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shell shock

Was shell shock what we consider modern day PTSD?

Were soldiers who suffered from shell shock treated well (by society and doctors) or were they blown off and sent back into the field?

Did many of the soldiers who suffered never ask for help?

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High, Hayley. "'My Dear Old Basil': Letters from a Shell-Shocked Soldier." Adam Matthew, a Sage company, 4 Dec. 2015, www.amdigital.co.uk/about/blog/item/letters-shellshock. Accessed 18 Dec. 2018.

Jones, Edgar. "During World War I, Some People Saw Shell Shock as Cowardice or Malingering, but Charles S. Myers Convinced the British Military to Take It Seriously and Developed Approaches That Still Guide Treatment Today." Time Capsule, p. 18. American Phychological Association, www.apa.org/monitor/2012/06/shell-shocked.aspx. Accessed 11 Dec. 2018. Originally published in Shell Shocked, vol. 43, no. 6, June 2012.

McDonald, Mary Catherine, et al. "From Shell-shock to PTSD, a Century of Invisible War Trauma." The Conversation, 3 Apr. 2017, padlet.com/reubanks3/y07g2di6tr2w. Accessed 11 Dec. 2018.

Riddle, Lincoln. "Shell Shock: A Sad Side-Effect of WWI." World War I. War History Online, www.warhistoryonline.com/instant-articles/shell-shock-first-world-war.html. Accessed 11 Dec. 2018. Originally published in War History Online: The Place for Military History News and Views, 6 Dec. 2017.

Simkin, John. "Medical Treatment of Shellshock." Spartacus Educational, Sept. 1997, spartacus-educational.com/FWWmental.htm. Accessed 11 Dec. 2018.

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https://www.apa.org/monitor/2012/06/shell-shocked.aspx

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https://www.warhistoryonline.com/instant-articles/shell-shock-first-world-war.html

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https://spartacus-educational.com/FWWmental.htm

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From shell-shock to PTSD, a century of invisible war trauma

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Mental health trauma has always been a part of war. Treatments have come a long way over the last century, but we still don’t understand why the responses change for different people and times.

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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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Abstract

During the First World War the National Hospital for the Paralysed and Epileptic, in Queen Square, London, then Britain's leading centre for neurology, took a key role in the treatment and understanding of shell shock. This paper explores the case notes of all 462 servicemen who were admitted with functional neurological disorders between 1914 and 1919. Many of these were severe or chronic cases referred to the National Hospital because of its acknowledged expertise and the resources it could call upon. Biographical data was collected together with accounts of the patient's military experience, his symptoms, diagnostic interpretations and treatment outcomes. Analysis of the notes showed that motor syndromes (loss of function or hyperkinesias), often combined with somato-sensory loss, were common presentations. Anxiety and depression as well as vegetative symptoms such as sweating, dizziness and palpitations were also prevalent among this patient population. Conversely, psychogenic seizures were reported much less frequently than in comparable accounts from German tertiary referral centres. As the war unfolded the number of physicians who believed that shell shock was primarily an organic disorder fell as research failed to find a pathological basis for its symptoms. However, little agreement existed among the Queen Square doctors about the fundamental nature of the disorder and it was increasingly categorised as functional disorder or hysteria.

Keywords: First World War, Trauma, Psychopathology, Case histories, Neurology, Hysteria

1. Introduction

Soon after the beginning of the First World War 'cases of nervous and mental shock' began to arrive in England. At first, the medical profession did not pay much attention to these psychological casualties which were seen as 'the more uncommon clinical products of the present war'. For most of 1914, the British medical press mainly reported single cases, such as functional blindness or complete loss of memory. Some authors even observed a decrease in admissions to mental hospitals and interpreted this as evidence for the invigorating powers of warfare:

It is not the great tragedies of life that sap the forces of the brain and wreck the psychic organism. On the contrary, it is small worries, the deadly monotony of a narrow and circumscribed existence, the dull drab of a life without joy and barren of an achievement, the self-centred anaemic consciousness, it is these experiences that weaken and diminish personality and so leave it a prey to inherited predispositions or to the slings and arrows of outrageous fortune.

Yet, advocates of the beneficial effects of war on mental health were soon faced with evidence that challenged their position. On 12 December 1914, the British Medical Journal had published an article by T.R. Elliott on a surprising number of functional paralyses following shell explosions. Consultant physician to the British Army in France, he acknowledged that these disorders were often difficult to distinguish from those caused by brain lesions. In addition, Elliott believed that they assumed diverse forms: 'the man may become blind, or deaf, or dumb; he may be seized by a violent and coarse tremor that shakes his body for days; or he may be paralysed with a hemiplegia or paraplegia'. Although these soldiers did not show any obvious physical injuries, the proximity to explosions was seen as the decisive causative factor and from the winter of 1914/15 onwards they were increasingly labelled as 'shell shock'.

The term found its way into medical terminology from the everyday language of soldiers in the trenches. Prominently featured in a Lancet paper by the Cambridge medical psychologist Charles Samuel Myers (1873-1946) in February 1915, the diagnosis became popular in the first half of the war but - following a recommendation by Myers - was subject to restricted use in official terminology in 1917. Army doctors were then instructed to label suspected mental cases as 'Not Yet Diagnosed (Nervous)' (NYDN) until they were assessed by a specialist. The relative contribution of organic and psychological processes to the syndromes of shell shock and the NYDN category remained a matter of ongoing debate in the British medical literature into the 1920s.

The diagnosis of shell shock was not purely a medical issue but also a product of the interplay between soldiers' experiences of war, the interpretations of physicians and official attitudes. Historians of medicine have often viewed the disorder in cultural terms seeking to interpret the meaning of symptoms and the function that they performed for both the patient and the clinician. Tracey Loughran, for example, has argued convincingly that shell shock has to be analysed in terms of the concerns, knowledge and practices of both patients and doctors. In addition, she emphasised how models of shell shock and its causation drew on pre-war concepts of mental health. Ben Shephard demonstrated that shell shock played a significant role in the British Army's attempts to understand breakdown and to find ways of accommodating the psychological casualty without branding him a coward or weakening the resolve of his comrades. Peter Barham made extensive use of hospital records and war pension files in his analysis of the treatment of servicemen who suffered from mental illness during the First World War. He argued that the asylum partly served as a repository for 'inefficient' soldiers who could not cope with the adverse conditions at the front line and were therefore a hazard in the army. Although Hans Binneveld drew extensively on reports of British, French and German soldiers who had broken down in combat, he did not have a clinical series on which to base an analysis of symptoms and interpretations. Drawing on war pension files and personal narratives, Fiona Reid's study of ex-servicemen explored enduring symptoms experienced by discharged soldiers attempting to reintegrate themselves within their families and the workplace.

To date, few scholars have studied original case records. Petra Peckl analysed a large number of original medical case records held at the Freiburg Military Archives. These records from various German military hospitals of the First World War not only illustrate treatment practices of individual institutions but also clarify referral paths and treatment networks for psychologically injured soldiers in wartime Germany. Peckl emphasises the importance of patient records as a source for historical research because they 'show a much more complex image of the psychological disorders of soldiers in the First World War than that reflected by the lofty impressions provided in the medical literature'. However, Peckl argues that 'expectations that patient perspectives might be reconstructed from medical records have proven rather too optimistic'.

