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How did the discovery of shell shock change the forms of treatment for mental health

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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,

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Studies about the mental-health impact of the war have focused almost exclusively on men, to the detriment of the women who suffered on the front lines and the home front.

United States Marine Corps Archives/Flickr

In late 1917, a British woman named Elizabeth Huntley decapitated her own daughter. When the case went to trial, her friends and family testified that she had been a "jolly-hearted woman"-that is, "until the air raids." Her sister told the judge that the raids in London caused Elizabeth to shake and have delusions, and that she had become depressed. Her doctor had tried to get her out of London and away from her children, because during the raids they "screamed" and "worried her," but he was too late. She had a nervous breakdown during a raid, and murdered her child. They called it "air raid shock."

During World War I, the relatively new field of psychoanalysis was full of possibility and, unfortunately, thousands of new patients. The war's destruction was not limited to the physical; the psychological devastation was immense, and soldiers returned home from the front every day exhibiting a range of new symptoms, including "hysterical paralysis," deafness, mutism, arthritis, facial spasms, "fear, disgust, fatigue," "delirium," "suicidal thoughts," "stammer," and more. Though we now recognize many of these as symptoms of post-traumatic stress disorder, doctors at the time struggled to find ways to categorize the rapid and widespread breakdown of the British mind. The solution for soldiers was the invention of a new condition: shell shock. The diagnosis and treatment of similar traumas in women, however, has been largely unexamined by historians.

The psychologist Dr. Charles S. Myers coined the term shell shock in an article for The Lancet in February 1915, after seeing a number of cases of mental distress in soldiers who experienced shells bursting near them at close range. Yet Myers quickly realized that many of the men exhibiting similar symptoms "had never been near an exploding shell, had not been under fire for months, or had never come under fire at all." He admitted shell shock was "a singularly ill-chosen term," and the British medical community quickly suggested "war neuroses" instead. But the public had already latched onto the memorable alliteration, and "shell shock" has remained in popular discourse ever since.

Though a misnomer, historians have argued that shell shock provided a convenient way for doctors to separate the mental traumas exhibited by soldiers from the "effeminate associations of 'hysteria.'" For centuries, hysteria was thought of as a uniquely female condition, used to explain everything from fainting to sexual desire. Victorian women assumed they were so susceptible to the disease that they carried smelling salts around with them, believing pungent smells could help keep their emotions in check. But while hysteria might have been accepted as an explanation for a Victorian woman's nerves, it was considered an inadequate, emasculating explanation for a male soldiers' mental health. Not only did medicine separate the experiences of men and women; the experience of the soldier was understood as uniquely difficult and traumatic.

It makes sense then that there is little evidence showing women at the time being treated for "shell shock"-the male and female minds, and their respective suffering, were considered distinct. But as the historian Susan Grayzel notes, Huntley's infanticide case and her "air raid shock" diagnosis pose difficult questions. Were air raid shock and shell shock considered similar, or even equivalent, conditions? "Was she in any way akin to those on the battlefields who suffered from similar war or fear-induced mental anguish? ... Under these circumstances-and it is hard to know to what extent Elizabeth Huntley was unique ... the blurring of the line indicating who exactly was under fire seems fully accomplished." If a woman at home in London could experience comparable mental distress to those in France and elsewhere, then not only would men no longer be the only ones "under fire;" women's minds could be seen as equivalent to men's, and their suffering just as great.

The solution, it seems, was not to accept that reality: Instead, psychologists and doctors invented yet another new condition, called "civilian war neuroses." The emphasis of "civilian" in the title is key, reinforcing a dichotomy between the home front and the war front. Medical authorities were willing to admit that those not directly in the line of fire-such as Huntley-were susceptible to the traumas of warfare, but were unwilling to completely equate the mental sufferings of soldiers and civilians.

Huntley was deemed "insane" and "unfit to plead," and was sentenced to Holloway Prison for adult women in north London, which is still operating today. Little else has been written about her case. But while her resolution may provide some answers for the diagnosis and treatment of civilian women, not all women at the time fit so neatly in the dual categories of shell-shocked solider and hysterical, "civilian" woman. Many women were on the firing line, suffering their own psychological trauma at the front, but their conditions seemed to have largely gone ignored and untreated-a gap in the understanding of women's experience of war that largely remains in histories to this day.

