Perhaps no facet of the First World War fascinates quite so much as shell-shocked soldiers, made famous in photographs and videos capturing their haunted eyes and stilted movements. Over the past several decades, historians have produced a large number of works on the subject of wartime traumas, ranging from initial breakdown, through diagnosis and treatment to trauma’s enduring legacies. The fault lines running through this historiography centre on questions of war and social change, particularly the ways in which battlefield traumas provoked change in medicine and psychology. It is into this debate that Tracey Loughran forcefully places her engaging and provocative Shell Shock and Medical Culture in First World War Britain (New York and London: Cambridge University Press, 2017).

Loughran discusses the intellectual underpinnings of the wartime shell shock debate, tracing evolving medical constructions and interpretations of mental illness and using shell shock to illuminate a broader medical culture and its encounter with the Great War. Loughran deems the dominant historiographical narratives overly teleological, citing their assumptions that post-war medical developments – particularly a more widespread acceptance of psychology – stemmed from the encounter with wartime trauma. Her purpose is three-fold: first, to reconstruct the intellectual milieu which allowed doctors to approach disturbances of the mind with seemingly contradictory ideas; second, to trace the advent of psychological medicine by means of shell shock through an anti-teleological lens; and third, to bring more nuance to the debate about rupture versus continuity that has structured so many works on the war and social change. Loughran offers concrete arguments for her first two objectives, positing that British doctors approached the mind within an evolutionary framework, which allowed them to incorporate parts of disparate theories in their explanations; the result of this flexibility was that although the war was indeed cataclysmic, it provoked only a reorientation of pre-existing beliefs on mental illness rather than the psychological revolution that other historians have claimed to identify. Furthermore, Loughran implicitly demonstrates that the continuity–rupture dichotomy, in seeking to capture social change in the broadest sense, often falsely attributes causality and occludes slower processes of change that are rarely either monocausal or complete. As she states, the more useful approach is ‘revolution through evolution’ (p. 215). The book’s central contribution, then, is its rejection of the premise that the sheer scale of wartime trauma forced doctors either to cling to conservative, outdated approaches or to fully embrace radical, fully psychological perspectives. In place of this explanatory model, Loughran’s work offers a refreshing glimpse into the wide-ranging and eclectic world of early twentieth-century mental medicine.

Loughran’s work follows a chronological path, examining medical culture as it pertained to mental illness from Darwin through to the inter-war years, and thus de-centralises the war in framing shell shock diagnoses. She lays out pre-war medical discourse on mind–body duality, emphasising that evolutionary thought played a crucial role in framing and diagnosing mental health and illness. These same currents, she contends, structured most wartime mental medicine, with doctors underscoring the importance of heredity, instinct and willpower in shell shock diagnoses. Although these evolutionary undercurrents survived the war, Loughran ends her work by considering how doctors added other influences into those perspectives; to these tenets, doctors added psychological and psychoanalytical facets and, ultimately, a new psychological medicine was born.

Shell Shock and Medical Culture in First World War Britain makes two crucial contributions. Loughran’s argument that doctors were both radical and conservative in their approaches to trauma, simultaneously relying on pre-war intellectual frameworks and integrating psychological or even psychoanalytical elements into those frameworks, is essential in pressing historians to question the assumption that the war provoked radical and rapid intellectual and social change. By highlighting that doctors’ responses to the mental crises were fragmentary and drew largely on pre-war developments in the study of the mind, Loughran successfully de-emphasises the war as the causal factor in bringing about psychological developments and, instead, presents a group of doctors making use of all available tools who, eventually, through slow processes of translation and adaptation, produced new forms of psychological knowledge and reform. Loughran consequently reorients the history of shell shock from a discrete, ultimately radical response to horrific violence towards a perspective that emphasises slower evolution and knowledge production, in which the war is an important but not essential component.

More broadly, however, Loughran’s work offers an important middle ground in how scholars of modern Europe conceptualise sudden ruptures and turning points. Historians have long debated whether the Great War represented a deep rupture with the long nineteenth century, or whether it caused a brief reinvigoration of nineteenth-century values. Loughran’s contention that medical culture experienced both a rupture and a continuation of earlier intellectual modes provides a third analytical framework, in which the war provides a context for people to reorient their thinking; some things change over time, while others continue to provide meaning in a new world. Too often, she suggests, we take the constructed narrative, whether progressive or regressive, at face value, ignoring the precariousness of change. Approaching not only trauma, but all facets of the war in this way can provide a clearer representation of historical change and its contingency.

Despite the book’s important interventions, the work is beset by a number of frustrating silences and she often provides only tantalising glimpses into some essential points. For example, she glosses over why doctors viewed the First World War as especially destructive to human civilisation, and never fully examines the notion that in spite of civilisational progress, modernity could produce unexpected pathologies. Further, she never makes clear how this slow evolution in thinking impacted on the doctor–patient relationship, and her discussion of how doctors felt about their patients is ambiguous. Nevertheless, the book provides a compelling and new analytical perspective on what shell shock meant to the doctors who diagnosed it, how it fitted into their known intellectual universe and how it contributed to, but did not cause, a slow (r)evolution in thinking on mental medicine.