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Here is a Scottish landscape to soothe the tortured soul. One small window looks west toward a wild and craggy bluff, its base wrapped in silky green - a golf course. The other turns the centre of Edinburgh, less than five kilometres away, into a setting for a fairy tale: a rugged coastline by the sea; tall church spires; a dark, mysterious castle atop a steep cliff.

This is the view from the room Siegfried Sassoon is believed to have occupied in 1917. But his was not a happy stay - the famed poet was forced to come to the imposing Italianate building then on the outskirts of Edinburgh. He called the place "Dottyville."

Built 40 years earlier as a medical spa, Craiglockhart War Hospital had been commandeered to battle the great mystery illness of the Great War: shell shock.

Today, photographs of soldiers taken just after they'd enlisted are a study in Victorian innocence - they had no idea what they would face. One minute, young men schooled in heroic, Tennysonian visions of warfare were erect atop their horses, gallant and cheerful, as crowds waved them off to the front. The next, they were in hospitals with bewildering symptoms - insomnia, nightmares, palpitations, headaches, tremors, partial paralysis, and amnesia - sometimes unable to talk or see, curled up in the fetal position whenever a loud noise sounded.

Shell shock was culture shock - it turned postwar Western sensibility into what U.S. literary scholar Sarah Stoeckl has called an "imaginative No Man's Land, unable to find consolation in previous modes of understanding but uncertain how to move forward."

It had powerful repercussions throughout society, largely because its cruel paradox was unimaginable.

At the turn of the 20th century, in an age of stolid Victorian beliefs, many based on class assumptions, who would have thought that courage may contain fragility; that our most noble instincts - a determination to serve, to be selfless - can be undercut by forces that are just as willful but not within our control? There was still so much yet to learn about both mind and body.

As we mark Remembrance Day in the centenary year of the start of the First World War - with Canadians now deployed in Iraq and Kuwait to join the international campaign against the insurgent Islamic State - we might ask ourselves: How much has changed in our understanding of war trauma?

Shell shock threatened the existing medical and institutional approach to mental illness, laying the groundwork for modern psychiatric practice in the process. One of the more progressive psychologists, W.H.R. Rivers, who treated patients at Craiglockhart, wrote that the war was "a vast crucible in which all of our preconceived views concerning human nature have been tested." But the diverse opinions about how to treat the ailment reflected the ambivalence of the medical establishment.

One hundred years later, much of that ambivalence remains. Millions of dollars are spent in research initiatives around the world to unravel the complexity of physical, psychological and emotional trauma - in the general population as well as among veterans diagnosed with post-traumatic stress disorder (PTSD) and other war-related psychiatric problems.

Today, the public has at least some grasp of what's at stake. Back then, the reaction was confusion, rejection - or worse.

Roughly 10,000 Canadians were treated for shell shock during the Great War, according to the Canadian War Museum in Ottawa. But the total number who suffered was likely much greater. Many affected soldiers may have not applied for a pension for neurological or psychological disorders - one way to assess the prevalence of them; others may have recovered by the war's end. Many may have felt too ashamed to acknowledge it at all.

My great-grandfather, William Barnard Evans, was one. Having volunteered in Montreal, he served on the Western Front for 17 months, before suffering a breakdown he never discussed or sought treatment for. His war diaries simply stop after he noted that he had asked for a leave as lieutenant-colonel of his battalion, and his commanding officer recommended a staff job. After the war, he returned to Canada and resumed, as best he could, his former life.

Others were less fortunate. Lieutenant-Colonel Sam Sharpe, a member of Parliament decorated for his service both at Vimy Ridge and Passchendaele, was sent home after falling prey to shell shock. A few days later, he leaped to his death from a window at Royal Victoria Hospital in Montreal.

'Modernity gone wrong'

Shell shock precipitated what one academic called "a crisis of masculinity," finding expression in the literary trope of the anguished male anti-hero. But more than that, shell shock fuelled unease about the conflict and became a "symbol of modernity gone wrong," observes Joanna Bourke, a professor of history at the University of London in England.

It would help make the war what she calls "the greatest rupture of the 20th century."

I was at the front this morning. You could not believe the scene of desolation. Mud, muck, misery and melancholy reigned supreme and a pitiless bombardment adds to the general discomfort. Death and glory I suppose they call it. All my friends are gone, and not a soul to go to ... I should love to get some leave, but I don't like to ask. It was suggested the other day but in such a way that if I had risen to it, I should have felt I was shirking [my duty].

This was a war in which explosives could reduce men "to particles so small that only the wind carried them," as Sebastian Faulks wrote in his celebrated 1993 novel, Birdsong. Much about it was new. And at first, some wondered if some dark force, unleashed by the industrialization of war, could be penetrating the brains of men. The machine gun, which had been invented in 1884 - with the firepower of 60 to 100 rifles - dominated the battlefield for the first time. Explosive shells rained down on the men with a blast force never seen before. The largely volunteer army had little training or psychological preparation for the stresses of artillery bombardment, which kept soldiers constantly on edge. And, of course, the terror weapon of gas was used for the first time.

In addition to the strain brought on by new kinds of weaponry, soldiers didn't do tours of duty as they do now. They went to war and were expected to see it through, with periodic rest periods behind the lines. One thing that had changed dramatically was the duration of battles - they went on for weeks, sometimes months. In his book, The Face of Battle, military historian John Keegan points out that 50 years earlier, the bloodiest battle of the U.S. Civil War - Gettysburg - was over in just three days.

The first reports of incapacitated, shell-shocked men returning to England came in September, 1914, barely more than a month after the start of the war. They were met with puzzlement about the "strange malady," creating a powerful tension between old-school military leaders, who were widely skeptical about its veracity, and medical professionals, who had to figure out how to treat it.

Initially, some military physicians tried to associate shell shock with physical or organic injury to the brain or central nervous system. They diagnosed a concussion caused by proximity to exploding shells.

Toxins such as carbon monoxide, released from shells, could be a cause, or changes in atmospheric pressure, resulting from proximity to an explosion, could produce microscopic brain hemorrhage, they believed.

The term "shell shock," which had come into usage through word of mouth by soldiers to express the emotional disturbance of modern war, was first used in medical circles by Charles S. Myers, a Cambridge University laboratory psychologist, who wrote a paper about it in the influential medical journal The Lancet in 1915.

But soon, it became clear that organic (or "commotional") injury wasn't the only possible cause. Ancillary staff and nurses who were nowhere near exploding shells often reported similar symptoms. Patients with no family history of mental illness - or "hereditary taint" as they put it - were affected.

