Shell Shock: The Response of UK Neurology.

The neurological and psychological manifestations of trauma, confinement, and terror became apparent throughout Europe as soldiers were evacuated from the trenches of the Western Front. The response in the UK evolved as a result of the experience of medical staff embedded with the troops in base hospitals and the philosophy of those treating returned soldiers in specialist establishment. There were widely disparate approaches to the management encompassing simple supportive care, a psychanalytic approach and radical electric shock therapy. The latter was partially driven by the Queen Square experience in the UK but was also concurrently widely pursued throughout Europe. With experience, care was increasingly undertaken close to the front lines using a philosophy of immediacy and expectation of recovery. Post-war analysis was startlingly unsympathetic, yet the experiences and management of shell shock have guided psychiatric and medical understanding of functional illness and post-traumatic stress over the subsequent century. In this historical review, we have sought to present features of the UK response to the neurological manifestations of trauma, the way in which these changed as the war proceeded and the political and medical response in the aftermath of war.

"Missing in Action" in Psychiatric Nursing History: The Role of Chief Nurse Adele S. Poston and Her Band of Nurses During World War I.

This is the first nursing journal article to introduce the pioneering work of American psychiatric nurse leader, Adele S. Poston. Poston supervised a team of nurses as they cared for soldiers serving with the American Expeditionary Forces during World War I in France. Poston and her nurses worked in the first American specialized neuropsychiatric hospital in a war. The soldiers they treated primarily had functional nervous disorders described at that time as "shell shock" or "war neuroses." The traumatized officers and enlisted men were considered capable of being cured and returned to active duty based on research done by American psychiatrists among British troops during the first 3 years of the war. The story of Poston's career prior, during, and after the war and her work with other nurses during a global war are significant in psychiatric nursing history. Bringing this hitherto missing piece of psychiatric and nursing history into the light gives us a unique opportunity to recognize Poston and the nurses who served with her, even as today we recognize the nurses who serve during the global COVID-19 pandemic. [Journal of Psychosocial and Mental Health Services, 59(6), 37-47.].

Functional neurology after the Second World War: The beginnings of neurology on screen (III).

Treatment of functional symptoms has a long history, and interventions were often used in soldiers returning from battle. On the 75th anniversary of the end of the Second World War, I review the portrayal of neurology in documentary film. Two documentaries were released in 1946 and 1948 (Let There Be Light and Shades of Gray, respectively), which showed a number of soldiers with functional neurology including paralysis, stuttering, muteness, and amnesia. The films showed successful treatments with hypnosis and sodium amytal by psychoanalytic psychiatrists. These documentaries link neurology with psychiatry and are remarkable examples of functional neurology and its treatment on screen.

Hurst Rehabilitated: the treatment of functional motor disorders by Arthur Hurst during the First World War.

Arthur Hurst was a British First World War physician, best known for his films of shell shock, 'War Neuroses'. He has often been portrayed an innovative pioneer of somewhat mysterious 'suggestion' techniques for functional motor disorders but also as an ambitious clinician who exaggerated the effectiveness of his treatments and failed to address psychological factors. His use of suggestion, persuasion and re-education together with occupational therapy, for chronic or severe cases of shell shock stirred controversy at the time because of the dramatic nature of some of his treatment responses and lack of outcome data. In part, this was a turf war between neurologists and psychiatrists for a dominant therapeutic model. A re-evaluation of his publications and new research into soldiers treated at Seale Hayne in Devon show that Hurst pioneered multidisciplinary and empathetic treatments for functional motor disorders with good short-term outcomes, though insufficient data survives to assess longer term outcomes.

Creative Minds in the Aftermath of the Great War: Four Neurologically Wounded Artists.

Many artists were involved in the First World War. Some of them were mobilized, like millions of soldiers, others enlisted to fight on the battlefield. The stories of writers who returned neurologically wounded from the war, such as Guillaume Apollinaire (1880-1918) or Blaise Cendrars (1887-1961), are well-known. The cases of painters and sculptors who suffered from First World War neurological wounds are scarce. Nevertheless, their injuries led to intense modifications of artistic practice. We detail four examples of artists whose creative mind was impacted by their First World War neurological wounds or diseases. The painter Jean-Julien Lemordant (1878-1968), who suffered from blindness after his injury, stopped his artistic work and became an icon of Franco-American friendship. The sculptor Maurice Prost (1894-1967), suffering from a neuroma due to the loss of his arm, built a special device to continue his work as a wildlife artist. The painter Georges Braque (1882-1963) was trepanned but carried on with his cubist work without ever mentioning the conflict. Conversely, the painter Fernand Léger (1881-1955), who suffered from a war neurosis, produced a significant war testimony through drawings and letters.

Writers as Shell Shock Witnesses during World War I.

