointestinal pain. The authors argued that a change in dietary habits together with the stress of a novel lifestyle were responsible ( Graham & Kerr 1941). Similar conclusions about causation were reached at a special meeting held at the Royal Society of Medicine in March 1941: irregular mealtimes and the heavier nature of army food ( Tidy 1941, 1943). Psychological factors were excluded because 'peptic ulcer and all dyspeptic disturbances were noticeably rare' during the First World War One when similar stresses arguably operated.

Not everyone agreed with this hypothesis. Hinds Howell reported 131 cases of 'neurotic dyspepsia' in 1941 at a UK military hospital, an increase of 12.4% over the figure for 1940 ( Hinds Howell 1941). By contrast, he proposed a constitutional explanation:

those people of poor personality who in peacetime are only just able to accommodate themselves to their home environment are no longer able to do so when this is changed on enlistment to the discipline of army environment. Whether it is pure chance that their neurosis is centred on their digestion it is difficult to say ( Hinds Howell 1941, p. 693).

Although studies conducted at the beginning of the war excluded psychological explanations, increasing contact with service patients led to a re-evaluation. An analysis of the social class and lifestyles of peptic ulcer mortalities led Morris and Titmuss to conclude that duodenal ulcer was a psychosomatic disorder related to a particular 'hypothalamic' type of personality. They considered that the stresses of metropolitan life, rather than nutritional factors, played a key causal role ( Morris & Titmuss 1944, p. 841).

Retrospective studies, based on mortality statistics, established that the war years witnessed an epidemic of peptic ulceration that subsequently rose to a peak prevalence in the mid-1950s ( Langman 1979). During the Second World War, there was no effective treatment for peptic ulcer, apart from risky gastrectomy, and a significant mortality from perforations fuelled a general fear of the disease ( Anonymous 1945). This suggests that 'pure chance' was probably not the explanation for the increase in non-ulcer dyspepsia and that forms taken by conversion disorders are influenced by popular health fears and limitations of medical science.

8. Effects of Agent Orange

Although effects of Agent Orange, observed in Vietnam veterans, reflected contemporary concerns with toxic exposures, it was far from being the first post-combat disorder associated with poisoning. 'Gas hysteria', a term coined in the First World War, was employed to describe soldiers who had been exposed to low levels of chlorine or phosgene, appeared to have completely recovered from their physical effects and yet continued to suffer from ill-health. For pension purposes, many such cases were reclassified as DAH, so similar were their symptoms. Initially, Frederick Mott (1853-1926) hypothesized that shell shock was a neurological disorder caused by exposure to carbon monoxide and other gases released by exploding ordnance ( Mott 1916). During the Second World War, the use of mepacrine (also known as atebrin) in Italy and South East Asia, as a prophylaxis against malaria, led some British and Australian troops to believe that it had caused impotence, a fear encouraged by German propaganda leaflets ( Walker 1952; Harrison 2004).

During the Vietnam War, dioxin (Agent Orange), a defoliant, was sprayed from aircraft over the jungle that provided cover for the Vietcong. Agent Orange derived its name, not from the chemical itself, as was popularly believed, but the colour of the drums in which it was stored. Some veterans suffering from chronic somatic symptoms attributed their illness to the effects of herbicide exposure, while it was also claimed to have been the cause of birth defects in their children. Indeed, the Vietnam Veterans Association of Australia suggested that exposure to Agent Orange could have led to a form of 'toxic neurasthenia' ( Hall & MacPhee 1985). To date, scientific and epidemiological studies have failed to identify a causal link ( Boyle et al. 1989; Anonymous 1994). However, it is noteworthy that the somatic symptoms frequently described by veterans who were exposed to Agent Orange were similar to those associated with other war-related illnesses ( Holden 1979). Exposure to Agent Orange reflected contemporary fears that organic solvents and other chemical compounds could provoke a widespread sensitivity crisis in the body, sometimes involving the immune system. These ideas found civilian expression in sick building syndrome, mercury poisoning syndrome and multiple chemical sensitivities, autoimmune diseases and dysregulation of immunological processes caused by modern synthetic chemicals ( Shorter 1997; Ford 1997).