Hard-line military leaders, schooled in traditional warfare, dismissed its significance as "malingering," a discipline problem or character weakness, punishable often by court martial and death by firing squad.

Uncharitable social beliefs were often invoked. "They have an awful class view that ordinary soldiers don't recognize fear because they're just too stupid," explains Edgar Jones, professor of military psychiatry at King's College London. He points out that Charles McMoran Wilson, a regimental doctor awarded the Military Cross in 1916, later wrote in his book, The Anatomy of Courage, that "the best soldiers are the peasant farmers because they live on the land and are accustomed to killing animals." But when they break down, they are "plainly worthless fellows."

William Walton, a 26-year-old sergeant in the King's Royal Rifle Corps, was a victim of the first wave of shell shock during what's known as the Great Retreat from Mons - when allied forces made an arduous 320-kilometre trek under continuous bombardment. Arrested four months after deserting in November, 1914, he explained that he was suffering from nervous exhaustion, but his superiors didn't buy it. He was court-martialled and became the 14th soldier executed for desertion since the retreat began.

'An infection in the ranks'

As far back as ancient Greece, a form of war neurosis has been documented. Herodotus described a soldier in the Battle of Marathon in 490 BC "deprived of his sight, though wounded in no part of his body." The Romans, too, found that their bravest men, the legionary eagle-bearers, sometimes broke down on the battlefield. In 1678, Swiss physician, Johannes Hofer called it "nostalgia," suggesting that the disturbed sleep, weakness and anxiety was similar to "the pain which the sick person feels because he is not in his native land." It was seen in the Napoleonic Wars, when it was considered a form of insanity, according to Anthony Babington in his book, Shell Shock, A History of the Changing Attitudes to War Neurosis; and again in the U.S. Civil War. An alternate diagnosis in the 19th century - in particular during the Crimean War - was that it was "soldier's heart," explains Prof. Jones, co-author of Shell Shock to PTSD, Military Psychiatry from 1900 to the Gulf War.

"They thought it was a physical illness affecting the heart. Palpitations. Chest pain ... It's how you feel when you're frightened and your heart beats faster. It's difficult to catch your breath," he adds. As it was seen as a physical cardiac illness, it brought no shame.

But the opening war of the modern age was different. It would be the first to have significant psychological ramifications for one simple reason - scale. And the perfect, horrific storm for shell shock arrived with the failure of the Battle of the Somme in 1916. After more than 600,000 men in the Allied forces had been killed, wounded or gone missing, after 141 seemingly endless days of fighting, it could be ignored no longer. Close to 40 per cent of the casualties at the Somme suffered from emotional disorders.

Shell shock was a full-blown military crisis, seen as "an infection in the ranks," according to military historian Tim Cook, the author of Shock Troops: Canadians Fighting the Great War, 1917-1918. And it could cost the allies the war.

Prison-like conditions

Neurologists were dispatched to the battlefields in France to investigate, and the increasing incidence of shell shock led to creative new theories among physicians in England - Charles Myers being one of them. Special hospitals were set up - by the end of war, there were 23 in the United Kingdom, where many Canadian soldiers were treated. Public outcry that shell-shocked soldiers would be sent off to asylums - the old system for handling mental illnesses, in which someone was certified insane, and sent for indeterminate amounts of time to institutions, run by local counties, in often prison-like, deplorable conditions - forced changes in institutional structure. But they weren't made just to appease the concerns of families who wanted proper care for their loved ones and to avoid the stigma of having them incarcerated in asylums. The goal of the War Office was to get the men well enough to return to the battlefield.

That imperative - this was a war of attrition, after all; the army with the most men would likely win - was also behind the decision first to grant (in 1916) and, a year later, remove the awarding of "wound stripes" to victims of shell shock. Worn on a man's left sleeve between the cuff and his elbow and made from strips of gold braid, wound stripes were an innovation - "a badge of heroism," Prof. Jones explains. As an understanding of shell shock developed, and doctors saw that, in some cases, there were no physical causes for it, they deemed it an illness rather than a wound.

"You wouldn't get a wound stripe if you got influenza, for example," he adds, explaining that the phenomenon called "secondary gain" - the idea that a psychiatric patient wouldn't be encouraged to get well if he was rewarded for being ill - also came into play.

Class was a mediating factor in the treatment, hospitalization and even nomenclature of the diagnosis. "Privates suffered 'hysteria' ... whereas officers were said to suffer from 'anxiety neuroses,' or 'neurasthenia,' which has a much higher status," says Prof. Bourke, the historian. Officers were sent to separate hospitals and often to spa-like country estates and private homes that were adapted for medical and therapeutic use. Ambivalence in the military establishment never completely abated. (Even at the end of the war, shell-shocked soldiers were being court-martialled and shot for desertion. The last was a Canadian, who had enlisted in 1914, been admitted to hospital in 1917, and still sent back to the front. He deserted in November, 1918.)

Medical thinking, however, was less rigid, Prof. Jones notes. "For the first time, a psychiatric diagnosis attracts the attention of thousands of doctors, some of whom wouldn't normally work in psychiatry."

One was Frederick Mott, a scientific researcher in neuropathology, who investigated the most severe cases of shell shock at the Maudsley Hospital in London, where approximately 12,000 patients were treated between 1916 and 1919.

An "atmosphere of cure" - involving rest, fresh air, warm baths, good food, and diversion - was his approach. Introspection was discouraged. One of the wards that remains today is a handsome building with big windows that overlook what was once a garden where the men planted vegetables, raised chickens, built an ornamental fountain, and laid out tennis courts. A hut was erected - still standing - for them to occupy themselves with woodworking and metalwork.

By 1916, Mott had identified three categories of shell shock: those who have a head wound and therefore suffer a physical effect of concussion; robust men who had simply endured horrific experiences; and the largest group - those who had an "inborn timorous or neurotic disposition" because of childhood trauma or hereditary vulnerability, which made them more likely to break down.

"It's a combination of your genetics, your upbringing and what happens to you, and that position is pretty well established by the end of the war," explains Prof. Jones, whose office is at the Maudsley.

The great insight was that every man, no matter his background, his education, his class, had a breaking point. As Mott himself wrote in 1917, "even the strongest man will succumb, and a shell bursting near may produce a sudden loss of consciousness, not by concussion or commotion, but by acting as the 'last straw' on an utterly exhausted nervous system."

But if that was the prevailing sentiment by the end of the war, there were two extremes of psychiatric thought and treatment during it.