Original case records are also available for the two main Canadian military hospitals in Britain that specialised in the treatment of shell shock cases, the Granville Special Hospital at Ramsgate and the Buxton Red Cross Special Hospital. Based on their analysis of admission and discharge books and randomly selected case records, Humphries and Kurchinksi concluded that neither diagnostic labels - in particular 'neurasthenia' and 'hysteria' - nor treatment methods were linked to the patient's social class. The authors also emphasised the importance of research into original case records in order to challenge the stereotypes that have become pervasive in both the scholarly and popular literature on the First World War. For example, they found that their data called for a revision of a 'binary [treatment] model of discipline and analysis'. This accords with our analysis of British and German treatment practice, which was far more varied and complex than such dichotomous labels would suggest. Although medical records inevitably reflect the biases of the respective institutions and their practitioners they are crucial sources for actual practices and attitudes in the treatment institutions. Ideally their physician-centred accounts would be complemented by original statements from the soldier-patients themselves, of which some can be found in the records as well.

Elaine Showalter, in the The Female Malady, and Pat Barker, in her novel Regeneration have created the impression that punishment was the hallmark treatment of Queen Square physicians. We have highlighted their misconceptions about Yealland's work in a recent paper. Showalter's claim that Yealland was 'probably the most extreme advocate of disciplinary treatment among the English doctors' is not borne out by the medical records. Treatment at Queen Square generally included the whole spectrum of procedures available at the time apart from psychoanalysis, and Yealland only resorted to painful strong currents if the patient did not respond to first-line treatment.

With 30 780 beds for other ranks and 5,884 beds for officers, London provided a little over 10% of the total UK hospital beds for military use in 1918 and almost 31% of the total of beds for officers. The National Hospital for the Paralysed and Epileptic (today called the National Hospital for Neurology and Neurosurgery) at Queen Square in the heart of London admitted a large number of soldiers with physical injuries, such as gunshot wounds affecting the peripheral or central nervous system or serious head traumas. Yet, Queen Square also ranked among the most important centres for the treatment of shell shock cases, the equal of Maghull, the Maudsley and Craiglockart. While funding and staff limitations forced many general hospitals to conduct low-cost mass treatments that required minimal input from qualified personnel, the National Hospital had specialist staff, extensive treatment and research facilities and less pressure to discharge patients within short periods of time.

Shephard has stressed that the study of case records and medical publications inevitably 'contains an inherent source-bias'. The reader is presented with the doctor's perspective and the patient's voice is rarely heard in an unfiltered way. Therefore the study of medical records should be complemented with patient views. The patient histories in the Queen Square records always contained verbatim quotes from the soldiers and - in a very few cases - handwritten reports or resumes by the patient.

2. The National Hospital: Neurologists Encounter Shell Shock

By 1914, the National Hospital for the Paralysed and Epileptic had gained an international reputation for the treatment of neurological disorders and neurosurgery, so it was scarcely surprising that severe or challenging military cases were referred there from France. As early as October 1914, two British soldiers arrived. They were suffering from 'GPI' (General Paralysis of the Insane), an advanced state of syphilis. In early November, the first soldiers with injuries to peripheral nerves and the spinal cord were admitted. However, the hospital was soon to be made aware of the problem of 'nervous and mental shock'. At its meeting on 10 November 1914 the Hospital's Board of Management discussed an appeal from Lord Knutsford, Chairman of the London Hospital House Committee, that had been published in the London newspapers (see Figure ):

There are a certain number of our gallant soldiers for whom no proper provision is at present obtainable but is sorely needed. They are suffering from very severe mental and nervous shock due to exposure, excessive strain, and tension. They can be cured if only they receive proper attention from physicians who have made a specialty of treating such conditions. These men are quite unsuitable patients for general hospitals, as their chance of recovery depends on absolute quiet and on the individual and prolonged attention of the physician. If not cured, these men will drift back to the world as wrecks, and miserable wrecks, for the rest of their lives.

James Collier and William Aldren Turner, two consultants from the National Hospital had already offered their support to the War Office. It was decided that Farquhar Buzzard, another consultant neurologist at Queen Square, would draft a letter to Lord Knutsford and the press, pointing out that the National Hospital would accept soldiers with mental and nervous affections. 'David Wire', one of the hospital wards, was prepared for the reception of such cases and the War Office informed that wounded soldiers, suffering from any nervous ailment were eligible for admission.

On 14 November 1914, a soldier was admitted with neurological symptoms that could not be attributed to an organic lesion: Adolf S., a 22-year-old Belgian unable to move his legs. Two more soldiers with unexplained neurological symptoms arrived at Queen Square on 8 December 1914. Walter E., a 23-year-old private from the First Royal Dragoons, suffered from weakness and 'violent trembling' of his legs. The other soldier was Steward B., an 18-year-old private of the London Scottish Regiment, who had been sent to the front in mid-October. The case record reads:

The life in the trenches was very hard. There was considerable rain. They were not able to get water. The diet consisted of 'bully beef', jam, cheese and bread. The sand would come into the food and this increased the thirst. They had little chance to sleep, the eye-strain was very severe. Patient had a great deal to do with handling wounded and dying soldiers which made a deep impression on him. The first day he was in a trench, he had in his line of vision a pile of corpses one of which had the face turned toward him and appeared to be sleeping - this made such an impression upon him that he cannot free himself of this vision.

Just before being sent home, he was five days and six nights in the trenches at a stretch under the above conditions. The noises made by shells and the uncertainty of where they would strike caused great uneasiness and strain. Patient's comrades remarked that he did not answer when they spoke to him and appeared not to realize that they were speaking to him. Of this he knew nothing until told later on. He could not hold his weapon properly, nor shoot accurately. He was very shaky. Suffered much from headache. He was sent away from trenches November 14 and arrived at Southampton November 21.

The physical examination did not reveal any abnormalities; a 'considerable improvement' was achieved through massages and pain medication.

Although the hospital opened its doors to casualties from France, its capacity to treat patients was initially undermined by the loss of experienced staff who had volunteered for military service. Increasingly junior medical posts were filled by female doctors and retired consultants who returned to take up clinical duties. Later in the war, demands on the clinical staff were intensified by a request from the Ministry of Pensions to hold special out-patient sessions for wounded servicemen. The high numbers of military casualties led to longer waiting lists for civilian patients and 'complaints by the medical staff that frequently there was no accommodation even for persons who were seriously ill and urgently required indoor treatment'.

Between 3 August 1914 and 31 December 1919, 1212 soldiers were treated at the National Hospital, accounting for 45% of all male admissions. For 462 soldiers, 38% of all military admissions, doctors could find no identifiable organic pathology. The Queen Square neurologists mainly classified such cases as 'functional disorder', 'hysteria', 'neurasthenia' 'neurosis' and 'shell shock' (see Table ). Consultants did not differ markedly in their preferences of diagnostic labels. Although as a group they were fairly consistent in the diagnostic terms they used, their preferences changed over time. These changes in diagnostic labelling mirrored the evolving aetiological models for disorders without clearly defined organic changes. The ideologically charged diagnosis of 'traumatic neurosis' indicating an organic aetiology was mainly used at the beginning of the war (ten cases in 1915). Similarly, 'shell shock' was employed as a diagnostic label in the first half of the war (one case in 1915, thirty cases in 1916) and was very rarely used afterwards (only two cases in 1917/8 respectively), in accordance with the official restriction on the use of the term. Both 'neurasthenia' and 'neurosis', very common in the first two years of the conflict, virtually disappeared as diagnoses in the second half of the war. Interestingly, 'hysteria' was resurrected as a diagnostic term by Queen Square neurologists during 1918, after it had almost been abandoned in 1915. In general, however, Queen Square physicians preferred the more descriptive diagnosis of a 'functional disorder' over aetiologically biased terms such as 'shell shock' or 'hysteria', although the 'functional disorder' category decreased in favour of the hysteria diagnosis in 1918.