The issue of First World War shell shock has been documented mainly from a medical perspective. Many medical texts dealing with war psychoneuroses and their aggressive treatments, such as electrotherapy, were published during the war. Accounts from shell-shocked soldiers are rare. Nevertheless, shell shock was described from a non-medical point of view by a few writers who had undergone or witnessed this pathology. Their texts deal mainly with the psychiatric forms, the most striking ones, but also with the more common concepts of commotion, emotion and pathological fear. The French philosopher Émile Chartier (1868-1951), alias Alain, described the commotional syndrome from which he suffered. The German writer Ernst Jünger (1895-1998), a brave officer and an example for his men, reported his emotional shock. Some psychiatric forms of shell shock are present in the work of the pacifist writer Jean Giono (1895-1970), the naturalist Maurice Genevoix (1890-1980), who suffered himself from a section of the left median and ulnar nerves, or the British poet Siegfried Sassoon (1886-1967). War hysteria and pathological fear have been described, on several occasions, by Blaise Cendrars (1887-1961) or the German writer Erich Maria Remarque (1898-1970). Electrotherapy has been scarcely reported except by Louis-Ferdinand Céline (1894-1961).

Abrupt treatments of hysteria during World War I, 1914-18.

Case reports of the abrupt recovery of hysterical disorders during World War I (1914-18), though undoubtedly subject to publication bias, raise both aetiological and treatment issues regarding pseudo-neurological conversion symptoms. Published clinical anecdotes report circumstantial, psychotherapeutic, hypnotic, persuasive (and coercive) methods seemingly inducing recovery, and also responses to fright and alterations of consciousness. The ethics of modern medical practice would not allow many of these techniques, which were reported to be effective, even in the chronic cases.

Edgar Adrian (1889-1977) and Shell Shock Electrotherapy: A Forgotten History?

The English electrophysiologist Edgar Adrian (1889-1977) was the recipient of the Nobel Prize for physiology in 1932 for his research on the functions of neurons. During World War I, at Queen Square in London, he devised an intensive electrotherapeutic treatment for shell-shocked soldiers. The procedure, developed with Lewis Yealland (1884-1954), was similar to "torpillage," the faradic psychotherapy used in France. Adrian and Yealland considered that the pain accompanying the use of faradic current was necessary for both therapeutic and disciplinary reasons, especially because of the suspicion of malingering. According to Adrian, this controversial electric treatment was only able to remove motor or sensitive symptoms. After the war, he finally admitted that war hysteria was a complex and difficult phenomenon.

The relationship between the First World War and neurology: 100 years of "Shell Shock".

The First World War was a global war, beginning on 28 July 1914, until 11 November 1918. Soon after the beginning of the war, there was an "epidemic" of neurological conversion symptoms. Soldiers on both sides started to present in large numbers with neurological symptoms, such as dizziness, tremor, paraplegia, tinnitus, amnesia, weakness, headache and mutism of psychosomatic origin. This condition was known as shell shock, or "war neurosis". Because medically unexplained symptoms remain a major challenge, and considering the close relationship of symptoms described in shell shock with clinical neurology, we should study their history in order to improve future care.

The relationship between the First World War and neurology: 100 years of "Shell Shock" / A relação entre a Primeira Guerra Mundial e a neurologia: 100 anos do "Shell Shock"

ABSTRACT The First World War was a global war, beginning on 28 July 1914, until 11 November 1918. Soon after the beginning of the war, there was an “epidemic” of neurological conversion symptoms. Soldiers on both sides started to present in large numbers with neurological symptoms, such as dizziness, tremor, paraplegia, tinnitus, amnesia, weakness, headache and mutism of psychosomatic origin. This condition was known as shell shock, or “war neurosis”. Because medically unexplained symptoms remain a major challenge, and considering the close relationship of symptoms described in shell shock with clinical neurology, we should study their history in order to improve future care.

RESUMO A Primeira Guerra Mundial foi uma guerra global, iniciada em 28 de julho de 1914, até 11 de novembro de 1918. Logo após o início da guerra, exatamente há 100 anos, houve uma “epidemia” de sintomas neurológicos conversivos. Soldados de ambos os lados começaram a apresentar com frequência sintomas neurológicos, tais como: tontura, tremor, paraplegia, zumbido, amnésia, fraqueza, cefaleia e mutismo de origem psicossomática. Esta condição ficou conhecida como shell shock, ou “neurose de guerra”. Como muitos sintomas e doenças inexplicadas continuam sendo um grande desafio, e considerando a estreita relação dos sintomas descritos no shell shock com a neurologia clínica, torna-se importante estudar essa parte da história com o objetivo de entendermos e melhorarmos os cuidados aos pacientes.

A war psychiatry approach to warfare in the Middle Byzantine period.