One treatment: shame

At one end was Lewis Yealland, a Canadian-born psychiatrist educated at the University of Western Ontario who qualified to practise medicine 1912 and came to Britain three years later to treat shell shock. Most of his patients were from the ranks, and he gained a reputation for facilitating a rapid recovery - and for controversy. He believed that war neurosis was within conscious control of soldiers; and he set out to solve the problem with shaming, a blatant use of paternalistic power and authority (he was known to threaten court martial) and often the application of electric-shock therapy in a locked and darkened room.

In one infamous case, Yealland treated a 24-year-old private, who had been mute for nine months after enduring many of the war's worst campaigns. "A man who has gone through so many battles should have better control of himself," Yealland reportedly told him. Strapped down with his mouth opened using a tongue depressor, he had electrical current applied to his pharynx and throat, "hot plates" inserted into his mouth, and the tip of his tongue burned with a cigarette. After four hours of this, the soldier managed to mumble a few words, and then was required to say "thank you" to Yealland.

At the other extreme was Rivers, a psychologist, physiologist and anthropologist among the first in England to support the psychoanalytic work of Sigmund Freud (which one pillar of the psychiatric establishment dismissed as "probably applicable to the people on the Austrian and German frontiers, but not to virile, sport-loving, open-air people like the British").

Rivers's understanding of shell shock reflected antiquated class assumptions. He believed it was beyond the control of officers, as their mental makeup was more "complex and varied" than that of men in the ranks, and their storied stiff-upper-lip mentality was part of the problem. But his treatment was progressive, stressing what he called "autognosis" or self-understanding through conversation, hypnosis and psychoanalysis. In some cases, after the war had ended, he encouraged the men to return to the scene of the trauma in France.

It was to him that Second Lieutenant Siegfried Sassoon was sent in the summer of 1917 amid intense media scrutiny, which reveals the ignorance and shame associated with the illness. From a prominent family, Sassoon had left Cambridge (without a degree) to lead a gentlemanly life of reading, writing and shooting. He served with the Royal Welsh Fusiliers, earning the nickname Mad Jack for his bravery after capturing an enemy trench single-handedly. He fought in the Battle of the Somme, and was awarded the Military Cross, but grew disillusioned. His brother had been killed at Gallipoli, and the Somme, billed as the Great Advance, "had been nothing of the kind," he wrote, noting that his battalion was rendered "almost unrecognizable by heavy casualties."

Back in England in 1917 after being hit by a sniper in the Battle of Arras, he became truly discontented, throwing the ribbon from his Military Cross ("my absurd decoration") into the River Mersey and watching it float away "as if aware of its own futility."

He also kept company with pacifists and reportedly hallucinated that he saw dead soldiers lying in the street. But his shell-shock diagnosis came after he decided to bring to Parliament his "Soldier's Declaration," saying the war was being "deliberately prolonged by those who have the power to end it." Court martial was threatened - he was still an officer, after all - causing friend and fellow poet Robert Graves, who had served with him at the Somme, to intervene. He persuaded a medical board that Sassoon was suffering from "neurasthenia" and should be admitted to Craiglockhart. The media went wild, suggesting that he was invoking class privilege.

Sassoon himself wouldn't admit to having broken down and, at Craiglockhart, often complained about "dotty" fellow patients wailing in their sleep. Rivers gave him a room of his own and much kindly personal attention. Their interesting and unusual relationship is the subject of Pat Barker's 1991 novel, Regeneration.

Treated for an "anti-war complex," Sassoon wrote and played golf. He also met Wilfred Owen, another convalescing soldier-poet, who recalled Sassoon encouraging him to "sweat your guts out writing poetry." After four months at the hospital, Sassoon returned to active service - to save face, he suggested later. Wounded again in 1918, he was granted sick leave for the duration. Owen, too, returned to the front after 127 days at Craiglockhart - and was killed one week before the war ended.

The Lost Generation

The shooting stopped in November, 1918, with nine million dead or missing; but rising from it came the spectre of the Lost Generation. "Men were hidden inside their homes by their families, who were ashamed they had broken down," explains Joanna Bourke, whose books include The Intimate History of Killing and The Story of Pain.

At officer hospitals such as Craiglockhart, "there was a deliberate destruction of medical records to protect [the men's] reputation because of stigma," Prof. Jones notes. Sexual impotence was a widespread symptom, according to some reports. "If the essence of manliness was not to complain, then shell shock was the body language of masculine complaint, a disguised male protest not only against the war but against the concept of 'manliness' itself," writes feminist culture critic Elaine Showalter in her book about depression, The Female Malady: Women, Madness and the English Culture 1830-1980.

In medical circles, Freudian talk therapy gained ground in part because the medical establishment had to devise new ways of dealing with the psychological wounds of outpatients - clinics for whom were a postwar innovation brought on by the number of recovering shell-shock victims. Rivers, who died unexpectedly in 1922, proposed an alternative view of Freudian psychoneurosis, based on his experience with shell-shock patients. He dismissed Freud's sexual theories as the driving factors of psychoneurosis, and suggested that, rather than sex, conflict between self-preservation and a desire to fulfill duty caused the mental breakdown.

As Prof. Jones explains, "Shell shock was a diagnosis that could save your life. It means you leave the battlefield. They're not faking it. They're wearing out. And there will be an unconscious wish to have the diagnosis. These are unconsciously created symptoms ... and the unconscious drive would be, 'This is the only way I can survive.'"

The debate continues

Doctors who had treated shell-shock patients during the war returned to regular practice once it was over. Some of the knowledge about stress-related mental illnesses was applied to workplace problems, but it wasn't until the Second World War that medical science had to grapple again with shell shock on a large scale. Experts found they still had a lot to learn.

To help soldiers as quickly as possible, psychological treatment centres were set up near the action. But the military still didn't recognize that "people can't go on forever and that everyone ultimately will break down, however well-trained and courageous," Prof. Jones says. That understanding didn't dawn until about 1943 or 1944, "when commanders, fighter pilots and captains of escort vessels, who were decorated, start saying, 'I can't do this any more.'"

It was only after Vietnam that the term PTSD was adopted. Psychiatric problems were handled well during that war, but when veterans returned, they often suffered from nervousness, sleeplessness and irritability, thought to be exacerbated by the anti-war environment at home. Finally, in 1980, PTSD was officially accepted as a disease - only after doctors lobbied the American Psychiatric Association because they had treated similar symptoms in civilians.

Study into PTSD, which concerns more psychological symptoms as opposed to physical ones such as tremors and heart palpitations, is ongoing. In 2009, U.S. researchers reported the results of a two-year, $10-million study on the effects of blast force on the brain. Its key finding: that the blast-exposed brain remains structurally intact but suffers injury by inflammation - verifying some of the initial thoughts about shell shock . Emory University in Atlanta, meanwhile, has harnessed virtual-reality therapy to help veterans suffering from emotional disorders.