9. Gulf War syndrome

To test the hypothesis that GWS was not a unique disorder, 1456 randomly selected veterans awarded pensions for post-combat disorders from 1900 to the Korean conflict were compared with 400 veterans of the Gulf War who believed that they had suffered adverse health effects. Cluster analysis of the 25 most common symptoms showed that no particular war syndrome stood apart (). Three groups were identified: a debility syndrome largely without psychological or cognitive symptoms, a somatic syndrome focused on the heart, and a neuropsychiatric syndrome with a range of associated somatic symptoms:

1. Debility cluster ( n=847): Fatigue, difficulty completing tasks, shortness of breath and weakness were prominent symptoms. Moderately represented were rapid heartbeat, tremor, headaches, dizziness, pains in joints, difficulty sleeping, changes in weight and anxiety. Psychological symptoms, such as depression, memory impairment, irritability and poor concentration were notably absent. Cases were not drawn from any particular war, though 73.6% of subjects in the group came from wars fought before 1918.

2. Somatic cluster ( n=434): Rapid heartbeat, shortness of breath, fatigue and dizziness were prominent. Moderately represented were: difficulty completing tasks, headaches, tremor and anxiety. This symptom cluster was indicative of a functional cardiac syndrome, though the group represented only 41.5% of all DAH cases and 44.1% of effort syndrome cases. This reflected the degree of overlap in the three groups and the fact that servicemen diagnosed with functional heart disorders had symptoms related to other areas of the body. Veterans of the First World War comprised 49.1% of the group, a conflict that was dominated by functional cardiac disorders. Relatively few veterans of the Second World War (19.1%) and Gulf War (8.8%) fell into this group.

3. Neuropsychiatric cluster ( n=575): Fatigue, headaches, depression, anxiety and difficulty sleeping were prominent. Moderately represented were: difficulty completing tasks, forgetfulness, rapid heartbeat, shortness of breath, tremor, dizziness, weakness, pains in joints, back pain, sweating, irritability, poor concentration, jumpiness, changes in personality, nightmares and weight change. Although this cluster included somatic symptoms, it was characterized by a range of psychological symptoms. Over half of the Gulf-related illness samples (54.0%) fell into this group.

GWS has often been attributed to environmental hazards such as depleted uranium, pesticides and the side-effects of vaccinations. However, it may be inferred that all three syndromes appear to be unrelated to any particular exposure as they were found across a range of wars, albeit with different frequencies. An analysis of death certificates also showed that veterans with post-combat syndromes did not develop a particular organic illness or suffered an increased mortality ( Grant 1925; Kang & Bullman 2001; ). This symptom-based investigation confirmed epidemiological and clinical studies that there is no unique illness related to service in the Gulf in 1991 ( Unwin 1999; Lee et al. 2002) and yet the term 'GWS' continues to enjoy popular support ( Lloyd 2004, pp. 41, 56, 57).

10. Discussion

Medically unexplained symptoms are common but in themselves are not diagnostic of a particular illness or disease; none of them are pathognomonic. Yet because they might indicate the presence of serious pathology, conscientious doctors conducted detailed physical investigations, which, though negative, were often interpreted by patients as a sign that something serious was amiss. During the Second World War, for example, physicians treating soldiers with suspected duodenal ulcer concluded that multiple investigations focused 'the susceptible soldier's attention increasingly on the stomach and help to perpetuate 'functional' symptoms' ( Anonymous 1945, p. 240).

(a) The influence of culture

Symptoms, diagnostic labels and culture are not independent but linked in a dynamic relationship ( Young 1995). Both doctors and patients were probably more alert to symptoms that related to current health priorities ( Shorter 1992). During the First World War, for example, when functional heart disorders accounted for over 15 000 admissions in 1915 and the causes of DAH were still being investigated ( Mitchell & Smith 1931, p. 315), cardiac symptoms were given prominence. By proposing the underlying psychological foundation of effort syndrome, Paul Wood and Maxwell Jones at Mill Hill plausibly prevented a fresh epidemic during the Second World War as many such cases were reclassified as psychoneurosis (, -). Discharges from the British army reflected these trends in medical understanding ( Bergman & Miller 2000).

Shorter has argued that the nature of medically unexplained syndromes has itself changed with a shift from apparently neurological symptoms such as paralyses, tremors and fits, to more ill-defined and subjective symptoms such as fatigue, pain and depression ( Shorter 1986). The apparent reversal of the trend towards greater psychological attribution during the Gulf War may reflect the biohazards of that conflict or a counter reaction to the increased awareness of PTSD from its formal recognition in 1980.

