On the other hand, growing numbers of the wealthy patients who suffered from some sort of nervous disorder were diagnosed as having ‘psychoneuroses’ like ‘neurasthenia’ and attended the growing number of specialist neurologists in Harley Street and elsewhere around the country. The terms used to describe their mental problems sounded far more scientific and serious. In London, Dr Aldren Turner was only one of many neurologists based at the National Hospital for the Paralysed and Epileptic in Queen Square, often combining part-time work at the hospital with private practice. A third kind of treatment that was new at the time was psychotherapy, in which doctors talked through the core problems with their patient and, sometimes using hypnosis, tried to unlock the key emotional issues that lay at the root of his or her mental disorder.
The specialists coming out of the universities in Britain where psychology was studied, Cambridge and Manchester, regarded the situation with respect to the treatment of nervous diseases in the country as ‘deplorable’. They despaired at the lack of treatment for those sent to lunatic asylums and at the complete absence of psychiatric clinics, places ‘exempt from any stigma’ to which patients could go for advice and counselling that might help them avoid admission to an asylum. They saw the lack of psychiatric training in Britain as the root cause of the problem. Training could help medical practitioners realise ‘the vitally important fact that mental disease is curable’. Although medical science had witnessed great advances in the treatment of heart disease, tuberculosis, diphtheria, tetanus and other common ailments, and great improvements in the use of antiseptics and anaesthetics and in the science of bacteriology, it was argued that there had been ‘little or no progress’ in fifty years when it came to the treatment of mental illness.16
In Europe the treatment of mental ailments was far more advanced than in Britain. In Germany, almost every university medical department had a psychiatric clinic attached to it. Paris had two major schools of neurology. At the Salpetrière Hospital, a vast complex on the site of an old gunpowder factory, Prof. Jean-Martin Charcot became known as the founder of modern neurology in the late nineteenth century. He helped to identify the causes of many mental disorders including epilepsy, stroke and hysteria. The word ‘hysteria’ derives from the Greek word for the womb, and it was often seen as primarily a woman’s condition until Charcot showed that men could display the same symptoms. By using hypnosis, Charcot was able to treat forms of paralysis of, say, the arm or leg that were put down to hysteria. His successor, Jules-Joseph Dejerine, believed that through conversations with his patients he could discover the cause of their trauma and cure it.
At La Pitié Hospital in Paris, Dejerine’s great rival, Joseph Babinski, used a very different technique. A specialist in treating hysteria, he believed that much hysteria was caused by suggestion – that the patient convinced himself he was suffering from the disease and consequently developed its symptoms. Babinski argued for the efficacy of forceful persuasion to try to reverse the emotional process that had caused the hysteria. The physical symptoms the patient displayed would then disappear. Sometimes this included forcefully telling the patient that he or she could easily recover. This much harsher treatment (known as traitement brusqué) also included the use of electric shock therapy to treat the patient’s symptoms.
Meanwhile, in Vienna, Sigmund Freud had taken psychotherapy one step further. The aim of psychoanalysis was to try to uncover memories or emotions that had been repressed and hidden in the ‘unconscious’ mind. Freud argued that many of these repressed emotions dated from childhood and were sexual in origin. Only when they had been discovered and brought to the surface of the conscious mind could a patient be cured and restored to normal mental health. All these European developments had their groups of advocates in Britain before the war, but they remained few in number and very much in the minority.
In confronting the mental problems of its soldiers, the army itself had a problem. Conventional military thinking held that a soldier was either fit and capable, in which case he was available to fulfil his duties; or he was sick or wounded, in which case he would be treated by military doctors until his recovery enabled him to return to the ranks. In the very few cases where a soldier had a nervous problem he was either classed as a malingerer and so would be subject to military discipline, or as a lunatic – in which case he was dismissed from the service and dispatched into the public asylum system. The idea of a man suffering from a nervous condition and needing treatment to recover so as to be able to return to his unit was alien to military culture. As has been seen, the RAMC had no expertise in the area of psychiatric medicine. And most senior figures in the army would have held the view that all soldiers, whether officers or from the rank and file, were supposed to put up with difficult or harsh conditions, to show a stiff upper lip and bear up. The large numbers who now appeared to be suffering from some form of mental breakdown vastly complicated this simple way of perceiving things. And the army was completely unprepared for the avalanche of shell shock victims that now faced them. Before the war, the only provision made for hospital care for soldiers suffering from mental or nervous breakdown was a single ward, ‘D’ Ward, in the Royal Victoria Hospital at Netley. Here, there were only 124 beds for an army of 200,000 men.17
During 1915 and the early months of 1916, Myers toured the CCSs and base hospitals and examined some 2,000 patients. Throughout these months the debate continued to rage about the causes of the multitude of psychosomatic conditions under the ‘shell shock’ label. Frederick Mott, a leading figure in neurology before the war and an adviser to London County Council, had spent some years studying the brains of lunatics in mental asylums. He was well known for taking the traditional line that heredity was a major factor in cases of insanity. During the war, he did not work at the front but studied victims of shell shock evacuated to the newly built Maudsley Hospital in south London. Carrying out a series of microscopic examinations of the brains of soldiers killed by blast, he identified cerebral lesions which he concluded were the cause of shell shock in patients who had survived the explosion of a nearby shell. He argued in a series of lectures that exposure to shell fire caused a pathological effect on the body’s nervous system, brought about by concussion to the brain from the impact of an explosion.