Still, questions remain, as does controversy in the military. In 2008, Canada introduced the Sacrifice Medal for wounds and death "under honourable circumstances," including PTSD, only after public protest - as the U.S. recently decided to do for its Purple Heart.

We stand in an interesting moment, looking back 100 years, and looking forward, as Canada sends soldiers to the Middle East once again. We should pause not just in remembrance, but in thoughtfulness as well. We should think about the cultural attitudes that will greet any who return with psychological trauma. In the past, they've been romanticized: seen as cautionary reminders that human beings are not designed for war. Which doesn't help. Despite memoirs about PTSD and efforts to destigmatize it, many sufferers still feel undertreated and shameful over something they cannot control.

We love cultural scripts about bravery and sacrifice; national myths are built on them. But if soldiers have limits, so do we in our ability to understand what they go through after a war. The conflict between the conscious and unconscious, the paradox of courage and fragility, is locked in the mind of the sufferer.

Where it remains a mystery.
Sarah Hampson is a Globe and Mail feature writer.

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Shell shock: How much has changed in 100 years?

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As Canada goes to war again, it knows that some fighters may come back with crippling wounds that do not show. The situation was radically different a century ago. No one was prepared for what shell shock was about to do.

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In September 1914, at the very outset of the great war, a dreadful rumor arose. It was said that at the Battle of the Marne, east of Paris, soldiers on the front line had been discovered standing at their posts in all the dutiful military postures-but not alive. "Every normal attitude of life was imitated by these dead men," according to the patriotic serial The Times History of the War, published in 1916. "The illusion was so complete that often the living would speak to the dead before they realized the true state of affairs." "Asphyxia," caused by the powerful new high-explosive shells, was the cause for the phenomenon-or so it was claimed. That such an outlandish story could gain credence was not surprising: notwithstanding the massive cannon fire of previous ages, and even automatic weaponry unveiled in the American Civil War, nothing like this thunderous new artillery firepower had been seen before. A battery of mobile 75mm field guns, the pride of the French Army, could, for example, sweep ten acres of terrain, 435 yards deep, in less than 50 seconds; 432,000 shells had been fired in a five-day period of the September engagement on the Marne. The rumor emanating from there reflected the instinctive dread aroused by such monstrous innovation. Surely-it only made sense-such a machine must cause dark, invisible forces to pass through the air and destroy men's brains.

Shrapnel from mortars, grenades and, above all, artillery projectile bombs, or shells, would account for an estimated 60 percent of the 9.7 million military fatalities of World War I. And, eerily mirroring the mythic premonition of the Marne, it was soon observed that many soldiers arriving at the casualty clearing stations who had been exposed to exploding shells, although clearly damaged, bore no visible wounds. Rather, they appeared to be suffering from a remarkable state of shock caused by blast force. This new type of injury, a British medical report concluded, appeared to be "the result of the actual explosion itself, and not merely of the missiles set in motion by it." In other words, it appeared that some dark, invisible force had in fact passed through the air and was inflicting novel and peculiar damage to men's brains.

"Shell shock," the term that would come to define the phenomenon, first appeared in the British medical journal The Lancet in February 1915, only six months after the commencement of the war. In a landmark article, Capt. Charles Myers of the Royal Army Medical Corps noted "the remarkably close similarity" of symptoms in three soldiers who had each been exposed to exploding shells: Case 1 had endured six or seven shells exploding around him; Case 2 had been buried under earth for 18 hours after a shell collapsed his trench; Case 3 had been blown off a pile of bricks 15 feet high. All three men exhibited symptoms of "reduced visual fields," loss of smell and taste, and some loss of memory. "Comment on these cases seems superfluous," Myers concluded, after documenting in detail the symptoms of each. "They appear to constitute a definite class among others arising from the effects of shell-shock."

Early medical opinion took the common-sense view that the damage was "commotional," or related to the severe concussive motion of the shaken brain in the soldier's skull. Shell shock, then, was initially deemed to be a physical injury, and the shellshocked soldier was thus entitled to a distinguishing "wound stripe" for his uniform, and to possible discharge and a war pension. But by 1916, military and medical authorities were convinced that many soldiers exhibiting the characteristic symptoms-trembling "rather like a jelly shaking"; headache; tinnitus, or ringing in the ear; dizziness; poor concentration; confusion; loss of memory; and disorders of sleep-had been nowhere near exploding shells. Rather, their condition was one of "neurasthenia," or weakness of the nerves-in laymen's terms, a nervous breakdown precipitated by the dreadful stress of war.

Organic injury from blast force? Or neurasthenia, a psychiatric disorder inflicted by the terrors of modern warfare? Unhappily, the single term "shell shock" encompassed both conditions. Yet it was a nervous age, the early 20th century, for the still-recent assault of industrial technology upon age-old sensibilities had given rise to a variety of nervous afflictions. As the war dragged on, medical opinion increasingly came to reflect recent advances in psychiatry, and the majority of shell shock cases were perceived as emotional collapse in the face of the unprecedented and hardly imaginable horrors of trench warfare. There was a convenient practical outcome to this assessment; if the disorder was nervous and not physical, the shellshocked soldier did not warrant a wound stripe, and if unwounded, could be returned to the front.

The experience of being exposed to blast force, or being "blown-up," in the phrase of the time, is evoked powerfully and often in the medical case notes, memoirs and letters of this era. "There was a sound like the roar of an express train, coming nearer at tremendous speed with a loud singing, wailing noise," recalled a young American Red Cross volunteer in 1916, describing an incoming artillery round. "It kept coming and coming and I wondered when it would ever burst. Then when it seemed right on top of us, it did, with a shattering crash that made the earth tremble. It was terrible. The concussion felt like a blow in the face, the stomach and all over; it was like being struck unexpectedly by a huge wave in the ocean." Exploding at a distant 200 yards, the shell had gouged a hole in the earth "as big as a small room."

By 1917, medical officers were instructed to avoid the term "shell shock," and to designate probable cases as "Not Yet Diagnosed (Nervous)." Processed to a psychiatric unit, the soldier was assessed by a specialist as either "shell shock (wound)" or "shell shock (sick)," the latter diagnosis being given if the soldier had not been close to an explosion. Transferred to a treatment center in Britain or France, the invalided soldier was placed under the care of neurology specialists and recuperated until discharged or returned to the front. Officers might enjoy a final period of convalescence before being disgorged back into the maw of the war or the working world, gaining strength at some smaller, often privately funded treatment center-some quiet, remote place such as Lennel House, in Coldstream, in the Scottish Borders country.

