Logo of medhistThe Wellcome Trust Centre of the History of Medicine (UCL)Medical History
Med Hist. Jul 1, 2006; 50(3): 399–400.
PMCID: PMC1483208

Book Review

Shell shock to PTSD: military psychiatry from 1900 to the Gulf War
Reviewed by Ben Shephard

Edgar Jones and Simon Wessely.
Shell shock to PTSD: military psychiatry from 1900 to the Gulf War, Maudsley Monographs, No. 47 Hove and New York: Psychology Press on behalf of the Maudsley. 2005, pp. xvii, 300, £24.95 (hardback 1-84169-580-7).

In the late 1940s, the United States Air Force was unsure which Soviet cities to target with its small nuclear arsenal. So it gave a Harvard team $1m to find out and, in the process, paid for two masterpieces, Merle Fainsod's How Russia is ruled and Alexander Dallin's German rule in Russia. Fifty years later, the British Ministry of Defence, facing legal action from a group of psychologically damaged veterans, commissioned an academic team to research the history of military psychiatry, which the services themselves had never bothered adequately to record.

The military's money was not wasted. The academic heavyweights hastily imported to the courtroom were able to give British military psychiatry an intellectual authority and humane face which its everyday practice, in the hands of underfunded medical journeymen, had largely lacked. The veterans' lawyers were outgunned and the judge impressed; the Ministry won the group action in 2003 (though it has since lost individual cases), and British taxpayers were saved millions of pounds. For their part, the well-funded academic team, having had privileged access to British records, were able to publish a stream of articles and now, a book. Although the court action is repeatedly mentioned in Shell shock to PTSD, Jones and Wessely's own role in it is not.

The book is not in the Fainsod or Dallin class; indeed, editorially, it is a dog's breakfast, more a series of essays than a coherent work. Four of the ten chapters reprint important articles reviewing the history of military screening and selection, war pensions and veterans' pressure groups, and “war syndromes”, while the new material consists of four historical chapters on British military psychiatry, one on the incidence of PTSD in the military, and a conclusion which deals with the current “culture of trauma”.

The historical chapters (presumably by Jones) are meticulously researched, loyalist in tone and administrative in focus. They set out, but do not quite sustain, an interesting revisionist argument—that whatever the claims made for their work by doctors like William Brown, forward psychiatry (PIE) was never in fact very effective, which was why the professionals, the regular military, had little time for it and repeatedly abandoned it; for example, in 1917–18 when Gordon Holmes (who thought like a military man) curtailed the role of the forward treatment centres Charles Myers had established in France. Similarly, the account of the Second World War focuses as much on Bishop's Lydeard Hospital as on Northfield and brings out the unsung role of Colonel A H Sandiford in reining in J R Rees and his Tavistock chums. (This is very much a Maudsley monograph). There is a detailed, but not very illuminating, account of British work in the Korean War, but nothing on such neglected topics as the depiction of shell-shock in Great War newspapers and the effectiveness of rehabilitation in the 1940s; or, less surprisingly, on the maladroit British response to PTSD in the 1980s or the shambolic record-keeping in the First Gulf War. The writing is generally dull and occasionally descends into Pooterish bathos.

A similar pessimism, even nihilism, pervades the thematic chapters, though they are presented with Wessely's usual intellectual energy and command of the literature. War, we are repeatedly told, inevitably produces psychiatric casualties and all efforts to prevent them by pre-selection of personnel or to treat them with psychotherapy will be largely ineffective; the only way to reduce casualties is to reduce the intensity of war or, better still, have no wars at all. What is more, warfare has always produced “medically unexplained symptoms”, which usually reflect the fears and beliefs then prominent in the culture; in Gulf War Syndrome, for example, the toxic fears of modern industrialized society are manifested. And, in addition, the modern culture of compensation has rewritten the soldier's contract and the risks that the military can ask him to take. These chapters offer efficient surveys of the literature by a master epidemiologist, and clinicians will find them enormously useful.

Wessely and Jones's work has done much to bring order and rigour to a field which a decade ago was awash with romantic mythology, conspiracy theories and (in the military) blinkered suspicion. Some of their articles are classics; their emphasis on the continuing importance of somatic ingredients in military psychiatric disorders has been very influential; and they have made public much information previously trapped in the anal portals of the War Pensions Agency. But their limitations are also by now apparent—a remoteness from military realities; a timidity and clumsiness in exploring the role of culture; a dependence on trauma theorists such as Allan Young, Ruth Leys and Patrick Bracken; above all, their one-dimensional intellectual apparatus. The history of psychiatry, for them, is a whiggish progression from the bad old days, when charismatic rogues like William Sargant could make all sorts of claims for their work, to the broad sunlit uplands of modern epidemiology. If only it were that simple.


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