Hundreds of women worked in France and Belgium as nurses and ambulance drivers, right alongside the male soldiers, or " Tommies." Their experiences included tremendous violence and physical suffering; their diaries and letters home include descriptions of being fired on by enemy forces, who used the ambulances to gauge distance to the trenches; spending long nights trapped in No Man's Land; suffering amputations and broken bones from crashes and falling shells; and even getting hit with "secondary gas," as the acrid fumes clinging to the victims they were helping could burn their eyes.

They also wrote of mental anxieties and traumas that bore striking resemblance to the era's understanding of "shell shock"-but they largely suffered them without diagnosis or treatment. If a female ambulance driver or nurse could not stand the strain of war, she was simply sent home. Unlike the male soldiers, women were expected to be mentally incapable of handling the trauma of war, and high female attrition was hardly a concern. The tremendous effort put into "curing" men with shell shock-87 percent of British troops diagnosed with the condition were returned to front line service within a month-was due to the army's need for combat-ready men. The supply of women was not rapidly diminishing.

However, the diaries and letters of women stationed on the front reveal countless instances of women discussing their "shock" and reaction to the emotional stress around them. One woman wrote of a friend who had gone temporarily deaf, and another who had trouble with her vision, as a result of the stress and strain of their work. Several novels, poems, and memoirs also explore the themes of mental instability among women at the front. In Helen Zenna Smith's Not So Quiet, a female ambulance driver is sent home from France on "sick leave" after she witnesses a friend dying at the front, but she receives no medical attention. In The Forbidden Zone, Mary Borden's memoir of her time as a nurse in France, she describes herself as becoming "delirious" and feeling like she "seemed to be breaking into pieces." She was sent home because officials felt she was "tired."

Even with these documents, women's mental health during the war has received attention from only a handful of historians, with sensational cases like Huntley's as the exception. Instead, the focus remains on the male experience. Jay Winter argues that historians have turned shell shock "from a diagnosis into a metaphor," a way to describe the "metaphysical" symptoms of war: soldiers who refused to be soldiers, men who refused to be "men." Even Elaine Showalter's seminal 1985 text on hysteria, The Female Malady, devoted its chapter on World War I entirely to men.

In a letter to her mother, a female ambulance driver wrote about her friend "Tommy," who "stutters still poor soul." Tommy suffered from one of the most recognizable symptoms of shell shock-and Tommy was not a male solider, but another female ambulance driver. Her symptoms and her nickname placed her in direct parallel to the Tommies fighting nearby, but her sex denied her similar status and treatment both during the war and afterwards, in histories of the conflict. If the only available terms for describing the mental trauma brought on by war are shell shock-a term only applicable to men-and civilian war neuroses, then women who served at the front have no place in the psychological understanding of warfare. The sublimation of their suffering at the time has led to ignorance of their experiences today.

We want to hear what you think about this article. Submit a letter to the editor or write to letters@theatlantic.com.

Hannah Groch-Begley is a research fellow at Media Matters for America.

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The Forgotten Female Shell-Shock Victims of World War I

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Studies about the mental-health impact of the war have focused almost exclusively on men, to the detriment of the women who suffered on the front lines and the home front. In late 1917, a British woman named Elizabeth Huntley decapitated her own daughter.

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Shell Shock - The Psychological Scars of World War 1 I THE GREAT WAR Special

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World War 1 Shell Shock Victim Recovery (1910s) | War Archives

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The Effects of Shell Shock: WWI Nueroses | War Archives

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The Deserters: A Hidden History of World War II

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From the American Revolution into the 20th century, American wars have had their heroic elements, the battles and heroes that have reached near-mythical status. They have also had a dark side that tends to be neglected if not buried.

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The united mental state of America: an eye-opening look at our nation's mental health

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Mental health is interlocked with physical health, and both together are the elements on which our overall well-being is founded. Beyond the physical state of our bodies, many facets of life contribute to sustaining mental health. These include our living conditions, the political climate, our social and economic status, and whether our relationships with family and friends are enriching or toxic.

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Post-traumatic stress disorder (PTSD), currently known as post-traumatic stress syndrome (PTSS), is a condition marked by feelings of anxiety, depression, thoughts of suicide, recurring nightmares, and sudden outbursts of violence. Traumatic events such as natural disasters or accidents can trigger PTSD, and it is quite common among combat veterans.

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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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A research team in the United States may have solved a mystery that has haunted soldiers and veterans for more than a century: how blast force from battlefield explosions injures the human brain.

The findings, published Thursday in the medical journal the Lancet Neurology, reveal a unique and consistent pattern of damage in the autopsied brains of eight military service members who had served in Iraq, Afghanistan, and elsewhere in the Middle East.