The Lennel Auxiliary Hospital, a private convalescent home for officers, was a country estate owned by Maj. Walter and Lady Clementine Waring that had been transformed, as had many private homes throughout Britain, into a treatment center. The estate included the country house, several farms, and woodlands; before the war, Lennel was celebrated for having the finest Italianate gardens in Britain. Lennel House is of interest today, however, not for its gardens, but because it preserved a small cache of medical case notes pertaining to shell shock from the First World War. By a savage twist of fate, an estimated 60 percent of British military records from World War I were destroyed in the Blitz of World War II. Similarly, 80 percent of U.S. Army service records from 1912 to 1960 were lost in a fire at the National Personnel Records Office in St. Louis, Missouri, in 1973. Thus, although shell shock was to be the signature injury of the opening war of the modern age, and although its vexed diagnostic status has ramifications for casualties of Iraq and Afghanistan today, relatively little personal medical data from the time of the Great War survives. The files of the Lennel Auxiliary Hospital, however, now housed in the National Archives of Scotland, had been safeguarded amid other household clutter in the decades after the two world wars in a metal box in the Lennel House basement.

In 1901, Maj. Walter Waring, a distinguished officer and veteran of the Boer War and a Liberal MP, had married Lady Susan Elizabeth Clementine Hay and brought her to Lennel House. The major was in uniform for most of the war, on duty in France, Salonika and Morocco, and it was therefore Lady Clementine who had overseen the transformation of Lennel House into a convalescent home for neurasthenic soldiers. The daughter of the 10th Marquess of Tweeddale, "Clemmie," as she was known to her friends, was 35 years old in 1914. She is fondly recalled by her grandson Sir Ilay Campbell of Succoth and his wife, Lady Campbell, who live in Argyll, as "a presence" and great fun to be with-jolly and amusing and charming. A catalog of Lady Clementine's correspondence, in Scotland's National Archives, gives eloquent evidence of her charm, referencing an impressive number of letters from hopeful suitors, usually young captains, "concerning their relationship and possible engagement."

Generally arriving at Lennel from treatment centers in London and Edinburgh, convalescing officers were received as country house guests. A handsome oak staircase dominated Lennel's entry hall and led under an ornate glass dome to the upper floor, where each officer found his own pleasant bedroom, with windows opening onto the garden or with views of the woodlands and the Cheviot Hills beyond; there appear to have been only about a dozen residents at any one time. Downstairs, the private study of Major Waring had been appropriated during his absence to the war as an officers' mess, while his paneled library was available to the bookish: Siegfried Sassoon, who was to emerge as one of the outstanding poet chroniclers of the war, found here "a handsome octavo edition" of a Thomas Hardy novel, and spent a rainy day carefully trimming its badly cut pages. Meals were presided over by the officers' hostess, the beautiful, diminutive Lady Clementine.

Their common status as officers notwithstanding, the men came from many backgrounds. Lt. R. C. Gull had been educated at Eton, Oxford and Sandhurst before receiving his commission in November 1914, for example, while Lieutenant Hayes, of the Third Royal Sussex Regiment, had been born in London, educated in England and Switzerland, and had emigrated to Canada, where he had been engaged in "Business & Farming" before the war. The officers had been Australian station managers, chartered accountants, partners in banking firms and, intriguingly, "a trader and explorer in Central Africa." The men had seen action in many campaigns, on many fronts, including the Boer War. A number had served at Gallipoli, and all too many had been injured on the Western Front.

Life at Lennel was conducted in the familiar and subtly strict routine of the well-run country house, with meals at set times, leisurely pursuits and tea on the terrace. Lady Clementine's family mixed freely with the officer guests, her youngest daughter, "Kitty," who was only 1 year old when the war broke out, being a special favorite. Kept busy throughout the day with country walks, chummy conversation, piano playing, table tennis, fishing, golfing and bicycling, and semiformal meals, each officer nonetheless retired at night to his private room and here confronted, starkly and alone, the condition that had brought him this peaceful interlude in the first place.

"Has vivid dreams of war episodes-feels as if sinking down in bed"; "Sleeping well but walks in sleep: has never done this before: dreams of France"; "Insomnia with vivid dreams of fighting"; and "Dreams mainly of dead Germans...Got terribly guilty conscience over having killed Huns."

The terse medical case notes, averaging some three pages per patient, introduce each officer by name and age, cite his civilian address as well as regiment and service details, and include a brief section for "Family History," which typically noted whether his parents were still alive, any familial history of nervous disorders and if a brother had been killed in the war. Education, professional life and an assessment of the officer's temperament before his breakdown were also duly chronicled. Captain Kyle, for example, age 23 and in service for three years and three months at the time of admittance to Lennel had previously been a "Keen athlete, enjoyed life thoroughly, no nerves." Brigadier General McLaren had also been "Keen on outdoor sports"-always the benchmark of British mental health-but had "Not very many friends."

Many treatments abounded for the neurasthenic soldier. The most notorious were undoubtedly Dr. Lewis Yealland's electric shock therapies, conducted at the National Hospital for Paralysed and Epileptic, at Queen Square, London, where he claimed his cure "had been applied to upwards of 250 cases" (an unknown number of which were civilian). Yealland asserted that his treatment cured all the most common "hysterical disorders of warfare"-the shaking and trembling and stammering, the paralysis and disorders of speech-sometimes in a single suspect half-hour session. Electric heat baths, milk diets, hypnotism, clamps and machines that mechanically forced stubborn limbs out of their frozen position were other strategies. As the war settled in, and shell shock-both commotional and emotional-became recognized as one of its primary afflictions, treatment became more sympathetic. Rest, peace and quiet, and modest rehabilitative activities became the established regimen of care, sometimes accompanied by psychotherapy sessions, the skillful administration of which varied from institution to institution and practitioner to practitioner.

While the officers at Lennel were clearly under medical supervision, it is not evident what specific treatments they received. Lady Clementine's approach was practical and common-sensical. She was, according to her grandson Sir Ilay, an early advocate of occupational therapy-keeping busy. Painting, in particular, seems to have been encouraged, and a surviving photograph in a family album shows Lennel's mess hall ringed with heraldic shields, each officer having been instructed by Lady Clementine to paint his family coat of arms. (And if they didn't have one? "I expect they made one up," Sir Ilay recalled, amused.) But beyond the nature of the men's treatment, of course, was the larger, central, burning question of what, really, was the matter.