Table 1:

Table records the consultants responsible for treating these cases. Principal among the consultants were Howard H. Tooth, James Collier, James Taylor, W. Aldren Turner, J.S. Risien Russell, Edward Farquhar Buzzard and Frederick Eustace Batten (see Figure ). The common feature of nearly two hundred cases was Lewis Ralph Yealland who as a junior medical officer was responsible for the daily care and treatment of servicemen.

Dr James Taylor (1859-1946), who had worked as a businessman before studying medicine, was a member of the Hospital's Board of Management and had additional appointments in the Royal London Ophthalmic Hospital and the Queen's Hospital for Children. The reminiscences of one of his later junior doctors, J. Purdon Martin, are an instructive account of the major achievements of the consultants and working atmosphere at the National Hospital. Farquhar Buzzard (1871-1945), appointed consultant physician in 1905, resigned from the National Hospital in 1921 to move to a post at St Thomas's and in 1928 became Regius Professor of Medicine at Oxford. Collier (1870-1935), who introduced the term 'motor neuron disease', was well known for his stimulating teaching sessions 'with just enough sense of drama and the histrionic'. J.S. Risien Russell (1864-1939), born in British Guiana, also known as an inspiring teacher, took an active part in the campaign for the deinstitutionalisation of mental disorders and became Chairman of the National Society for Lunacy Reform. He was the first physician at Queen Square to introduce the malarial treatment of general paralysis. Unlike Russell, who was particularly interested in mental disorders, Gordon Holmes (1876-1965) was a 'pure neurologist' and with his thorough scientific approach 'apt to forget that he was dealing with flesh and blood'. Being based at military hospitals in France throughout the war, he only treated four soldiers with functional neurological symptoms at Queen Square, and he had a reputation of being 'unsympathetic towards soldiers with shell shock'. Rejected by the Royal Army Medical Corps at the beginning of the war because of his poor eyesight, he joined Percy Sargent, a surgeon at Queen Square, at a Red Cross Hospital in France. There Holmes treated soldiers with brain and spinal trauma. In view of the urgent demand for doctors, his fitness was reconsidered and Holmes was eventually appointed consulting neurologist to the British Expeditionary Force in France. As British soldiers were not issued with helmets until 1916, he had a constant supply of case material and published extensively on injuries of the spinal cord, the cerebellum and the visual cortex. Holmes' clinical career was advanced significantly by his wartime practice and he served as editor of Brain from 1922 to 1937.

Howard H. Tooth (1852-1925) was described by Holmes as 'careful and conscientious in the care of his patients and an excellent teacher'. During the Boer War, he had worked in a large base hospital in South Africa. Having gained experience of post-combat disorders, most military patients with functional neurological disorders referred to Queen Square during the first two years of the war came under Tooth's care. However, he was then appointed as a consulting physician to British forces in the Near East, which significantly reduced his clinical time at the National Hospital (only seven of his eighty-four patients were 1917/18 admissions). His notes demonstrate his conscientiousness and high attention to detail.

In January 1916, Frederick Eustace Batten (1865-1918), pathologist at the National Hospital from 1889 and honorary physician and Dean of its Medical School from 1900, published an article on soldiers with functional disorders admitted to the hospital between January and November 1915. Yealland might have been inspired by Batten's case histories and treatment descriptions when he wrote his book on Hysterical Disorders of Warfare in 1918. In contrast to his junior colleague Yealland, Batten covered in great detail 'the patient's mental attitude'. For example, he discussed loss of memory and psychotic phenomena in response to the war trauma in his 1916 article. However, contemporaries observed 'a consistent aloofness to psychological phenomena' in his demeanour. Unlike Yealland, Batten presented no consistent treatment concept and he openly admitted that his treatment outcomes were disappointing.

3. The Soldier-Patients of Queen Square

The 462 soldiers with functional neurological symptoms provided the material for our analysis (see Table ). In 1914, only five soldiers with functional disorders were admitted to Queen Square, the numbers rising to 122 in 1915 and 121 in 1916 before falling to 94 in 1917 and 87 in 1918, while in 1919 there were only 33 new military in-patients with functional disorders. The vast majority were private soldiers (83%); 16% were non-commissioned officers (ranks of lance corporal, corporal, sergeant and sergeant major). This distribution is similar to that in the forward psychiatric centres where 83% of patients were private soldiers, 11.7% corporals and 4.48% sergeants and warrant officers. Only four officers with functional disorders were admitted to Queen Square during the war years, which is lower than would be expected given their distribution in the army (about one to thirty men), but can be explained by the provision of treatment specifically for officers, for example at Golders Green, North London. In addition, consultants at Queen Square saw outpatients with war trauma on a private basis, none of whose records have survived), and, given their ability to pay, there may have been a higher proportion of officers amongst this group.

Most soldiers were British, but there were also Irish, Belgian, Canadian and South African servicemen. On average they had developed their symptoms nine months before admission to Queen Square. The mean age on admission was twenty-eight years. The youngest referral was seventeen, while the oldest was sixty years. The average length of stay in hospital for soldiers with functional disorders was sixty-nine days, exceeding the fifty-three days of average treatment duration before the war. Of the 462 soldiers studied, 433 had been involved in front-line service, but 29 soldiers developed functional disorders without even having been exposed to combat. Our analysis of German case records revealed a similar phenomenon. Here, too, it appeared that the anticipation of danger could trigger similar processes as actual threat. Of the soldiers who were treated for functional disorders, 119 also had physical wounds.

The international reputation of the hospital was illustrated by the case of George C., a 25-year-old private from the Australian Infantry who was admitted to Queen Square on 22 October 1915 having been invalided from Gallipoli. He had been transported to Egypt on a hospital ship where he was treated at the 21st General Hospital in Alexandria. George C. gave a hand-written account of his efforts to obtain a transfer to the National Hospital for treatment:

When in the 21st General Hospital Alexandria Egypt I was ordered home to Australia .... And was told that so many had gone there [to Queen Square] that they were only sending curable cases there and as mine would be a very long time I would have to go to Australia. But if I wanted to get to England I had to sign to the effect that if I was not cured within three months, I would have to pay my fare back to Australia because I came here on my own decision as the Board had decided to send me to Australia. Anyhow I thought it would give myself a chance as so many had got back their voice in England and I had not been home for five years. So I chanced paying my own fare anyhow whatever happening and now I have wrote to Commissioner of Australia Sir George Reid, and he informed me that all would be well with me whatever happened.

I came to England on the Glengorm Castle to Southampton I believe and then to Camberwell Hospital. I had a coughing for a night or two and since then I have been a bit mixed. I have not spoken a word since I have been in England but one of my mates told me I said three words in Alexandria but over excited myself and the doctor said it would be alright in a few days. By all accounts I could not cough or whistle but now I do both. And also since I have had a cough I have been able to whisper .... I was under treatment by another doctor here somewhere which have seemed done me a little good.

This soldier was discharged from the National Hospital as 'cured'.

4. Symptoms

The symptoms of traumatised soldiers were diverse and could affect every system of the body (Table ). British medical journals of the war years were filled with reports of the common functional syndromes, such as disordered action of the heart but also recorded less common functional phenomena such as the 'Big Belly' or 'les gros ventres de la guerre' in French soldiers, where the abdomen was 'excessively prominent, recalling that of a woman seven or eight months pregnant' or 'miner's nystagmus', a functional disorder with visual disturbances and rhythmic oscillation of the eyes that was known from peacetime coal miners.

Myers believed that there was often a link between the form that a functional somatic disorder took and earlier traumatic experiences, such as accidents. In addition, he argued that the symptoms themselves could reflect the nature of the shocking event; for example, a blaze of light across the eyes leading to functional blindness or an intolerably intense sound leading to deafness without organic cause. Furthermore, Myers hypothesised that some disorders could be a remnant of a stuporous or confused state following an acute shock (for example mutism) or 'the persistent expression of the emotion which ha[d] produced [the] condition' (such as facial tics as expression of horror).

