Book Review |
FORGOTTEN LUNATICS OF THE GREAT WAR
By Peter Barham
2004. New Haven: Yale University Press.
Price £19.99
ISBN 1-098-76543-2
HYSTERICAL MEN, WAR, PSYCHIATRY, AND THE POLITICS OF TRAUMA IN GERMANY, 1890–1930
By Paul Lerner
2003. Ithaca: Cornell University Press.
Price £23.95
ISBN 0-801-44094-7
MEDICINE AND VICTORY, BRITISH MILITARY MEDICINE IN THE SECOND WORLD WAR
By Mark Harrison
2004. Oxford: Oxford University Press.
Price £45.99
ISBN 0-199-26859-2 ‘War and Mental Health: shell shock, battle exhaustion and PTSD’
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In essence, Barham argues that World War I exposed the deficiencies in the way that mental illness was conceptualized and the rigidities in the administration of the asylum system. By recruiting a vast citizen army (5.7 million males served in the British armed forces) and exposing many of them to intolerable stresses, the conflict created unprecedented psychological casualties. While many broke down and were unable to function without actually becoming psychotic, others were driven mad by their military experiences. Barham suggests that popular sympathy for servicemen and the hardships they had endured at the front led to a wider appreciation of mental illness and increased emphasis on the human and social rights of individuals. Barham is patient focused and as he himself admits the tone of his book is ‘unashamedly angry at points’ (p. 9). Post-war improvements to the asylum system, he argues, arose not because of enlightened doctors or developments in treatment, but because the war galvanized the public to campaign for the rights of those who had volunteered to serve their country in wartime and now found themselves stigmatized as pauper lunatics. Having served their country in situations of great danger, psychiatric patients began to be thought of as citizens, rather than hereditary degenerates.
While Barham is undoubtedly right to highlight injustices suffered by veterans, he is less appreciative of the pressures and frustrations felt by military psychiatrists, who in some respects were an equally beleaguered and forgotten group. Doctors who sought to treat psychiatric casualties were misunderstood and often ridiculed by colleagues and military authorities. Without effective treatments for major mental illness, there was, in reality, little that they could do for their patients, some of whom were a risk to themselves or others. While the shortcomings of the systems administered by the Board of Control and the Ministry of Pensions to manage ex-service lunatics were often evident, it was far more challenging to conceive of a humane regime that adequately addressed the needs of such veterans, given the financial and medical constraints of the period. Nevertheless, Barham has produced a fitting memorial to the hardships endured by ex-servicemen who suffered from major mental illness.
Paul Lerner's study of male hysteria provides an important and authoritative analysis of how psychiatric trauma was conceived in Germany from the late 19th century to the 1930s and the response of psychiatrists to the Nazi eugenic snare. World War I is identified as central in driving the principles of ‘modernity’ as defined by Max Weber: increasing standardization and homogenization, the encroachment of bureaucratic administration into people's personal affairs and the establishment of the scientific expert as a source of authority. The need to enlist, train and manage a mass civilian army for an attritional war drew the state into the daily lives of most families. The efficient treatment of soldiers' wounds, both physical and mental, was determined not by any humanitarian goal but by the need to return men to battle as quickly as possible. Ideas that would have been rejected in peacetime suddenly found institutional support because they appeared to offer a solution to a pressing military dilemma. By 1917, for example, large regional observation centres, often staffed by university specialists, were set up throughout Germany to assess psychiatric casualties referred from field hospitals. On the basis of their diagnoses, soldiers were referred to a network of special nerve hospitals (called ‘neurosis stations’) linked to systems of agricultural and industrial employment. They were deliberately small-scale, in part, because of a belief in the contagious nature of hysteria. Despite the introduction of such a well-structured system, the reality was that few psychiatric battle casualties were returned to combat units after treatment, the vast majority being deployed to civilian tasks within the war economy.
Lerner demonstrates the importance of culture in defining mental illness and its management. The system set up by the German military differed significantly from that designed by the British and French armies. In spring 1915, the French had set up specialist units relatively close to the front line for the rapid treatment of neuro-psychiatric cases. The idea was to prevent their referral to base hospitals far from the trenches where return-to-duty rates were low. In December 1916, suffering manpower shortages as a result of the Somme offensive, the British copied this structure, setting up four ‘Not Yet Diagnosed, Nervous’ (NYDN) Centres, which were ‘as remote from the sounds of warfare as is compatible with the preservation of the "atmosphere" of the front’ (Myers, 1940
, p. 124). In practice, they operated about 10 miles from the fighting, established in casualty clearing stations or tented hospitals.
The most revealing contemporary account of the clinical operation of a NYDN Centre was drafted by Dudley Carmalt Jones (1874–1957) in December 1917 and subsequently published in Brain (Jones, 1919). A physician at St Mary's researching vaccines before enlistment, he found himself in charge of the experimental shell shock division of No. 4 Stationary Hospital, Arques (Jones and Wessely, 2005). In 9 months, he and four colleagues treated 4700 cases of shell shock, including psychological casualties from the battles of Arras and Passchendaele. Carmalt Jones concluded that the cause in the vast majority of cases was ‘physical and emotional strain’. To account for the wide variation in combat exposure amongst his patients, ranging from days to over 3 years, he concluded that individuals differed significantly in their ‘resisting powers’ (Jones, 1919, p. 176). With so many admissions and conscious of the military imperative to return as many to duty as possible, Carmalt Jones avoided psychological interventions, including hypnotism because he believed that it conveyed a sense of occult power in the doctor, which was one reason why others used the technique. Under his treatment regime, soldiers were examined medically, allowed a short period of rest with medication to help them sleep and then put on a programme of graduated exercise, ending with route marches. He estimated that only 40% of admissions returned to duty with their units, though such follow-up data as were available to him suggested that a significant number relapsed. Carmalt Jones believed that after a second breakdown no man should be sent back to his battalion as such individuals ‘are quite unreliable in any stress and probably do little but harm in showing a bad example’ (p. 212).