The symptoms recorded in the case notes, familiar from literature of the time, are clear enough: "palpitations-Fear of fainting...feeling of suffocation, of constriction in throat"; "Now feels worn out & has pain in region of heart"; "Depression-Over-reaction-Insomnia-Headaches"; nervousness, lassitude, being upset by sudden noise"; "Patient fears gunfire, death and the dark...In periods of wakefulness he visualizes mutilations he has seen, and feels the terror of heavy fire"; "Depressed from incapacity to deal with easy subjects & suffered much from eye pain." And there is the case of Second Lieutenant Bertwistle, with two years of service in the 27th Australian Infantry, although only 20 years of age, whose face wears a "puzzled expression" and who exhibits a "marked defect of recent and remote memory." "His mental content appears to be puerile. He is docile," according to the records that accompanied him from the Royal Victoria Military Hospital in Netley, on England's south coast.

The official Report of the War Office Committee of Enquiry Into "Shell-Shock" made at war's end gravely concluded that "shell-shock resolves itself into two categories: (1) Concussion or commotional shock; and (2) Emotional shock" and of these "It was given in evidence that the victims of concussion shock, following a shell burst, formed a relatively small proportion (5 to 10 per cent)." The evidence about damage from "concussion shock" was largely anecdotal, based heavily upon the observations of senior officers in the field, many of whom, veterans of earlier wars, were clearly skeptical of any newfangled attempt to explain what, to their mind, was simple loss of nerve: "New divisions often got 'shell shock' because they imagined it was the proper thing in European warfare," Maj. Pritchard Taylor, a much-decorated officer, observed. On the other hand, a consultant in neuropsychiatry to the American Expeditionary Force reported a much higher percentage of concussion shock: 50 percent to 60 percent of shell shock cases at his base hospital stated they had "lost consciousness or memory after having been blown over by a shell." Unfortunately, information about the circumstances of such injuries was highly haphazard. In theory, medical officers were instructed to state on a patient's casualty form whether he had been close to an exploding shell, but in the messy, frantic practice of processing multiple casualties at hard-pressed field stations, this all-important detail was usually omitted.

Case notes from Lennel, however, record that a remarkable number of the "neurasthenic" officers were casualties of direct, savage blast force: "Perfectly well till knocked over at Varennes...after this he couldn't sleep for weeks on end"; "He has been blown up several times-and has lately found his nerve was getting shaken." In case after case, the officer is buried, thrown, stunned, concussed by exploding shells. Lieutenant Graves had gone straight from Gallipoli "into line & through Somme." In fighting around Beaumont Hamel in France, a shell had landed "quite close & blew him up." Dazed, he was helped to the company dugout, after which he "Managed to carry on for some days," although an ominous "Weakness of R[ight] side was developing steadily." Ironically, it was precisely the soldier's ability "to carry on" that had aroused skepticism over the real nature of his malady.

The extent to which blast force was responsible for shell shock is of more than historic interest. According to a Rand Corporation study, 19 percent of U.S. troops sent to Iraq and Afghanistan, about 380,000, may have sustained brain injuries from explosive devices-a fact that has prompted comparisons with the British experience at the Somme in 1916. In 2009, the U.S. Defense Advanced Research Projects Agency (DARPA) made public the results of a two-year, $10 million study of the effects of blast force on the human brain-and in doing so, not only advanced the prospect of modern treatment but cast new light on the old shell shock conundrum.

The study revealed that limited traumatic brain injury (TBI) may manifest no overt evidence of trauma-the patient may not even be aware an injury has been sustained. Diagnosis of TBI is additionally vexed by the clinical features-difficulty concentrating, sleep disturbances, altered moods-that it shares with post-traumatic stress disorder (PTSD), a psychiatric syndrome caused by exposure to traumatic events. "Someone could have a brain injury and be looking like it was PTSD," says Col. Geoffrey Ling, the director of the DARPA study.

Differentiation between the two conditions-PTSD and TBI, or the "emotional" versus "commotional" puzzle of World War I-will be enhanced by the study's most important find: that at low levels the blast-exposed brain remains structurally intact, but is injured by inflammation. This exciting prospect of a clinical diagnosis was presaged by the observation in World War I that spinal fluid drawn from men who had been "blown up" revealed changes in protein cells. "They were actually pretty insightful," Ling says of the early medics. "Your proteins, by and large, are immunoglobulins, which basically are inflammatory. So they were ahead of their time."

"You can never tell how a man is going to do in action," a senior officer had observed in the War Office Committee report of 1922, and it was this searing truth of self-discovery that the patients at Lennel feared. They were betrayed by the stammering and trembling they could not control, the distressing lack of focus, their unmanly depression and lassitude. No list of clinical symptoms, such as the written records preserve, can do justice to the affliction of the shellshocked patient. This is more effectively evoked in the dreadful medical training films of the war, which capture the discordant twitching, uncontrollable shaking and haunting vacant stares. "Certainly one met people who were-different," Sir Ilay recalled gently, speaking of damaged veterans he had seen as a boy, "and it was explained of their being in the war. But we were all brought up to show good manners, not to upset."

Possibly, it was social training, not medical, that enabled Lady Clementine to assist and solace the damaged men who made their way to Lennel. If she was unsettled by the sights and sounds that filled her home, she does not seem to have let on. That she and her instinctive treatment were beneficial is evident from what is perhaps the most remarkable feature of the Lennel archive-the letters the officers wrote to their hostess upon leaving.

"I am quite unable adequately to express my gratitude to you for your kindness and hospitality to me," wrote Lieutenant Craven, as if giving thanks for a pleasant weekend in the country. Most letters, however, run to several pages, their eager anecdotes and their expressions of anxieties and doubt give evidence of the sincerity of the writer's feeling. "I got such a deep breath of 'Lennel,' while I was reading your letter," wrote one officer from the Somme in December 1916, "& I'll bet you had your tennis shoes on, & no hat, & a short skirt, & had probably just come in from a walk across the wet fields"; "Did you really and truly mean that I would be welcome at Lennel if I ever get the opportunity for another visit?" one officer asked yearningly.

A number of the letters are written from hotels while awaiting the results of medical boards. Most hoped for light duty-the dignity of continued service but without the dreaded liabilities. "The Medical Board sent me down here for two months light duty after which I must return to the fray!" writes Lieutenant Jacob, and, as a wistful postscript; "Did you ever finish that jolly Japanese puzzle picture?!" For some, the rush of the outside world came at them too fast: "I have been annoyed quite a lot at little things & my stammer has returned," one officer confided. Several write from other hospitals; "I had not the remotest idea of how & when I came here," Lieutenant Spencer wrote to Lady Clementine. "I do not know what really happened when I took ill but I do sincerely hope that you will forgive me if I was the cause of any unpleasant situation or inconvenience."

