Sir: We read with interest Howorth's (Psychiatric Bulletin, June 2000, 24, 225-227) paper on the treatment of shell-shock and, while agreeing with much of what he wrote, question the accuracy of several points. In general, he implies that psychological knowledge grew in a smooth progression from insights gained in the First World War to the present day. In fact, our research has shown that these new ideas were largely abandoned in the interwar period and had to be resurrected when war threatened in 1939 (Reference Jones, Wessely, Chickering and MatternJones & Wessely, 2000). Both Myers and McDougall were so disillusioned by their experiences that the former moved to the field of industrial psychology and the latter emigrated to the USA. So upset was Myers by the rejection of his ideas by the military authorities that he refused to give evidence to the Southborough Committee on shell-shock because, as he wrote in 1940, “the recall of my past five years' work proved too painful for me”. Millais Culpin, Professor of Medical Industrial Psychology at the London School of Hygiene, observed that few doctors with any regard for their reputation would mention an interest in psychoanalysis during the 1920s “without the verbal equivalent of spitting three times over the left shoulder, and even to speak about the revival of war memories carried the risk of being accused of advocating free fornication for everyone” (Reference CulpinCulpin, 1952).

While post-traumatic stress disorder. (PTSD) and shell-shock undoubtedly have some elements in common, both disorders have been influenced by cultural forces, so that it may not be true to say that one is a precursor of the other. Shell-shock is a reflection of the medical ideas of the early 20th century and its very name encapsulates the terrifying qualities of trench warfare. PTSD, first identified in the 1960s, was originally termed ‘post-Vietnam syndrome’ and it expresses many of the conflicts of that war. In our detailed examination of the medical records of shell-shock cases, we have found that the majority of servicemen did not exhibit delayed symptoms (even though their applications for a war pension may not have been made until the early 1920s). Clinicians of the time commented how symptoms could readily become chronic unless they were treated swiftly by the methods of abreaction that Howorth describes. Finally, the notion that all soldiers, even those that were well led and highly trained, could break down in action was not accepted by the military authorities until the Second World War. The Southborough Report (War Office Committee of Enquiry into ‘Shell-Shock’, 1922) concluded in 1922 that regular units with high morale were virtually immune from such disorders as shell-shock.