All had suffered trauma after exposure to blast force on the battlefield, mostly from improvised explosive devices (IEDs)-the signature injury of recent campaigns, just as shell shock from exploding artillery shells had been the signature injury of World War I, a hundred years before.

In medical terminology, traumatic brain injury, or TBI, covers conditions that range from penetrating head wounds to blunt-force trauma typical of concussions.

But as the new study claims to demonstrate, the pattern of damage caused by exposure to blast force observed in the eight military personnel is distinct from that commonly observed in the brains of football players or boxers who have suffered blunt-force TBI.

Outside medical opinion has yet to weigh in on the findings. But Daniel Perl-a neuropathologist at the Uniformed Services University of the Health Sciences, in Bethesda, Maryland, who led the team behind the groundbreaking paper-said that when he realized that the lesion representing blast damage was distinctive, he knew it was the kind of once-in-a-lifetime breakthrough scientists dream of.

"What we found was a pattern of scarring that in 40 years of examining thousands of brains at autopsy I've never seen before and as far as I know is not described in any of the medical literature," Perl said.

The implications of this finding are profound, pointing to the possibility that symptoms long thought to be psychological-ascribed to post-traumatic stress disorder (PTSD)-may instead be direct results of physical damage to the brain.

"It will mean reevaluating people we've labeled as having PTSD," Perl said. "There's nothing obvious in terms of treatment, but at least it suggests that one should not think about approaching the problem as a purely mental health problem." It would mean reexamining such treatments as talk therapy and psychological medications.

The blast shock finding also opens up potentially fertile new ground for research: Can the injury be healed or even mitigated? What equipment can be designed to protect service members against blast damage to their brains? Can tests be devised to identify damage in combatants on the battlefield in real time?

And it raises a philosophical question for young men and women drawn to military service: If you know that exposure to a blast event-the signature mechanism of injury in modern warfare-may well irreparably damage your brain, will you still join up?

From the earliest years of the Iraq campaign, military personnel exposed to blast reported symptoms that included headache, sleeplessness, problems with memory and concentration, mood disorders such as anger and depression, and impulsiveness. Many of these symptoms are also characteristic of PTSD, which afflicts an estimated 11 to 20 percent of all veterans of the wars in Iraq and Afghanistan in any given year.

Medical practitioners therefore initially assumed the symptoms to be psychological. Furthermore, no routine imaging technology had succeeded in identifying any evidence of physical injury to the brain. But by the end of the first decade of this century, researchers had begun to recognize that while blast damage could not be seen, it was nonetheless real.

The U.S. Department of Defense estimates that some tens of thousands of U.S. veterans and military service members deployed in Iraq and Afghanistan have sustained traumatic brain injury as a result of exposure to a blast event. But given that exposures to blast events were not even logged in the early years of the campaigns, the figure may be much higher.

One of the brains that the team studied also showed signs of chronic traumatic encephalopathy (CTE), a neurodegenerative disease caused by the repetitive blunt-force trauma typical of concussions sustained in contact sports. Another showed features suggestive of an extremely early stage of the disease.

"CTE is not what these service members are suffering when they come home," Perl said. "But this study suggests there are further concerns. They come home with the symptoms caused by the immediate damage-the blast injury-but down the line, in decades, many of these guys will also be hit with CTE."

A wide array of research has attempted to discover the nature of blast injury. (See " The Invisible War on the Brain," National Geographic, February 2015.) Efforts have included sophisticated studies of the physics of blast itself, as well as lab experiments conducted on animals, computer modeling of blast effects, and searches for biomarkers of blast exposure.

An explosion is a complex event that unleashes multiple mechanisms of injury. The primary blast effect is the shock wave, a balloon of rapidly expanding gases that compresses surrounding air and advances outward from the detonation faster than the speed of sound. This shock wave is what enters the brain, passing so rapidly that it has come and gone before the people hit have even had time to move their heads.

Just how a shock wave enters the brain is still not understood. Some believe entry is through the natural openings in the skull: the eye sockets, ears, nostrils, and mouth. Another theory is that since shock wave pressure hits the entire body, not just the head, it's transmitted into the chest or abdominal cavities and surges to the brain by way of the body's vasculature.

Once inside the skull, the wave advances through the brain at the speed of sound, passing through both fluids and matter, which respond differently to the wave's properties. As the new paper reports, the distinctive pattern of scarring occurs precisely in those places where different compositions of brain tissue intersect.