4.1. Triggers

Physicians involved in the treatment of traumatised soldiers documented the circumstances surrounding their patients' breakdown as potential clues to the aetiology of these disorders. The Queen Square records list both physical (for example, injuries obtained during front-line service or being buried alive*) and psychological (for example, witnessing a comrade's death) factors (see Table ). The physicians' view on the role of shell explosions in a soldier's mental breakdown evolved as the war unfolded. W.H.R. Rivers (1864-1922), who had treated traumatised soldiers at Maghull and Craiglockhart, wrote in the foreword to War Neuroses by John MacCurdy:

By 1918, most British doctors had moved away from the idea of an underlying organic lesion caused by the impact of the explosion. The shell explosion was rather seen as part of a complex aetiological model, where physical and psychological triggers interacted. Even the neuropathologist Frederick Walker Mott (1853-1926), who never abandoned the primacy of the organic in the genesis of shell shock, stated in his Chadwick Lecture on 'Mental Hygiene And Shell Shock During And After The War' in the summer of 1917:

Interestingly, several soldiers who had coped well with life in the trenches, broke down during their home leave. For example, 19-year-old Private Edward C., who had joined the 20th London Regiment soon after war was declared and been involved in heavy fighting on the Western front, was admitted while on leave in London. On 19 January 1917 at home in bed, he was disturbed at seven in the evening by a colossal explosion at a munitions' factory in Silvertown, about half a mile from his home. Although the detonation killed 73 workers and injured a further 400, Edward C.'s house was undamaged. However, the medical notes state that the patient 'was much upset and jumped out of bed. He began to shake all over and has continued to shake without intermission ever since'. After admission to the National Hospital his symptoms persisted and doctors recommended him for discharge from the army. In other cases, relatively minor incidents during home leave appeared to have triggered a mental breakdown, such as falling down the stairs at Victoria station or tripping when getting off a London bus. In all these cases of breakdown during home leave, admission to Queen Square had a potentially life-saving function, preventing the return of the soldier to the trenches.

Another trigger not directly related to combat was marital infidelity. Private George H., hospital orderly in France, developed severe anxiety and sleeplessness after having received 'news from England informing him of conjugal infidelity on the part of his wife'. John L. 'had a great mental shock for on arrival home after four years' absence, his wife was out and he found out shortly afterwards that she had been in misalliance with another man'. John L. developed severe depression with sleeplessness, fatigue, loss of appetite and extreme nervousness. His depression was so severe that he failed to apply for a pension.

4.2. Motor and Somato-Sensory Symptoms

At Queen Square, most soldiers with functional disorders suffered from a combination of motor and somato-sensory symptoms (see Table ). The majority had paralyses of arms or legs, combined with numbness or an altered sensation in the affected area of the body. The other main group of motor symptoms included involuntary movements in form of shaking, tremor or tics. One example was 27-year-old Rifleman Frank D. who was admitted to Queen Square on 4 May 1915 with a diagnosis of 'functional tremor' and 'neurosis like "dog chorea"'. The case record reads:

The patient showed 'lightening-like synchronous twitching of both arms with contraction of both pectoral muscles, quite involuntary but less frequent if attention is fixed on something else'. After two weeks he was discharged 'recovered' to a convalescent home.

Another instructive case with abnormal motor function was 23-year-old Scottish private Henry M. from the 18th Hussars who was admitted to Queen Square on 18 June 1915 with a diagnosis of functional facial spasm.

Within four weeks of inpatient treatment, this soldier made a 'practically complete recovery'. He was recommended for Home service. This case is noteworthy for several reasons. First, it is one of the very rare Queen Square cases where simulation of symptoms was suspected. Even if presentations seemed bizarre or mannered, the genuineness of these conditions was hardly ever doubted by any of the Queen Square doctors, and not a single patient was discharged with a diagnosis of 'malingering' or simulation. Contemporary publications also stressed the rarity of 'pure malingering ...in the British and French armies' and the rarity of discussions of malingering in the medical records suggests that this account was not mere propaganda. However, it is also possible that malingerers had been sifted out before reaching Queen Square. Secondly, this is a case where functional motor symptoms were grafted onto physical injuries or following local surgery. Functional contractures and paralyses often occurred 'after leaving France, often after the removal of a splint following surgical treatment for a wound to the limb received there' and could be mistaken for a physical injury. Thirdly, this case demonstrates the immense suffering psychologically wounded soldiers experienced and the impact the trauma had on everyday life. (See Figure )

A great diversity of abnormal, and often bizarre, gait patterns is documented in the Queen Square records and in medical publications of the time as well as in Arthur Hurst's film on War Neuroses. To illustrate this diversity of gait disorders, we have chosen five cases of soldiers admitted to Queen Square who presented with abnormal gait patterns:

'He sways but catches himself as if in danger of falling. When walking brings feet down in short jerky very forceful steps. Sways and when walking alone seems to dance'.

'Patient walks with back bent, legs stiff, takes steps more or less on his toes, has to be supported when attempting to walk'.

'He walks stiff legged holding his body and back stiff and walking on the toes which are stiff. A very peculiar bizarre sort of gait'.

'Very peculiar functional gait. Patient if placed on his legs becomes very rigid, only the toes rest on the floor, the rest of the body bends backwards and becomes very tremulous. His whole body is in a state of clonus'.

'Is typically functional. He walks with his knees crossed in a scissor like fashion. He can walk without a stick but he is very unsteady'.

The notes record that all five cases responded well to treatment and the servicemen were discharged from hospital able to walk normally. However, no follow-up studies were conducted to establish whether the cure was sustained. This clinical evidence contrasts with the symptom patterns recorded in the war pension files held at TNA. A random sample of two hundred cases of shell shock found that gait abnormalities were rare, though tremor and dizziness were widely reported. There are three possible explanations for this. First, bizarre movement disorders, as visible symptoms, may have attracted disproportionate attention from doctors. Secondly, as reported in the contemporary literature, gait disorders appeared to respond well to treatment and thus rarely provided a basis for pension claims. Thirdly, cases characterised by a grossly disordered gait could have been rare but were concentrated in specialist neurological units giving the false impression of being widespread.

Other common motor disorders at Queen Square related to the production of speech (see Table : sixty-five cases in our sample), either presenting as stuttering/stammering (disordered speech) or a complete inability to talk or even whisper (mutism). Mott was particularly interested in functional speech disorders and he tried to understand why 'these mutes, whose silent thoughts are perfect, [should] be unable to speak? They comprehend all that is said to them unless they are deaf; but it is quite clear that in these cases their internal language is unaffected, for they are able to express their thoughts and judgements perfectly well by writing, even if they are deaf. [...] Many who are unable to speak voluntarily yet call out in their dreams expressions they have used in trench warfare and battle.' Although Mott stopped short of an interpretation in terms of psychological defence mechanisms, he emphasised the symbolic meaning of functional symptoms. The patient was 'paralysed by fear' or 'dumb with fear'. In his aetiological model, tics were 'the result of perseveration of the startling and dodging reflexes, and some of the choreiform movements ... due to perseveration of gesture movements of horror'.

4.3. Non-Epileptic Seizures

Non-epileptic seizures occurred in about 7% of all non-organic cases (without confirmed traumatic lesion or other brain disease) of soldiers admitted to Queen Square. Hysterical seizures proved to be highly 'contagious', as illustrated in one case record of 29-year-old ex-soldier William Charles L. who was admitted to the Queen Square Annex on 31 July 1919. William Charles L. had had his first fit five months previously when he

This patient continued to have fits during his hospital stay, sometimes lasting between four and five hours. His fits were characterised by struggling and 'talking nonsense, normally about Germans'. He was finally discharged 'in status quo'.