Mott agreed that psychological factors played a part and that a man’s state of mind before an explosion might well affect his reaction to it. However, as he saw more and more cases, he modified his line and accepted that there were soldiers with a fine record for bravery and no history of a ‘neuropathic tendency’ who also succumbed. Some people were more disposed to suffer from the horrors of trench life than others, Mott concluded. This helped reconcile him to the fact that many apparently healthy young men were going down with shell shock. He argued that fear was a biological instinct and the anticipation of death or mutilation was a major cause in what he called the ‘neuroses of war’.18
An alternative view came from Harold Wiltshire, an experienced physician who worked at a base hospital in Rouen, France for a year before concluding that the symptoms of shell shock were entirely of psychological rather than physical origin. He observed that men who had lost limbs from being hit in shell explosions did not suffer from shell shock. In hospital they were often cheery and supportive of the medical and nursing staff. This contrasted with the morose gloom and lack of hope of patients in a shell shock ward. He believed that men suffering from shell shock had been worn down by the prolonged strain of trench warfare into a position in which a sudden psychological shock could tip them over the edge. ‘Gradual psychic exhaustion from continued fear is an important disposing cause of shell shock,’ he wrote. ‘Horrible sights are the most frequent and potent factor in the production of this shock. Losses and the fright of being buried are also important in this respect.’19 He cited the example of a soldier who suffered from mental shock because he was ordered to clear away the remains of a number of men who had been blown to pieces by a shell. Wiltshire located t
he causes of shell shock firmly in the realm of psychology.
It was becoming clear to those working with patients that ‘shell shock’ was, as Myers himself later admitted, ‘a singularly ill-chosen term; and in other respects … a singularly harmful one’.20 In the vast majority of cases, Myers accepted, shell shock had psychological and not physical causes. But by this point, the term was well established. Pears and Grafton Smith agreed that it was a ‘popular but inadequate title for all those mental effects of war experience which are sufficient to incapacitate a man from the performance of his military duties’.21 But the use of ‘shell shock’ as a term was by now too prevalent to be abandoned.
The existence of so many different medical attitudes towards nervous disorders meant there was no consensus for the army to draw upon in formulating its approach to shell shock. But something had to be done in the attempt to treat and classify the numbers of men coming out of the lines suffering from paralysis neuroses. So the military accepted both of the very different attitudes within the medical profession about shell shock, adopting two principal divisions from the start. First, there was a class-based distinction between officers and men. The rank and file were diagnosed as suffering from shell shock, often seen as a form of hysteria. The condition manifested itself in physical symptoms of deafness, blindness and paralysis. Mott concluded that soldiers converted their mental distress into physical signs of hysteria.
On the other hand, it was believed that officers suffered from neurasthenia, the cause of which was understood to be a prolonged process of breakdown, and the result of the extra responsibility they had to bear. The anxiety neuroses of officers were more likely to produce symptoms like exhaustion, loss of concentration, bad nightmares or depression. Officers, it was argued, were used to being more active, to giving orders and to being in command, and as they traditionally repressed their emotions with the so-called ‘stiff upper lip’ attitude, they were gradually ‘worn down’ by the anxieties of command in the trenches. The men, however, were used to taking a more passive position, to obeying orders, and were therefore thought more likely to suddenly ‘snap’ under pressure in the trenches. As Myers put it, ‘The neurasthenic remains an intact, though worn out individual whereas (more or less recognisably) the personality of the hysteric has changed. The breakdown in the neurasthenic is due to persistent wear and tear; in the hysteric … this is avoided by a sudden snap or fission.’ He concluded that the reasons for the difference between the condition affecting officers and that from which men suffered were not difficult to find. ‘The forces of education, tradition and example make for greater self control in the officer. He, moreover, is busy throughout a bombardment, issuing orders and subject to worry over his responsibilities, whereas his men can do nothing during the shelling but watch and wait.’ Bizarre though these distinctions might seem today, they were commonly accepted during the war.22
In addition to this class-based divide, doctors took either a ‘soft’ or a ‘hard’ line in recommending how the army should treat this strange new condition. Those who were more sympathetic to the existence of emotional or psychological problems within otherwise perfectly normal and healthy individuals believed that the emotional basis of their condition could and should be identified and cured. Others, who saw all nervous and mental disorders as a symptom of some sort of weakness of character, or even mental degeneration, took a harsher line and were more likely to want to bully the men back to their fighting units as quickly as possible.