At war's end, the legions of shellshocked veterans dispersed into the mists of history. One catches glimpses of them, however, through a variety of oblique lenses. They crop up in a range of fiction of the era, hallucinating in the streets of London, or selling stockings door to door in provincial towns, their casual evocation indicating their familiarity to the contemporary reader.

Officially they are best viewed in the files of the Ministry of Pensions, which had been left with the care of 63,296 neurological cases; ominously, this number would rise, not fall, as the years passed, and by 1929-more than a decade after the conclusion of the war-there were 74,867 such cases, and the ministry was still paying for such rehabilitative pursuits as basket making and boot repairing. An estimated 10 percent of the 1,663,435 military wounded of the war would be attributed to shell shock; and yet study of this signature condition-emotional, or commotional, or both-was not followed through in the postwar years.

Following the Great War, Major Waring served as Parliamentary private secretary to Winston Churchill. For her work at Lennel House, Lady Clementine was made a Commander of the British Empire. She died in 1962, by which time the letters and papers of her war service were stored in the Lennel House basement; there may be other country houses throughout Britain with similar repositories. Lennel House itself, which the family sold in the 1990s, is now a nursing home.

The fate of some officers is made evident by Lady Clementine's correspondence: "Dear Lady Waring...my poor boys death is a dreadful blow and I cant realize that he has gone forever....Oh it is too cruel after waiting three long weary years for him to come home." Very occasionally, too, it is possible to track an officer through an unrelated source. A photograph that had been in the possession of Capt. William McDonald before he was killed in action in France, in 1916, and which is now archived in the Australian War Memorial, shows him gathered with other officers on the Lennel House steps, with Lady Clementine. Some later hand has identified among the other men "Captain Frederick Harold Tubb VC, 7th Battalion of Longwood," and noted that he died in action on 20 September 1917; this is the same "Tubby" who had written to Lady Clementine a month earlier, at the completion of an 11-hour march, heading his letter simply "In the Field": "An aeroplane tried to shoot us last night with a m[achine] gun besides dropping sundry bombs around. It rained a heavy storm last night. It is raining off an[d] on today. The weather is warm though. My word the country round here is magnificent, the splendid wheat crops are being harvested...."

Caroline Alexander's latest book is The War That Killed Achilles: The True Story of Homer's Iliad and the Trojan War.

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In September 1914, at the very outset of the great war, a dreadful rumor arose. It was said that at the Battle of the Marne, east of Paris, soldiers on the front line had been discovered standing at their posts in all the dutiful military postures-but not alive.

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Here are 11 facts that try to covey a sense of the massive, unprecedented slaughter of World War One. This section makes grim reading and viewing - but the war was extremely grim.

Although in terms of the scale of the slaughter World War One was surpassed by World War Two, the sense of pointless and wasteful loss of life that the meeting of antiquated tactics with industrial weaponry created, remains unparalleled.

1. Total casualties caused directly by the war are estimated at 37.5 million

2. Approximately 7 million combatants were maimed for life

3. Germany lost the most men, with 2,037,000 killed and missing in total

4. On average 230 soldiers perished for every hour of fighting

5. 979,498 British and Empire soldiers died

See a Commonwealth War Dead: First World War Visualised - based on figures from the Commonwealth War Graves Commission.

6. 80,000 British soldiers suffered shell shock (roughly 2% of all that were called up)

Shell shock was an incapacitating mental illness believed to be brought on by intense sustained artillery shelling.

7. 57.6% of all combatants became casualties

8. It cost the Allies $36,485.48 to kill an opposing serviceman - significantly more than it cost the Central Powers

Niall Ferguson makes these estimations in The Pity of War.

9. At nearly 65% the Australian casualty rate was the highest of the war

10. 11% of France's entire population was killed or wounded

11. On the Western Front total casualties were 3,528,610 dead and 7,745,920 wounded

The Allies lost 2,032,410 dead and 5,156,920 wounded, The Central Powers 1,496,200 dead and 2,589,000 wounded.

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11 Facts About World War One Casualties | History Hit

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Here are 11 facts that try to covey a sense of the massive, unprecedented slaughter of World War One. This section makes grim reading and viewing - but the war was extremely grim. Although in terms of the scale of the slaughter World War One was surpassed by World War Two, the sense of pointless and ...

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Create a new document and edit with others at the same time -- from your computer, phone or tablet. Get stuff done with or without an internet connection. Use Docs to edit Word files. Free from Google.

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Would understanding of mental health still be the same today without WW1?

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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 emergence of the concept of shell shock during the First World War had focused unparalleled attention to the issue of traumatic illness.
Today, the recognition of post-traumatic stress disorder ( PTSD) has established in the minds of the public, media and the health professionals that war can produce long-term and severe psychological effects. However, it was not always so.
Vulnerability to Stress
In the late nineteenth century, passengers who had been exposed to a terrifying train crash were often diagnosed with "railway spine" to explain why their psycho-somatic symptoms endured after physical wounds had healed. Medical opinion was divided as to whether these were organic effects, related to lesions in the central nervous system, or whether they were due to an inborn or acquired vulnerability to stress.

During World War One, soldiers exhibiting similar patterns of symptoms were given the label "shell shock." The cause of their invalidity and, therefore, the appropriate form of management was the subject of considerable debate. Some hardline medical doctors, such as Gordon Holmes, believed that servicemen who broke down on the battlefield and failed to return to duty after a short period of recuperation showed a lack of resolve, which should be addressed by military discipline rather than continued hospitalization. By contrast, Charles Myers, consulting psychologist to British forces in France, argued that each soldier patient should be assessed on his merits.

Having observed the capacity of artillery bombardment to erode the morale and determination of the toughest combatant, Myers considered shell shock a legitimate illness, requiring expert treatment no less than any wound or disease. By exposing the citizen armies of Europe to prolonged and extreme danger, World War One generated psychological casualties on an industrial scale. This, in turn, created a military crisis that drew doctors from a diverse range of specialties into the field of mental health; never before had so much attention been focused on a single psychiatric disorder.

Shell Shock

The term "shell shock" emerged in the harsh winter of 1914-15 as soldiers sought to describe how they felt when under fire. During training, they had been instructed to conceal their fears because panic was known to spread rapidly through battalions. Yet, apart from trusting to luck, there was little that an infantryman could do to protect his life when being shelled. Without regulated tours of duty and no prospect of an early end to the conflict, many frontline soldiers were worn down by the emotional demands of trench warfare.

In the aftermath of the Battle of the Somme, shell shock became a military priority as a flood of psychiatric casualties eroded the strength of front-line units. Specialist centers were set up within the sound of the guns to provide rapid treatment and to discourage soldiers from believing that they had escaped military duty. In addition, new regulations governed the use of diagnostic terms, seeking to stem the flow of casualties across the Channel.