The contagious nature of psychogenic fits was discussed widely in the German literature, as such seizures seem to have been more frequent. The analysis of the medical literature of the time supports the impression that this group of functional symptoms was not particularly prominent in Britain. For example, Lieutenant Colonel Dudley Carmalt Jones only identified three cases of 'violent hysterical fits' among his 1300 cases of war-related functional disorders treated at a specialist shell shock unit in France, and we have not come across any papers specifically dedicated to functional seizures in the British medical literature.

4.4. Sensory Disorders

Sensory disorders such as functional deafness or functional blindness were comparatively rare among the Queen Square admissions. Arthur Hurst, in charge of a neurological ward at Netley, was convinced that these disorders were primarily a problem of inattention.

These descriptions broadly conform to Yealland's ideas and also Janet's model of narrowing of attention or 'contraction of the field of consciousness'. Queen Square neurologists embraced psychological illness models, as evidenced by the frequent reference to psychological triggers (for example the death of comrades) in the medical records. However, unlike Rivers and Myers, they did not explore the meaning and protective nature of these symptoms. Furthermore, their treatment approach focused very much on the symptoms rather than on any underlying trauma.

4.5. Autonomic Dysfunction

Pain and autonomic dysfunction were often part of the clinical picture (see Table ). Autonomic dysfunction most commonly affected the cardio-respiratory system (with palpitations, shortness of breath, fainting, pericardial pressure), followed by the gastrointestinal system (with nausea, diarrhoea, bloating) and - less frequently documented - the genito-urinary tract (with incontinence of urine and urgency). The following characteristic case with multiple functional somatic symptoms and hypochondriacal ideas was admitted to Queen Square on 3 March 1916 with a diagnosis of 'neurasthenia'. The 23-year-old private Albert R. from the 18th Middlesex Regiment, a miner in civil life, complained about twitching across the temples, a 'feeling of worms crawling in the lower part of the abdomen', shortness of breath, dizzy spells, sleeplessness, weakness and a 'feeling of choking' in his throat. He had developed symptoms after a shell explosion in the trenches in June 1915. When admitted to Queen Square he had

The use of chemical weapons from April 1915 introduced a new dimension of threat to trench warfare. Gas had an enduring psychological effect on soldiers whose symptoms often mimicked those of mild exposure to gas but could also be dominated by anxiety, fears, sleep difficulties, dizziness and tremor. These symptoms applied to several soldiers admitted to Queen Square who had been exposed to gas and elaborately described its devastating effects:

4.6. Psychological Symptoms

It is evident from the last case that patients not only presented with classical neurological deficit syndromes and somatisation, but also frequently exhibited psychological symptoms. Common symptoms described in the Queen Square records included irritability, difficulty sleeping and increased sensitivity to noise. These symptoms, which resemble the increased arousal cluster of today's post-traumatic stress disorder patients, were reported as being common to almost all soldiers who had been through traumatic experiences. These 'subjective' disturbances, which could be easily overlooked in a cursory examination, could cause considerable suffering and 'make life for some of their victims a veritable hell'.

Soldiers with severe depression were rarely seen at Queen Square because they were referred to specialised mental hospitals. Similarly, psychotic symptoms were not a common presentation. In the Queen Square records, we identified only one case with auditory and visual hallucinations occurring after a shell explosion in the trenches. The observation that a large proportion of psychotic and confusional states in soldiers on active service were 'of an eminently recoverable character' led to the passage of the Mental Treatment Bill, which was introduced into the House of Commons by Cecil Harmsworth, the Under Secretary for Home Affairs, on 20 April 1915. This bill removed the necessity for formal certification of mental disorders occurring in soldiers during active service and allowed informal treatment for up to six months.

Transient states of altered consciousness with reduced responsiveness, sometimes with aggressive behaviour and re-enactment of battle scenes, occurred in about 5% of all soldiers admitted to Queen Square with functional disorders. These dream-like states were frequently reported in medical publications during the war years and bore similarities to the syndrome described as 'terror psychosis' by the German neurologist and psychiatrist Karl Kleist. Mott, based at the Maudsley Hospital, reported a dreamlike state with disorientation to time and place in which combat scenes were relived, often amounting to vivid imagery and sometimes hallucinations.

During these episodes, patients were reported as being highly anxious and aroused. Aggressive outbursts, ideas of reference and persecution (without taking the form of delusions) as well as misjudgements of the situation were also common. Some of these symptoms, particularly anxiety and hallucinations were more pronounced at night. Patients often startled from their sleep and continued to experience the dream in a subconscious state. After these symptoms of arousal had passed, Queen Square doctors often recorded irritability, jumpiness and amnesia for the traumatic experience. The tendency of the individual exposed to long-lasting adversity to drift into an altered mental state for 'temporary relief' was described by Charles Samuel Myers, in his book Shell Shock in France. Mott also described dissociative states as a protective mechanism and natural response to trench warfare.

According to Aldren Turner, front-line soldiers also presented with stupor and confusion in acute reaction to fear, horror and commotion. However, these states could also take a chronic course, as in 26-year-old private Harry D. who was treated for 'shell shock' from 1 July 1916 until 20 February 1917. He had developed a catatonic state:

After ten days of inpatient treatment with isolation, massages and sedatives, Harry D. improved considerably and was then able to give a clearer account of his terrifying experiences at the front. Nevertheless, he never fully recovered and after eight months of inpatient treatment he was recommended for discharge from the army.

4.7. Changes of Symptoms Over Time

The Queen Square case records allow us to track changes in the clinical presentation across the war years (see Table 1 ; each patient could have symptoms from up to four symptom categories). Their relative prevalence changed over time. While motor symptoms (mainly paralyses, but also involuntary movements), somato-sensory disturbances and speech disorders were equally distributed over the war years, cases of anxiety and depression were prominent only during the first two years of the war. This phenomenon probably reflected the development of improved assessment and referral procedures for servicemen invalided to the UK. From 1916 onwards, neuropsychiatric cases invalided from France were sent to the Maudsley Hospital or D Block at Netley for specialist appraisal before being referred for specific treatment so that cases of shell shock manifested primarily by psychological symptoms were no longer referred to Queen Square. These findings contradict Leese's impression that 'in 1915 many of the complaints (of invalided soldiers) were less severe than the fatigue and anxiety cases of 1916 and 1917'.115 In 1917 and 1918 soldiers admitted to Queen Square were very rarely suffering from mood symptoms (difference statistically significant: Chi-Square, , pooled for 1915/16 versus 1917/18).

5. Cultural Influences on Symptoms

The most striking difference between the Queen Square records and our German patient samples116 concerns the incidence of functional seizures. In our Berlin sample, functional seizures were 3.5 times more frequent than at Queen Square ( versus at Queen Square). This result accords with contemporary medical publications. British journals paid little attention to psychogenic seizures and concentrated on functional disorders concerning the heart and sensory-motor system. Conversely, German psychiatrists and neurologists consistently reported high rates of seizure disorders and conducted numerous studies designed to differentiate between functional seizures and genuine epilepsy.117 Jones and Wessely argued that functional somatic syndromes may be particularly prone to cultural forces: 'culture, perhaps, has its greatest opportunity to influence the form of, and meaning attached to, medical disorders when scientific experiment and clinical investigation have failed to define or identify their aetiology'.118 In the pre-EEG era, a clear distinction between organic or psychogenic causation in seizure disorders could not be made and doctors had to make their diagnosis on the basis of patient history and clinical observation. Jones and Wessely also thought that doctors were likely to look for and pay attention to symptoms that fell within their specialist area. If the psychiatrists in Berlin and Jena had been specialists in seizure disorders, then this plausibly would have influenced their diagnostic decisions. Furthermore, these centres would have attracted higher referrals of cases characterised by seizure disorders. However, this argument for the higher incidence of functional seizures in Germany is unlikely to provide a full explanation because these factors would have applied at least equally to the National Hospital, a neurological hospital which had a special focus on epilepsy.