While cultural forces played an important part in the presentation and recognition of symptoms, they were not the sole factor. In the study by , it is significant that cluster analysis did not reveal a gastrointestinal group composed in the main of veterans of the Second World War. Indeed, soldiers diagnosed with non-ulcer dyspepsia were distributed between all three clusters, though to a lesser extent in the neuropsychiatric group. Similarly, ex-servicemen with a diagnosis of shell shock or neurasthenia were not found in a single cluster associated with the First World War. Some of them exhibited symptoms in common with Gulf War veterans and men who fought in the Boer War. These results suggest that the symptom patterns of war syndromes are diverse and less focused on bodily areas than contemporary descriptions and interpretations have suggested. By no means were all sufferers of post-combat disorders in the First World War troubled by the symptoms of shell shock, and many manifested the traditional cardiac picture of DAH. Effort syndrome endured well into the Second World War when stomach problems and psychological symptoms were thought to dominate. It appears, therefore, that culture may play less of a part in determining symptom patterns than has been suggested. Its main impact may relate to explanations and the ways that physicians categorize and interpret functional somatic presentations and the ways that patients act on and explain their symptoms. Thus, culture can often condition a novel medical explanation that satisfies most of society at a particular time but at the cost of ignoring exceptions and continuities ( Jones & Wessely 2005b).

(b) Advance of medical knowledge

The progressive advance of medical knowledge has both eliminated areas of the body as potential sites for medically unexplained symptoms but also created areas of uncertainty to which they could be attached. DAH flourished for 80 years largely because the heart was a no-go area for surgery, while medication for cardiac disease was limited. Because investigative techniques were limited to auscultation and percussion, together with post-mortem studies, cardiologists tended to conceptualize heart disease in terms of morbid anatomy, such as deformity of the valves. As a result, they struggled to understand disturbances of function, often failing to distinguish between serious disease and non-organic abnormalities. In acute febrile illness, for example, the hyperdynamic circulation can produce a systolic murmur, which in the late nineteenth century was sometimes misinterpreted as a sign of an organic lesion.

Citing the example of hysterical paraplegia, Shorter demonstrated that this disorder was doomed once neurologists had developed accurate neurophysiological methods to distinguish between organic and psychological causation ( Shorter 1986). This example suggests that it is unlikely that non-ulcer dyspepsia will ever again be a prominent medically unexplained syndrome. The discovery of histamine H ₂-antagonists as an effective treatment of peptic ulcer in 1976, subsequent research into the pathological role of Helicobacter pylori and the development of accurate endoscopic techniques have removed any doubt or mystery surrounding stomach disorders. Today medically unexplained symptoms are often associated with the immune and central nervous systems, hence the popularity of explanations that involve toxins or the side effects of medicines.

(c) Changing nature of warfare

The nature of war and tactical doctrine have changed dramatically over the last century. Troops who fought in the Boer War often had to march considerable distances to engage the enemy; it was a war of movement without mechanization. Contemporaries believed that the physical exertion involved was, in part, responsible for the various heart disorders encountered. Similarly, shell shock was framed in terms of trench warfare: an expression of the terror felt by men forced to endure the effects of artillery bombardment often without adequate protection and in identifiable positions. Fifty-nine per cent of wounds inflicted on British soldiers were as a result of artillery, and three times as many men were killed by shells as by bullets.

Although professional soldiers are better protected than ever before with flak jackets, NCB suits, vaccination programmes and armoured vehicles, they are also at risk from a greater range of more potent weapons. The threat of chemical and biological warfare has perhaps found expression in symptoms of headache, poor concentration and memory impairment. While the pace of battle has quickened and its technical complexity advanced, at root combat still involves soldiers risking their lives. In its fundamentals, the stress of battle has not changed as troops in the teeth arms are still required to kill or be killed.

An analysis of the military records of servicemen in the study revealed that the proportion involved in actual fighting fell over time as numbers in combat-support roles has risen. Of the Boer War veterans, 77% had been in combat, of the First World War pensioners 73.4%, of the Second World War sample 52%, while only 19.8% of the Gulf War sample had seen action. War syndromes arose, therefore, not only in servicemen who fought but also those faced with the prospect of battle.

