Shell shock and mild traumatic brain injury: A historical review

Mild traumatic brain injury is now claimed to be the signature injury of the Iraq and Afghanistan conflicts. During World War I, shell shock came to occupy a similar position of prominence, and postconcussional syndrome assumed some importance in World War II. In this article, the nature of shell shock, its clinical presentation, the military context, hypotheses of causation, and issues of management are explored to discover whether there are contemporary relevancies to the current issue of mild traumatic brain injury. When shell shock was first postulated, it was assumed to be the product of a head injury or toxic exposure. However, subsequent clinical studies suggested that this view was too simplistic, and explanations soon oscillated between the strictly organic and the psychological as well as the behavioral. Despite a vigorous debate, physicians failed to identify or confirm characteristic distinctions. The experiences of the armed forces of both the United States and the United Kingdom during World Wars I and II led to two conclusions: that there were dangers in labeling anything as a unique “signature” injury and that disorders that cross any divide between physical and psychological require a nuanced view of their interpretation and treatment. These findings suggest that the hard-won lessons of shell shock continue to have relevance today.

For many, shell shock was, and indeed remains, the signature injury of World War I, just as traumatic brain injury is claimed in some quarters today to be the characteristic injury of the Iraq and Afghanistan conflicts (1 – 3) . In this article, we explore the symptoms, military context, hypotheses of causation, and issues of management of shell shock, in the expectation that some contemporary parallels will emerge.

In 1915, shell shock was initially conceived as a neurological lesion, a form of commotio cerebri, the result of powerful compressive forces (4 , 5) . However, doubts soon arose about the contribution of direct cerebral trauma to shell shock, and some expressed the view that the symptoms were more psychological than organic in origin, even to the extent of characterizing them as “traumatic neuroses” (6 , 7) . Some military doctors went so far as to state that the disorder was environmentally or contextually determined and that the way in which health care and compensation were organized served to reinforce both symptoms and disability. A vigorous debate ensued between the various schools of thought that led to a series of novel managerial interventions designed to limit what had become an epidemic of patients and war pension claims.