In the contemporary medical literature, functional seizures were linked to young soldiers and those of lower social and military status.119 Differences in patient populations, therefore, may have accounted for the higher proportions of functional seizures reported in Berlin compared with London. However, as the average age of soldiers in our patient samples was very similar ( for Berlin and for London) and all institutions mainly cared for the lower ranks (88% in Berlin and 83% in London), these factors do not appear to be responsible for the different proportions of functional seizures among military admissions.

While aetiological models revealed only slight differences between Britain and Germany, the medical literature of the time pointed towards more pronounced differences in therapeutic approaches, which could explain the different rates of functional seizures in both countries. However, despite apparent differences in British and German treatment preferences, the management of functional seizure disorders was very similar in both countries. Because of the contagious nature of functional seizures and their tendency to become more prominent with increased attention and compassion the favoured treatment in Britain and Germany was isolation. Even Yealland, a strong advocate of electrotherapy, did not apply electric currents in this patient group and instead based his treatment on suggestion, re-education and isolation. German isolation therapy was arguably more aggressive - with stricter isolation ('psychische Abstinenzkur') and also confinement to locked wards - but these slight differences in the quality of treatment are unlikely to explain the higher rates of functional seizures at the Charité and in Jena.

Differences in institutions, disposal systems, patient populations, aetiological illness models and treatment approaches appear unlikely to have been major confounding factors. If the incidence of functional seizures was significantly lower in British soldiers compared with their German counterparts, then cultural differences had plausibly influenced the expression of post-traumatic reactions in otherwise similar circumstances. The physical expression of distress may be mediated by cultural forces through popular health fears which alert patients and doctors to particular areas of the body. Multiple investigations have been shown to reinforce symptoms. What public opinion considers acceptable or unacceptable, authentic or false, respectable or shameful also influences the expression of distress. Popular attitudes towards seizures and the role of electricity may have been different in Britain and Germany. Andreas Killen has demonstrated how the rapid rise of electrical industries in Berlin and electrification of many aspects of daily life transformed thinking not just about technology but about society and the human mind. The influence of the electrical industry, led by Siemens and AEG, set Berlin apart from both London and Paris. Conceptual links between electricity and epilepsy had already been proposed in the mid-nineteenth century by the anatomist Jacobus Schroeder van der Kolk (1797-1862) in the Netherlands and by the physician to King's College Hospital, Robert Bentley Todd (1809-1860), in Britain. However, the first experimental demonstration of this link had to wait until 1914 when the Polish physiologists Cybulski and Jelenska-Macieszyna published a photographic record of changes in electrical activity in the cerebral cortex of a dog during a seizure. The question of whether these electrophysiological observations had any direct influence on German and British neuropsychiatry of the time - let alone on the public perception of epilepsy - has so far received little attention and research in this area would be needed to assess their cultural relevance.

Our finding that functional seizures were more frequently reported in the case notes of German soldiers than in comparable British records has raised important questions about the way symptoms were identified and interpreted. Culturally determined differences in war syndromes thus support Loughran's model of shell shock as a diagnosis shaped by a specific set of contemporary concerns, knowledge and practices.

6. Conclusion

The Queen Square case records reveal how servicemen who had been diagnosed with functional disorders expressed a rich variety of clinical forms. They offer an insight into the impact of trench warfare on the soldier's mind and how this traumatic experience occupied his thoughts during the day and dominated his dreams at night. Public perception of shell shock focused on certain iconic clinical pictures that were popularised in contemporary medical film and later media adaptations, such as hysterical gait disorder. Yet the Queen Square cases reveal a much greater range of symptoms. Although physical manifestations were particularly prominent, psychological symptoms were ubiquitous and persistent, causing considerable suffering and long-lasting disability. In relation to the most prominent contemporary account of functional disorders at Queen Square, Yealland's book on hysteria, this study shows that his case reports, albeit accurate, only captured a sub-population of patients. Yealland focused on patients with functional motor symptoms who responded well to electrical treatments, but under-represented both the psychological syndromes and the range of treatments offered at the National Hospital. While shell shock was one of the few new disease categories added to the diagnostic inventory at the beginning of the war, doctors generally agreed that 'the War ha[d] not produced any new form of mental disease'. The difference between the conflict and the pre-war period was 'one of frequency rather than of kind', though symptoms such as nightmares and hallucinations were commonly coloured by experiences in the field. Like their German colleagues, British doctors eventually concluded that such cases would not be able to 'stand the strain of active service without relapsing' and should therefore be discharged from their military duties and returned to civil life.

This analysis of case records from the leading neurological institution in Britain, combined with earlier research into an equivalent German hospital, supports the hypothesis that similar traumatic triggers can produce different phenomenological consequences in different cultural settings. The changing patterns of human responses to traumatic experience and their historical and cultural constraints are still relevant for our approach to traumatic and war-related disorders today.

Footnotes

Leese Peter, Shell Shock: Traumatic Neurosis and the British Soldiers of the First World War (New York: Palgrave, 2002), 60; Hans Binneveld, 16. From Shell Shock to Combat Stress: A Comparative History of Military Psychiatry (Amsterdam: Amsterdam University Press, 1997), 86-7; Shephard, op. cit. (note 13), 31.

Binneveld, 17. op. cit.(note 16), 84-5; Binneveld cites Myers's case histories published in the Lancet: Charles Samuel Myers, 'Contributions to the Study of Shell Shock: Being an Account of Certain Cases Treated by Hypnosis', The Lancet, 190, 4819 (1916), 65-9; for the First World War case reports also see Shephard, op. cit. (note 13), eg. the chapter ' Psychiatry at the Front, 1917-18 ', 53-71.

18. Peckl Petra, 'What the patient records reveal: reassuring the treatment of "war neurotics" in Germany (1914-1918)', in Hofer Hans-Georg, Pruell Cay-Ruediger and Eckart Wolfgang U. (eds), War, Trauma and Medicine in Germany and Central Europe (1914-1939) (Freiburg: Centaurus, 2011), 148

Showalter Elaine, The Female Malady: Women, Madness and English Culture 1830-1980 (London: Virago, 1987), 178; Pat Barker, 27. Regeneration (London: Penguin, 2008).

40. Minutes from the Board of Management meeting, 10 November 1914, Queen Square Archive (see Figure 1).

41. Steward B., Queen Square Records, Dr Batten, 1915, Queen Square Archive; the pain medication was 'aspirin'.

43. Minutes from the Board of Management meeting, 12 January 1915 and 9 November 1915, Queen Square Archive.

45. Minutes from the Board of Management meeting, 10 November 1914, Queen Square Archive: Howard Henry Tooth (1856-1925), consultant neurologist at Queen Square since 1887, informed the Board in writing that he had taken command of a military hospital and would not be able to attend to his duties at the National Hospital for some time. Also: Minutes from the Board of Management meeting, 12 January 1915, Queen Square Archive: Absence of W. Aldren Turner (1864-1945): 'A letter was read from Dr Aldren Turner that he had been called away to France for a period of about two months ...'.