In 2013 the Department of Defense established the Center for Neuroscience and Regenerative Medicine Brain Tissue Repository, under the direction of Perl, to pursue postmortem study of brains at the tissue level.

"Our microscopes have resolutions a thousand times greater than any imaging technology," Perl said. "Autopsy is the gold standard for this kind of investigation."

The eight brain specimens his team studied represented chronic cases, in which the person had lived at least six months after the blast event, as well as acute cases, in which death had followed within 60 days. "The acute cases are revealing," Perl said. "The injury is only four days old, and yet we see the very beginning of the foundation of scars. And these early signs-these early scars-are in the right places, form the right pattern."

Blast waves seem to cause damage at the boundaries of different structures, such as between brain matter and cerebrospinal fluids and between gray and white brain matter. That damage, Perl said, "is consistent with experiments that have modeled blast waves' effects on the different substances forming the brain."

More starkly revealing than any words are the brain images that illustrate what Perl describes. Panels show brain tissue, as delicate as butterfly wings, spatter-marked as if with buckshot, bearing outright tears surrounded by broken tendrils of scarring or dark clouds of damage looming from the folds and furrows.

This blast damage reaches its spider legs into different regions of the brain: the frontal lobe, which controls attention span and emotional control; the hypothalamus, which regulates sleep; the hippocampus, responsible for the formation of memories. The symptoms resulting from damage to these areas are exactly the kinds of symptoms often attributed to PTSD.

What the Eight Men Endured

Emerging from the welter of medical data are details about the lives of the men who make up the research study. They had all been exposed to bombs, IEDs, and high explosives, and they had lived from as long as nine years after blast exposure to as little as four days. They ranged in age from 26 to 45 at the time of death. They had endured headaches, anxiety, depression, insomnia, memory and concentration problems, seizures, and chronic pain.

One was a Navy SEAL who conducted explosives training exercises and lost his coherence of thought; he began to jumble his speech and became overwhelmed by such routine tasks as driving or even packing a car.

Three of the men had acute brain injury and died shortly after exposure to the explosion, suffering burns, fractures, and hemorrhage. Four of the remaining five men who had chronic blast-induced brain injury died by suicide or from drug overdoses. The cause of death of the eighth service member was not determined.

In December 2015, Congress passed a bill mandating the Department of Defense and the Department of Veterans Affairs to examine the effects of combat service "on suicides and other mental health issues among veterans."

The new paper mayadd to mounting evidence that destructive behaviors, including suicide, are outcomes directed by damaged regions of the brain-as symptomatic of blast damage as such common conditions as sleeplessness and ringing in the ears.

A century ago, in February 1915, the Lancet, the parent journal of the Lancet Neurology, published the first medical case study of shell shock in World War I. In the war's aftermath, medical judgment held that thousands upon thousands of shell-shocked men were "neurasthenic" or subject to "neuroses."

These mostly young veterans suffered through their lives in the belief that they had lost their nerve on the field of battle-in short, that they had failed. From the British government Ministry of Pensions files we can catch occasional glimpses of their postwar fates.

One case: a shell-shocked soldier who'd spent 118 days in the hospital being treated for loss of speech, inability to sleep, and loss of memory and concentration-and had been returned to active duty. Case notes made after the war remark on his complaints about "general weakness" and tremors in his hands. It is noted that his mental development is poor, and his answers to questions are "vague and contradictory." Then, like so many others, he slips from history's sight.

"We can't let this happen again," Daniel Perl said. "This study will certainly stimulate important further research and, we predict, will dramatically change how we think about these problems."

Beyond the specifically medical questions, the finding raises a number of issues, such as care costs many years into the future and whether those diagnosed with TBI should be awarded the Purple Heart.

"People that have seen the paper are very excited about it. Blast people working on military TBI are very excited," Perl said. "Then they start asking questions: How large a dose of blast is damaging? Are multiple small exposures doing this? How common is this?-I have a feeling this is pretty common. Can you see it by imaging? And so far the answer to all of these is, we don't know."

Caroline Alexander is the author of "The Invisible War on the Brain," National Geographic,February 2015, which examined the mystery of blast force on the brain. She has written often about the toll of war, including a new translation of Homer's Iliad,published in 2015.

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'Shell Shock'-The 100-Year Mystery May Now Be Solved

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A research team in the United States may have solved a mystery that has haunted soldiers and veterans for more than a century: how blast force from battlefield explosions injures the human brain.

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