A number of authors, both psychiatrists and historians, have suggested that post-traumatic stress disorder (PTSD) is akin to a ‘universal stress reaction’ and can be identified in the past under different labels, including railway spine from the 1860s and shell shock in World War I. Lerner emphatically rejects this account of PTSD as failing to account for the socio-politico context in which mental illness was framed. Furthermore, he reveals a far more complex conflict of ideas at the Munich ‘War Congress’ of September 1916. The concept of ‘traumatic neurosis’, advanced by Hermann Oppenheim, suggested that psychological suffering had a basis in anatomical and physiological changes, which rendered treatment largely superfluous and entitled the veteran to compensation. Led by Robert Gaupp, Max Nonne and Alfred Hoche, the majority view was that breakdown in battle was not the result of a neurophysiological event but a failure of will power and self-control, a form of male hysteria that was best treated by behavioural methods and firm discipline.
Although a general study of British military medicine during World War II, Harrison addresses the dilemmas faced by psychiatrists in the armed forces and the solutions they proposed. Structured by campaign, he analyses the re-discovery of so-called forward psychiatry in the Western Desert in May 1941 and evaluates its effectiveness during the intense fighting for Normandy and in the jungles of Burma, where it could be argued that the absence of an effective evacuation procedure had the most potent effect on return-to-duty rates. The term shell shock had been proscribed in July 1939 to prevent a further epidemic of war pension claims. As a result, psychiatrists needed a new name to label men who ceased to function in combat without having suffered a wound or defined illness. Brigadier G. W. B. James, a decorated veteran of World War I, adopted the term ‘exhaustion’ in summer 1942 to describe servicemen worn out by the physical and mental demands of fighting in the desert. The label was chosen to imply that this was merely a temporary state from which the soldier would recover naturally with a period of rest and recuperation, while avoiding any medical terminology.
However, unlike Lerner, Harrison falls for the psychiatrists' own propaganda designed to win them medical and military credibility. He accepts at face value the optimistic outcomes published by Major Harold Palmer who treated psychiatric casualties from the Western Desert. Palmer claimed to have returned 98% of admissions to duty within 3 weeks (p. 183), figures that contemporaries doubted (Shephard, 2000, p. 217). He also repeats the myth that ‘cases of hysteria were comparatively rare during the Second World War’ (p. 62), whereas both contemporary accounts and retrospective studies of admission and discharge registers have revealed no diminution in the incidence of functional somatic disorders (Jones and Wessely, 2004). Harrison is at his best when relating changes in treatment and patient management to underlying social forces and analysing the impact of advances in medical services such as blood transfusion units and anti-malarial initiatives. Despite these caveats about the assessment of psychiatry, this remains an important and much needed update of British military medicine, the first since the publication of the official histories in the 1950s.
Although military psychiatrists now have a number of clinically effective treatments available to them (principally SSRI anti-depressants and exposure-based CBT), we are still no closer to resolving the dilemma created by the serviceman who suffers from psychological injury. How do armies treat the traumatized soldier sympathetically without encouraging rational beings to avoid the very real risk of wounding or death? Not every recruit enters the armed forces with the same vulnerability to stress and no screening instrument exists that can accurately detect those most likely to breakdown in battle. In the chaos of warfare, exposure to life-threatening events is partly chance. Examples drawn from World War II, and to a lesser extent from earlier conflicts, suggest that the unofficial subtext in the military is that a breakdown has to be earned. If a soldier was recognized by his peers as having done his bit at the front, then the system could be bent to accommodate him. Military psychiatrists were often used to find loopholes in regulations or to find a reason why a man should not be punished for what appeared on the surface to be a failure of duty, though as Barham has demonstrated officers were often treated more leniently than men. If, however, a soldier had just arrived in the front line and indicated an unwillingness to serve, then he was more likely to fall foul of disciplinary procedures. Received wisdom indicates that an overly sympathetic policy to psychiatric casualties encouraged malingering and factitious illness, while a tough line, such as the ‘lack of moral fibre’ (LMF) system adopted by the RAF in March 1940 designed to shame those who refused to fly, cut the level of psychological injury. However, this hypothesis has never been tested. All three books demonstrate that war comes with a costly price tag in terms of mental health and that the only effective preventative measure is the maintenance of peace.
Institute of Psychiatry, King's College, London
References
Jones Carmalt DW. War-neurasthenia acute and chronic. Brain 1919; 42: 212–13.
Jones E, Wessely S. Hearts, guts and minds: somatisation in the military from 1900, J Psychosomatic Res 2004; 56: 1–5.[CrossRef][Medline]
Jones E, Wessely S. Shell shock to PTSD, military psychiatry from 1900 to the Gulf War. Hove: Maudsley Monograph, Psychology Press; 2005.
Myers CS. Shell shock in France 1914–18, based on a war diary. Cambridge: Cambridge University Press; 1940.
Shephard B. A war of nerves, soldiers and psychiatrists 1914–1994. London: Jonathan Cape; 2000.
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