46. Minutes from the Board of Management meeting, 10 November 1914, Queen Square Archive: Frederick Eustace Batten (1866-1918), Dean of the National's Medical School who had resigned from his clinical duties in 1909, took responsibility for Tooth's patients in his absence.

McDonald Ian, 'Gordon Holmes Lecture: Gordon Holmes and the Neurological Heritage', Brain, 130, 1 (2007), 288-298: 295. Holmes openly admitted that he had mainly seen the 'psychoneuroses' as a source of income in peace-times, as cited in Myers, 57. op. cit. (note 8), 20.

Holmes Gordon, 'The Goulstonian Lectures on Spinal Injuries of Warfare: Delivered before the Royal College of Physicians of London', BMJ, 2, 2867 (1915), 855-861; Gordon Holmes, 'Disturbances of Vision by Cerebral Lesions', 59. British Journal of Ophthalmology, 2, 7 (1918), 353-84; Gordon Holmes and W.T. Lister, 'Disturbances of Vision from Cerebral Lesions, with Special Reference to the Cortical Representation of the Macula', Brain, 39, (1916), 34-73, Percy Sargent and Gordon Holmes, 'Preliminary Notes on the Treatment of the Cranial Injuries of Warfare', BMJ, 1, 2830 (1915), 537-41.

Yealland Lewis Ralph, Hysterical Disorders of Warfare (London: MacMillan, 1918). For a more detailed description of Yealland's work see Linden, Jones, and Lees, 62. op. cit. (note 23). Yealland's cases were admitted between May 1916 and January 1918.

Turner, 65. op. cit.(note 1); William Aldren Turner, 'Nervous and Mental Shock', BMJ, 1, 2893 (1916), 830-2; William Aldren Turner, 'The Bradshaw Lecture on Neuroses and Psychoses of War: Delivered before the Royal College of Physicians of London on November 7th, 1918', The Lancet, 192, 4967 (1918), 613-17.

69. George C., Queen Square Records, Dr Tooth, 1915, Queen Square Archive; patient's handwritten account attached to case record.

75. Silvertown in West Ham, Essex, now part of the London Borough of Newham.

76. Edward C., Queen Square Records, Dr Tooth, 1917, Queen Square Archive.

77. George H., Queen Square Records, Dr Russell, 1915, Queen Square Archive.

78. John L., Queen Square Records, Dr Collier, 1919, Queen Square Archive; correspondence between the National Hospital and the London War Pensions Committee, as attached to the clinical record.

79. Frank D., Queen Square Records, Dr Tooth, 1915, Queen Square Archive.

80. Henry M., Queen Square Records, Dr Tooth, 1915, Queen Square Archive.

Hurst Arthur Frederick, Medical Diseases of the War, 2nd edn. (London: Edward Arnold, 1918), 28-29 Other physicians who emphasised that cases of malingering were exceptional were Mott and Myers: Mott, 81. op. cit. (note 48), 123. Myers, op. cit. (note 8), 40.

85. Harry C., Queen Square Records, Dr Collier, 1917, Queen Square Archive.

86. Frederick M., Queen Square Records, Dr Buzzard, 1919, Queen Square Archive.

87. Frederick S.M., Queen Square Records, Dr Tooth, 1919, Queen Square Archive.

88. George C., Queen Square Records, Dr Collier, 1916, Queen Square Archive.

89. Charles S., Queen Square Records, Dr Steward, 1916, Queen Square Archive.

93. William Charles L., Queen Square Records, Dr Tooth, 1919, Queen Square Archive.

Janet Pierre, The Major Symptoms of Hysteria: Fifteen Lectures Given in the Medical School of Harvard University, 2nd edn. (New York: Macmillan, 1920); also discussed in Linden, Jones, and Lees, 97. op. cit. (note 23).

100. Albert R., Queen Square Records, Dr Turner, 1916, Queen Square Archive.

102. Harry M., Queen Square Records, Dr Tooth, 1915, Queen Square Archive.

Turner, 'Nervous and Mental Shock', 105. op. cit.(note 1); for a contemporary analysis of patient populations at specialised mental institutions see R. Eager, 'A Record of Admissions to the Mental Section of the Lord Derby War Hospital, Warrington, from June 17th, 1916, to June 16th, 1917', The Journal of Mental Science, 64 (1918), 272-95 and D.K. Henderson, 'War Psychoses: An Analysis of 202 Cases of Mental Disorder Occurring in Home Troops', The Journal of Mental Science, 64 (1918), 165-89, both for the mental section of the Lord Derby War Hospital near Warrington in Lancashire; for the Dykebar Hospital for mental diseases in Paisley in Scotland, see R.D. Hotchkis, 'Renfrew District Asylum as a War Hospital for Mental Invalids: Some Contrasts in Administration. With an Analysis of Cases Admitted During the First Year', The Journal of Mental Science, 63 (1917), 238-49.

106. Harold D., Queen Square Records, Dr Turner, 1916, Queen Square Archive.

For example by Mott in Mott, 108. op. cit.(note 74) and Mott, op. cit. (note 48), 113, where he calls these states 'hallucinatory mental confusion'; also by Turner in Turner, op. cit. (note 1).

114. Harry D., Queen Square Records, Dr Russell, 1916, Queen Square Archive.

Smith and Pear, 134. op. cit.(note 104), 24: 'For shell shock has brought us no new symptoms ...'; Harold Wiltshire, 'A Contribution to the Aetiology of Shell Shock', The Lancet, 187, 4842 (1916), 1207-12: 1207; Judson S. Bury, 'Pathology of War Neuroses', The Lancet, 192 (1918), 97-9: 97; MacCurdy, op. cit. (note 73), 87: 'no symptoms described in the war cases ...which have not been well known in times of peace'.

Mott, 138. op. cit.(note 48), 144. Hurst, op. cit. (note 82), 64. 'A man who has once had a mental breakdown is very unlikely to be able to stand the strain of active service without relapsing ... . [S]uch men should never be allowed to return to military duty.'; also Jones, op. cit. (note 95): 'I doubt if anyone who has once developed it will ever be fit for front-line soldiering within the time limit of any war'.

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'Shell shock' Revisited: An Examination of the Case Records of the National Hospital in London

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During the First World War the National Hospital for the Paralysed and Epileptic, in Queen Square, London, then Britain's leading centre for neurology, took a key role in the treatment and understanding of shell shock. This paper explores the ...

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PTSD Symptoms

Post-traumatic stress disorder is a mental health condition that occurs when someone witnesses or experiences a severely traumatic event. This can include war or combat, serious accidents, natural disasters, terrorism, or violent personal assaults, such as rape.

People with the disorder may experience PTSD symptoms such as frequent fear, stress, and anxiety stemming from the traumatic event. They may relive the event through flashbacks or nightmares and have intense, disturbing thoughts and feelings related to the event. They sometimes avoid people, places and situations that remind them of the trauma.

They may also experience increased arousal and reactive symptoms, such as feeling jumpy (startling easy), having problems concentrating or sleeping, being easily angered or irritated and engaging in reckless or self-destructive behavior.

What Is PTSD?

It's not entirely known what causes PTSD to develop, but it may be related to the stress hormones.

That is, traumatic events put the body into a survival "fight or flight" mode, in which body releases stress hormones (adrenaline and norepinephrine) to provide a burst of energy while pausing some of the brain's other tasks, such as filling short-term memories.

People with PTSD continue to produce high amounts of these hormones outside of dangerous situations and their amygdala-the part of the brain that handles fear and emotion-is more active than people without PTSD.

Over time, PTSD changes the brain, including by causing the part of the brain that handles memory (the hippocampus) to shrink.

PTSD in Epics and Classics

Long before the dawn of modern psychiatry, people and situations depicting PTSD may have been recorded in early works of literature.