Combat stress cases were traced in historical texts and military manuals on warfare from the Middle Byzantine period; they were mainly labelled as cowardice. Soldiers suffered from nostalgia or exhaustion; officers looked stunned, or could not speak during the battle. Cruel punishments were often enforced. Suicide and alcohol abuse were rarely mentioned. The Byzantines' evacuation system for battle casualties was well organized. Psychological operations were conducted and prisoners-of-war were usually part of them. The Byzantine army had 'parakletores', officers assigned to encourage soldiers before combat. The leaders dealt with combat stress by using their rhetoric skills and emphasizing religious faith in eternal life. The treatment of the 'cowards' was rather similar to modern war psychiatry principles of treatment. No description of PTSD was found.

Trauma and the state with Sigmund Freud as witness.

Just before and after the end of World War I, Sigmund Freud took on an activist role and in his writings and speeches, redirected the concept of war trauma from individual failure to a larger issue of community responsibility. Testifying in Vienna as an expert witness for the state, Freud said that the military psychiatrists-not the soldiers-had "acted like machine guns behind the front" and were the "immediate cause of all war neurosis." Freud was called on by the legal community when Julius Wagner-Jauregg, a future Nobel Prize winner (and also future Nazi Party adherent), head of the municipal Clinic for Psychiatry and Nervous Diseases, was accused of the lethal use of electrotherapy on shell-shocked soldiers. As sociological as psychoanalytic in his responses, Freud's withering critique came just 2years after he avowed that "it is possible to foresee that the conscience of society will awake." That speech on the human right to mental health care affirmed Freud's alliance to the social democratic position and inspired the second generation of psychoanalysts to develop community-based clinics throughout Europe where treatment was free of cost, for war neurosis and beyond.

Tackling Shell Shock in Great War Oxford: Thomas Saxty Good, William McDougall, and James Arthur Hadfield.

Shell shock was an important object of diagnostic and therapeutic concern in Oxford during the Great War. The efforts of three Oxford physicians--Thomas Saxty Good, William McDougall, and James Arthur Hadfield--are of particular significance to our story. All worked on the problem at various sites throughout the city. They often collaborated. All were committed to employing innovative techniques such as psychotherapy and hypnosis. Each rose, to differing extents, to prominence in the field of psychological medicine during the succeeding decades. Yet all have been neglected in the current historiography. I argue that a close examination of their practices reveals a curious combination of therapeutic pragmatism and psychoanalytically informed techniques that later helped inform clinical psychology's challenge to psychiatry's dominance over the concept and care of mental disorder.

Neurological Impact of World War I on the Artistic Avant-Garde: The Examples of André Breton, Guillaume Apollinaire and Blaise Cendrars.

World War I erupted at a time when artistic avant-gardes were particularly thriving across Europe. Young poets, writers, painters and sculptors were called to arms or voluntary enrolled to fight, and several of them died during the conflict. Among others, it dramatically changed their creative output, either through specific wounds or through personal encounters and experiences. These individual events then significantly modified the course of the literary and artistic avant-garde movements. Three particularly illustrative examples of avant-garde French poets are presented here: André Breton (1896-1966), Guillaume Apollinaire (1880-1918) and Blaise Cendrars (1887-1961). The deep source of the surrealist movement can indeed be found in André Breton's involvement as an auxiliary physician with critical interest in neuropsychiatry, which caused him to discover automatic writing. Guillaume Apollinaire's right temporal subdural hematoma strongly modified his emotional state and subsequent artistic activities. Alternatively, after losing his right, writing hand, Blaise Cendrars not only substituted it with a phantom but also rapidly switched from poetry to novels after he learnt to write with his left hand.

Neurology in the Vietnam War.

Between December 1965 and December 1971, the United States maintained armed forces in Vietnam never less than 180,000 men and women in support of the war. At one time, this commitment exceeded half a million soldiers, sailors, and airmen from both the United States and its allies. Such forces required an extensive medical presence, including 19 neurologists. All but two of the neurologists had been drafted for a 2-year tour of duty after deferment for residency training. They were assigned to Vietnam for one of those 2 years in two Army Medical Units and one Air Force facility providing neurological care for American and allied forces, as well as many civilians. Their practice included exposure to unfamiliar disorders including cerebral malaria, Japanese B encephalitis, sleep deprivation seizures, and toxic encephalitis caused by injection or inhalation of C-4 explosive. They and neurologists at facilities in the United States published studies on all of these entities both during and after the war. These publications spawned the Defense and Veterans Head Injury Study, which was conceived during the Korean War and continues today as the Defense and Veterans Head Injury Center. It initially focused on post-traumatic epilepsy and later on all effects of brain injury. The Agent Orange controversy arose after the war; during the war, it was not perceived as a threat by medical personnel. Although soldiers in previous wars had developed serious psychological impairments, post-traumatic stress disorder was formally recognized in the servicemen returning from Vietnam.