Underlying much of this was the suspicion among many senior officers, and also plenty of medical officers, of malingering, that many of those who claimed to be suffering were simply pretending to have shell shock as a means to escape the horror of the trenches. Either that or they were weaklings who did not have the moral fibre to stand up to the duty that was expected of them. In army parlance they were called ‘skrimshankers and malingerers’. Medical officers complained to Myers, ‘We have seen too many dirty sneaks go down the line under the term “shell shock” to feel any great sympathy for the condition.’ ‘“Shell shock” should be abolished’ was another response. Later, Myers himself would be in ‘hearty agreement’ with these views, accepting that there were several instances of soldiers swinging the lead and trying it on.
Shell shock had quickly attained a certain cache of social approval. The subject received wide coverage in the newspapers, provoking a broadly sympathetic response to its sufferers. For the relatives of soldiers back home, it came as a source of relief if a man was diagnosed as suffering from shell shock. It gave him a certain dignity worthy of respect, like a soldier who had lost an arm or a leg. Fit men would turn up at an aid post, and when asked what was wrong with them would proudly boast, ‘Suffering from shell shock, sir.’ Myers believed they would never have wanted to be labelled as suffering from mental breakdown or ‘nervous shock’.23 Hence the army clearly had one major priority in its approach to shell shock: to pick out the malingerers and return them to their units.
Myers, in the main, took a ‘soft’ line in treating the first cases he came across. As a psychologist, he believed not only that he understood some of the causes of the various neuroses he treated but that he could help to cure them. As an army doctor he realised he had to accept that his responsibility was to treat wounded men and return them to the fighting line as soon as possible. In March 1915 he was sent to the base hospital at Boulogne. Within days of arriving he was dealing with several extreme cases. At times Myers used hypnosis to try and cure patients. One young soldier was convinced he was still in the trenches and spent his time dodging shells while hiding under his bed. Other men had dreadful stoops and could not walk straight. Myers treated a man who had been struck mute by a dreadful experience in the trenches and within days was able to restore his power of speech. Myers brought to his new role an almost evangelical energy. He was thoroughly committed to showing that if the causes were understood, shell shock could be treated successfully, and he was able to return about one-third of his patients to duty.24 Although the army high command was still deeply suspicious, they put up with Myers as long as he delivered a reasonable success rate in returning men to their battalions, and he was promoted to lieutenant-colonel.
Much medical thinking about shell shock in the early phases of the war emphasised the fact that men with previous experience of nervous conditions were more likely to be affected than those who had never suffered before. Myers observed that ‘Previous emotional disorder, worry, insomnia and above all, a psycho-neurotic predisposition favour the onset of the [shell] shock.’ This notion was also fundamental to Mott’s belief that a hereditary link to insanity was the reason why most people suffered from nervous conditions. An American doctor working for Mott at the Maudsley researched the heredity of 100 shell shock victims and found that 74 per cent had a family history of neurotic disease (as against 10 per cent of the general wounded). This seemed to prove to Mott that most nervous conditions were hereditary and he wrote that his views were ‘now based on statistics’.25
Even Myers was not averse to describing this in moral terms. He said such victims could be divided between the ‘good and the bad: the former, often a highly intelligent person, keeping full control over his highly sensitive nervous system; the latter, usually of feebler intellect, having little hold over his instinctive acts to escape danger, the emotions which impel him to them, and the resulting conflicts’.26 Once again, in this delineation of men into those who are ‘highly intelligent’ and those of ‘feebler intellect’, a clear class division appears. Most officers would belong to the former category and men from the rank and file, of course, to the latter. It is easy to see why, in this climate of thinking, some senior military officers were sceptical that shell shock was any sort of legitimate medical condition and not just a case of men with ‘weak’ or ‘feeble’ minds suffering from the strains of war.
The situation grew worse as 1915 advanced and more men were reported to be suffering from some form of shell shock or
neurasthenia. After a few months, 7–10 per cent of officers and 3–4 per cent of other ranks in the main hospital at Boulogne had been sent home to Britain to recover from ‘the effects of nervous and mental shock’.27 The fact that many of these men came from good backgrounds with no experience of previous mental disorders, and had excellent military careers, made it more difficult for the military to dismiss shell shock as simply a condition experienced by ‘misfits’ of one sort or another. Some officers, however, came up with a simple explanation. They saw the phenomenon as a sign of the transition from a trained and professional army to a volunteer or previously part-time army. Lieutenant-General Sir John Goodwin said after the war that he had known no cases of shell shock in the original BEF that went to France in 1914. He emphasised the importance to regular soldiers of the ‘inculcation of an esprit de corps, loyalty, pride in himself and his unit, and the old history of the regiment to which he belongs’, something it was essential to instil in training.28 Like many other pre-war officers who took a similar view, Goodwin was demonstrating once again the disdain felt by the regulars towards the Territorials and Kitchener’s New Army.
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