11. Conclusions

Post-combat syndromes have arisen after all major wars over the last century, and we can predict that they will continue to appear after future conflicts. What cannot be accurately forecast is their form as they are moulded by the changing health fears and the nature of warfare itself. They have proved notoriously difficult to treat largely because veterans and their physicians were often in disagreement about causation. Having recognized the need to offer financial compensation to ex-servicemen disabled as a result of wounds and disease, it was then impossible to exclude war syndromes as pensionable disorders. As a result, they have cost the state considerable sums and proved an emotive focus for dispute. To introduce preventative measures and devise effective clinical interventions, it is necessary to understand their characteristics and the circumstances in which they arise. If each new post-combat syndrome is not interpreted as a unique or novel illness, but as part of an understandable pattern of normal responses to the physical and psychological stress of war, then it may plausibly be managed in a more effective manner.

Footnotes

One contribution of 17 to a Theme Issue 'The health of Gulf War veterans'.

References

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Harrison M. Medicine and victory, British military medicine in the Second World War. Oxford University Press; Oxford, UK: 2004.

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# data[].attributes.attachment_link.title
Historical approaches to post-combat disorders

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Almost every major war in the last century involving western nations has seen combatants diagnosed with a form of post-combat disorder. Some took a psychological form (exhaustion, combat fatigue, combat stress reaction and post-traumatic stress disorder), while others were characterized by medically unexplained symptoms (soldier's heart, effort syndrome, shell shock, non-ulcer dyspepsia, effects of Agent Orange and Gulf War Syndrome).

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The Stress of War · Medicine in World War I · Online Exhibits@Yale

# data[].attributes.attachment_link.description
The most common treatment for shell shock was, at the time, electric shock therapy. During the course of war, shell shock became recognized as one of the primary afflictions and new forms of treatment were incorporated, including psychotherapy.

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Physical Treatment of Acute War Neuroses

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Find out more
Books and articles
Shell Shock: A History of the Changing Attitudes to War Neuroses by Anthony Babington (Leo Cooper, 1997)

From Shell Shock to Combat Stress by JMW Binneveld (Amsterdam University Press, 1997)

War Neurosis and Cultural Change in England, 1914-22 by Ted Bogacz (Journal of Contemporary History, volume 24, 1989)

Dismembering the Male: Men's Bodies, Britain and the Great War by Joanna Bourke (Reaktion Books, 1996)

No Man's Land: Combat and Identity in World War One by Eric J Leed (Cambridge University Press, 1979)

Problems Returning Home: The British Psychological Casualties of the Great War by Peter Leese (The Historical Journal, volume 40, 1997)

Female Malady: Women, Madness and English Culture 1830-1980 by Elaine Showalter (Virago, 1987)

The Regeneration Trilogy by Pat Barker (Viking, 1996 )

Links

Archive of primary documents from World War One Established and maintained by the World War One Military History discussion group, the site focuses on 1890-1920, discussing topics from military, diplomatic, social, and economic issues to the arts.

The Great War The PBS site for 'The Great War and the Shaping of the 20th Century' series goes beyond the military and political history of World War One to explore its ongoing social, cultural and personal impact.
The Wilfred Owen Multimedia Digital Archive

# data[].attributes.attachment_link.description
Books and articles Shell Shock: A History of the Changing Attitudes to War Neuroses by Anthony Babington (Leo Cooper, 1997) From Shell Shock to Combat Stress by JMW Binneveld (Amsterdam University Press, 1997) War Neurosis and Cultural Change in England, 1914-22 by Ted Bogacz (Journal of Contemporary History, volume 24,

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What makes for excellence in a crossnational context? Three factors emerge as salient. One is the existence of a university system based on the "Humboldtian" model of combining teaching and research, conceived by Wilhelm von Humboldt (1767-1835), the Prussian education minister in Berlin, in Napoleonic times.

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this article mainly focuses on how people were put into asylums

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This article focuses on giving a basic understanding of War Neuroses and also highlights the kinds of treatments used in different countries

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Topic: the war's long-lasting health affects on soldiers--- War Neurosis and treatment
Inquiry: Could doctors have done more to address the post war medical health issues of soldiers?