For example, in the Epic of Gilgamesh, the earliest surviving major work of literature (dating back to 2100 B.C.), the main character Gilgamesh witnesses the death of his closest friend, Enkidu. Gilgamesh is tormented by the trauma of Enkidu's death, experiencing recurrent and intrusive recollections and nightmares related to the event.

Later, in a 440-B.C. account of the battle of Marathon, Greek historian Herodotus describes how an Athenian named Epizelus was suddenly stricken with blindness while in the heat of battle after seeing his comrade killed in combat. This blindness, brought on by fright and not a physical wound, persisted over many years.

Other ancient works, such as those by Hippocrates, describe soldiers who experienced frightening battle dreams. And outside of Greco-Latin classics, similar recurrent nightmares also show up in Icelandic literature, such as Gísli Súrsson Saga.

In the Indian epic poem Ramayana, likely composed around 2,500 years ago, the demon Marrich experiences PTSD-like symptoms, including hyper-arousal, reliving trauma, and avoidance behavior, after nearly being killed by an arrow. Marrich also gave up his natural duty of harassing monks and became a meditating recluse.

Nostalgia and Soldier's Heart

In the last several hundred years, medical doctors have described a few PTSD-like illnesses, particularly in soldiers who experienced combat.

In the late 1600s, Swiss physician Dr. Johannes Hofer coined the term "nostalgia" to describe Swiss soldiers who suffered from despair and homesickness, as well as classic PTSD symptoms like sleeplessness and anxiety. Around the same time, German, French and Spanish doctors described similar illnesses in their military patients.

In 1761, Austrian physician Josef Leopold Auenbrugger wrote about nostalgia in trauma-stricken soldiers in his book Inventum Novum. The soldiers, he reported, became listless and solitary, among other things, and efforts could do little to help them out of their torpor.

PTSD in the Civil War

Nostalgia was a phenomenon noted throughout Europe and the "disease" reached American soil during the U.S. Civil War (1861-1865). In fact, nostalgia became a common medical diagnosis that spread throughout camps. But some military doctors viewed the illness as a sign of weakness and one that only affected men with a "feeble will"-and public ridicule was sometimes the recommended "cure" for nostalgia.

While nostalgia described changes in veterans from a psychological perspective, other models took a physiological approach.

After the Civil War, U.S. doctor Jacob Mendez Da Costa studied veterans and found that many of them suffered from certain physical issues unrelated to wounds, such as palpitations, constricted breathing, and other cardiovascular symptoms. These symptoms were thought to arise from an overstimulation of the heart's nervous system, and the condition became known as "soldier's heart," "irritable heart," or "Da Costa's syndrome."

Interestingly, PTSD-like symptoms weren't restricted to soldiers in the 1800s. During the Industrial Revolution, rail travel became more common-as did railway accidents.

Survivors of these accidents displayed various psychological symptoms (anxiety and sleeplessness, for instance), which collectively became known as "railway spine" and "railway brain" because autopsies suggested railway accidents caused microscopic lesions to the central nervous system.

Shell Shock

Post-traumatic stress disorder was a major military problem during World War I, though it was known at the time as "shell shock."

The term itself first appeared in the medical journal The Lancet in Feb. 1915, some six months after the "Great War" began. Capt. Charles Myers of the Royal Army Medical Corps documented soldiers who experienced a range of severe symptoms-including anxiety, nightmares, tremor, and impaired sight and hearing-after being exposed to exploding shells on the battlefield. It appeared that the symptoms resulted from a kind of severe concussion to the nervous system (hence the name).

By the following year, however, medical and military authorities documented shell shock symptoms in soldiers who had been nowhere near exploding shells. These soldiers' conditions were considered neurasthenia-a type of nervous breakdown from war-but was still encompassed by "shell shock" (or war neurosis).

There were some 80,000 cases of shell shock in the British army alone by the end of the war. Soldiers often returned to the war zone after only a few days' rest, and those who were treated for longer periods of time sometimes underwent hydrotherapy or electrotherapy.

In World War II, British and American described traumatic responses to combat as "battle fatigue," "combat fatigue" and "combat stress reaction"-terms that reflected the belief that the conditions were related to long deployments. Up to half of military discharges during the war may have been related to combat exhaustion, according to the National Center for PTSD.

Modern-Day PTSD

In 1952, the American Psychiatric Association (APA) added "gross stress reaction" to its first Diagnostic and Statistical Manual of Mental Disorders, or DSM-I. The diagnosis related to psychological issues stemming from traumatic events (including combat and disasters), though it assumed that the mental health issues were short-lived-if the problem lasted for more than 6 months, then it was thought that it had nothing to do with wartime service.

In the DSM-II, published in 1968, the APA removed the diagnosis but included "adjustment reaction to adult life," which did not efficiently capture PTSD-like symptoms. This removal meant that many veterans who suffered from such symptoms weren't able to receive the proper psychological help that they needed.

Drawing on research involving people who survived severely traumatic events, including war veterans, Holocaust survivors and sexual trauma victims, the APA included post-traumatic stress disorder in the DSM-III (1980). The diagnosis drew a clear distinction between traumatic events and other painful stressors, such as divorce, financial hardships and serious illnesses, which most individuals are able to cope with and don't produce the same symptoms.

The diagnostic criteria for PTSD was revised in the DSM-IV (1994), and DSM-IV-TR (2000), and DSM-5 (2013) to reflect ongoing research. In the DSM-5, PTSD is no longer considered an anxiety disorder because it's sometimes associated other mood states (depression), as well as angry or reckless behavior; it's now in a category called Trauma- and Stressor-Related Disorders.

Today, about 7.7 million American adults have PTSD, according to the Anxiety and Depression Association of America.

Sources

Post-traumatic stress disorder (PTSD) - Causes; NHS.
What is PTSD?; WebMD.
What Is PTSD?; Everyday Health.
What is Posttraumatic Stress Disorder?; American Psychiatric Association.
Sheth et al. (2010). "Anxiety disorders in ancient Indian literature." Indian Journal of Psychiatry.
Marc-Antoine Crocq and Louis Crocq (2000). "From shell shock and war neurosis to posttraumatic stress disorder: a history of psychotraumatology." Dialogues in Clinical Neuroscience.
History of PTSD in Veterans: Civil War to DSM-5; VA.
When Nostalgia Was a Disease; The Atlantic.
Timeline: Mental illness and war through history; Minnesota Public Radio.
Did Civil War Soldiers Have PTSD?; Smithsonian.
Anderson, David (2010). "Dying of Nostalgia: Homesickness in the Union Army during the Civil War." Civil War History.
The Shock of War; Smithsonian.
History of PTSD in Veterans: Civil War to DSM-5; National Center for PTSD, VA.
When Soldiers Snap; The New York Times.
PTSD; Anxiety and Depression Association of America.

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Post-traumatic stress disorder is a mental health condition that occurs when someone witnesses or experiences a severely traumatic event. This can include war or combat, serious accidents, natural disasters, terrorism, or violent personal assaults, such as rape. People with the disorder may experience PTSD symptoms such as frequent fear, stress, and anxiety stemming from the traumatic event.

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From shell-shock to PTSD, a century of invisible war trauma

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We now know that what these combat veterans were facing was likely what today we call post-traumatic stress disorder, or PTSD. We are now better able to recognize it, and treatments have certainly advanced, but we still don’t have a full understanding of just what PTSD is.

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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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Masculinity, trauma and 'shell-shock' | The Psychologist

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Many historians have argued that the experience of mass breakdown in the First World War led to the reconfiguration of ideals of masculine behaviour. The literary historian Samuel Hynes believes that after 1918, war was imagined in fundamentally new ways.