In theory, hospitals in Britain were reserved for severe or intractable cases of shell shock. There, teams of doctors researched causation and experimented with treatment. From this concentrated effort emerged various schools of trauma therapy: At the Maudsley Hospital under the direction of Frederick Mott, "an atmosphere of cure" was emphasized through purposeful activity (graduated exercise, carpentry, gardening, games and social events), whilst at the Red Cross Hospital in Maghull clinicians used ideas borrowed from anthropology and psycho-analysis. At Seale Hayne in Devon, where Arthur Hurst had access to farmland and a pottery, occupational therapy was emphasized as a way of restoring soldiers' self-confidence and physical function.

By the early 1950s it was recognized that all soldiers have a breaking point, however well trained and motivated. As well as the link between physical and psychological casualties, it was also established that factors such as morale, leadership, regular sleep and confidence in equipment could mediate the size of the association but not the association itself.

At least 250,000 UK servicemen suffered from some form of psycho-somatic illness related to the conflict. Many failed to recover once peace had been restored. At first, the government funded treatment for veterans. "Special medical clinics" were opened by the Ministry of Pensions in provincial towns to provide a nationwide service of out-patient psychotherapy. With shortages of doctors qualified in trauma therapy, a training school was set up under Lt Colonel R.G. Rows, medical superintendent of Maghull.

By October 1920, 29 clinics were in operation and in February of the following year, it was estimated that 14,771 ex-servicemen with shell shock were either attending boards for assessment or clinics for treatment. However, a dramatic downturn in the economy and a government committed to public sector cuts saw the clinics close. By the mid-1920s trauma psychiatry had fallen down the health agenda and it took another world war to bring the sub-specialty to prominence.

World War Two

During World War Two breakdown on the battlefield again became a priority for the Allied democracies concerned that high casualties would undermine popular support for the conflict. Military psychiatry became an essential element of medical provision. With the direct involvement of the United States and its wealth of resources, attention was turned to evaluating the nature of breakdown and the effectiveness of treatments. Towards the end of the war, large-scale investigation was conducted into the psychological demands of combat (notably Samuel Stouffer's two-volume study The American Soldier).

In addition, Gilbert W. Beebe, a sociologist, Michael E. DeBakey, a surgeon, and Albert Glass a military psychiatrist researched the relationship between physical and psychiatric casualties. Their findings provided objective evidence on which to build policy for subsequent conflicts.

By the early 1950s it was recognized that all soldiers have a breaking point, however well trained and motivated. As well as the link between physical and psychological casualties, it was also established that factors such as morale, leadership, regular sleep and confidence in equipment could mediate the size of the association but not the association itself. Yet, it was still believed that combat was secondary to personality in terms of causation. War, it was argued, served as a trigger to underlying vulnerability. Robust individuals with no family history of mental illness were expected to recover from the trauma of battle relatively quickly with no lasting ill effects.

Vietnam

The political crisis created by the Vietnam War, combined with significant cultural change, inspired a new interpretation of trauma psychiatry. Anti-war campaigners argued that veterans who had been able to contain their distressing experiences whilst on active service broke down on return to the US when confronted by an unsympathetic public. They called the phenomenon "delayed stress syndrome" or "post-Vietnam syndrome."

A campaign by veterans and clinicians led to the formal recognition of PTSD by the American Psychiatric Association in 1980. It represented a turning point in aetiological theory. In both World Wars the individual had been held responsible for his breakdown: whether his genetics, family history, up-bringing or unconscious conflict. PTSD reversed this causal explanation. The traumatic exposure, criterion A in the DSM-III definition, was now primary and everyone, whether citizen or soldier, was potentially vulnerable to the new traumatic disorder if exposed to a life-threatening event. Personality factors were now considered secondary determining, amongst other things, the speed of recovery or severity of the disorder.

Post-Traumatic Stress Disorder

Shell shock and PTSD are not the same disorder by a different name. The former was a catch-all term for any soldier who broke down and was unable to perform his duties. It was expressed through a range of psycho-somatic symptoms such as chest pain, fatigue, headache, tremor, palpitations and nightmares. PTSD has some features in common with shell shock (notably startle reaction, poor concentration and intrusive images). Both disorders arose in a context of heightened emotion conditioned by extreme threat. They can be seen as culturally determined expressions of distress.

Although there is no direct chain of events from World War One through to the recognition of PTSD in 1980, the shell shock episode had focused unparalleled attention to the issue of traumatic illness. Never before had so many soldiers suffered from psychological disorder. Furthermore, their illness could not be explained by pre-war theories of degeneration, heredity or the side effects of infectious disease. Neurologists, general physicians and even surgeons, doctors who before 1914 would not have shown any interest in psychiatry, were drawn to shell shock.

By bringing new ideas to the discipline, it gave a fresh impetus to the search for psychological understanding and, in this sense, PTSD can be viewed as a progeny of World War One. Whilst today we are better equipped to diagnose and treat psychological trauma, we seem no further forward in preventing the conflicts that are the cause of these illnesses.
The views expressed in this article are the author's own and do not necessarily reflect Fair Observer's editorial policy.

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Psychological Wounds of Conflict: The Impact of World War One - Fair Observer

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The emergence of the concept of shell shock during the First World War had focused unparalleled attention to the issue of traumatic illness. Today, the recognition of post-traumatic stress disorder ( PTSD) has established in the minds of the public, media and the health professionals that war can produce long-term and severe psychological effects.

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During WWI, Charles S. Myers convinced the British military to take shell shock seriously and developed approaches that still guide treatment for PTSD today.

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Presented by Sian Williams Broadcaster

Presented by Sian Williams Broadcaster

Soldiers who served in World War One endured some of the most terrible forms of warfare ever known. They faced the daily sight of death and mutilation caused by exploding shells, machine guns or silent but deadly poison gas. Many thousands began suffering strange symptoms from uncontrollable twitching to terrible nightmares.

A number of names to describe this new 'illness' were suggested but the one that stuck was shell shock.

We now know it was an understandable reaction to the horror of modern warfare, but at the time it was the cause of much confusion, distress and lack of understanding. After all, by the end of the war 80,000 men would have been diagnosed with shell shock.

The scale of World War One meant that it touched the lives of entire populations, not just those on the front line. Click on the labels below to read about how non-combatants were also deeply affected.

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Images courtesy of Getty, Mary Evans and Topfoto

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Did shell shock make us serious about mental health?

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In World War One shell shock affected 80,000 soldiers. Sian William's questions how this shaped our views of mental health in Britain.

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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

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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,