Shell Shock to PTSD

Military Psychiatry from 1900 to the Gulf War

Edgar Jones, Simon Wessely

• Publisher: Psychology Press
• Year: 2005
• ISBN:
  9781135420574
• Edition: 1
• Topic: Psicología
• Subtopic: Psicología clínica

The application of psychiatry to war and terrorism is highly topical and a source of intense media interest. Shell Shock to PTSD explores the central issues involved in maintaining the mental health of the armed forces and treating those who succumb to the intense stress of combat.

Drawing on historical records, recent findings and interviews with veterans and psychiatrists, Edgar Jones and Simon Wessely present a comprehensive analysis of the evolution of military psychiatry. The psychological disorders suffered by servicemen and women from 1900 to the present are discussed and related to contemporary medical priorities and health concerns.

This book provides a thought-provoking evaluation of the history and practice of military psychiatry, and places its findings in the context of advancing medical knowledge and the developing technology of warfare. It will be of interest to practicing military psychiatrists and those studying psychiatry, military history, war studies or medical history.

CHAPTER ONE
Pre-1914 British military psychiatry*

Military psychiatry in the UK is generally regarded as having begun in World War One and, indeed, the recognition of psychiatric injury in general (Binneveld, 1997; Stone, 1985). Certainly, it then became an important service designed in the main to treat troops suffering from so-called shell shock, the acute effects of battle, so that they could be returned to their units as quickly as possible. However, a significant developmental phase pre-dated this conflict when physicians attempted to explain and treat servicemen suffering from a range of unexplained, somatic disorders, including disordered action of the heart (DAH) and psychogenic rheumatism. These arose in a context of ‘palpitation’ seen during the Crimean War and irritable heart described by Da Costa in the American Civil War. In addition, military doctors encountered cases whose symptoms suggested a neurological cause. These were both acute (cases of exhaustion after combat), and chronic (veterans who remained debilitated for years after their discharge), mirroring neurasthenia in the civilian population.

Although the discipline of psychiatry remained embryonic in the UK divided between alienists, who treated so-called lunatics in asylums (Jones, 1991), and physicians with an interest in psychological matters, there was a

small but growing debate about medically unexplained disorders. Neurasthenia and the phenomenon of railway spine tended to divide doctors into those who sought an organic explanation and those who interpreted these as psychological disorders. Furthermore, the rapidly filling asylums encouraged ideas of degeneracy by which the masses were conceived as destroying civilization with their mental imbecility or savagery precisely when Darwin was dictating that only fit societies would survive (Porter, 1987; Shorter, 1997a). Debilitated servicemen added to fears of an irreversible hereditary decline. Set against this pessimism a few clinicians, such as Daniel Hack Tuke, attempted to introduce psychological explanations and therapies (Clark, 1981). However, most physicians simply regarded abnormal mental phenomena as indicators of pathological processes in the central nervous system rather than important clues to changing states of mind. Psychological approaches were still regarded with suspicion in that they might encourage morbid introspection and egoism, heightened suggestibility and aggravate an existing deficiency of willpower. It was against this complex background of medical and cultural forces that military psychiatry began to evolve and address the difficult questions of treatment and prevention. * In this chapter we present a revised and expanded version of a previously published paper (Jones & Wessely, 2001b).

WIND CONTUSIONS, NOSTALGIA, AND OTHER EARLY WAR SYNDROMES

Discharged servicemen had been a cause for concern after the Napoleonic Wars when their odd behaviour led to the introduction of the Vagrancy Act of 1824. Some veterans may have been flashing but others seem to have exhibited their war wounds either to gain sympathy or even perhaps as a way of expressing a traumatic experience. The legislation prohibited such acts and declared that ‘every person wilfully, openly, lewdly and obscenely exposing his person with intent to insult any female…shall be deemed a rogue and a vagabond’ (Smith and Hogan, 1978).

We cannot assume that soldiers in the late eighteenth century were immune from the stresses of combat. A phenomenon, which bears more than a passing resemblance to shell shock, had been observed during the Napoleonic Wars. Cases of ‘cerebro-spinal shock’, evidenced by tingling, twitching and even partial paralysis, were described in soldiers who had been close to the passage of a projectile or its explosion but not suffered a physical wound. Termed ‘wind contusions’, most cases were treated with scepticism by military physicians (Anon, 1914b). It is possible that the description, ‘windy’ (meaning lack of courage) derived from this phenomenon.

Of older provenance was the disorder termed nostalgia. Described in various Swiss and Spanish accounts of the seventeenth century, it was characterised by a state of deep despair found in conscripted troops sent to foreign territories where they had little prospect of leave (Rosen, 1975). Writing in 1678, Johannes Hofer believed it was due to pathological processes in those parts of the mind where images of desired persons and places were stored. Treatment, in the form of purges, was designed to improve digestion thereby freeing up vital spirits. Patients were also encouraged by the promise of leave and the provision of diverting company, while chronic cases were sent home as this was shown in most cases to produce a cure. A novel explanation was proposed by J.J.Scheuchzer to explain the incidence of nostalgia among Swiss troops. As mountain people, he argued, they inhale refined air, which is also carried into the body by food and drink. When they descend to the lowlands, the delicate fibres of the skin are compressed, the blood forced into the heart and brain, its circulation is slowed. If a soldier is unable to resist these deleterious effects then anxiety and homesickness result (McCann, 1941). Treatment principally involved moving the soldier back to the mountains and the administration of youthful wine and saltpetre to increase internal body pressure.

Yet cases of nostalgia were not confined to the Swiss and found in French and German eighteenth-century accounts and even among sailors of the Royal Navy. By 1800, it had become a recognised hazard of troops on campaign, and was increasingly categorised as a form of melancholy. Nostalgia came to prominence during the American Civil War when rates of 2.3 per thousand and 3.3 per thousand were recorded among Northern troops in 1861 and 1862 respectively. Assistant Surgeon De Witt C.Peters observed that it was particularly prevalent among inexperienced troops serving in the far south where mail was irregular. J.T.Calhoun, an army surgeon, believed that the main cause was the recruitment of poorly motivated soldiers with unrealistic expectations of what war involved. Calhoun advocated a generous furlough system in place of the existing system by which leave was granted only as a reward for re-enlistment or to deal with emergencies at home.

The diagnosis of nostalgia does not appear to have found favour with doctors in the British army, who in the nineteenth century at least preferred the diagnosis melancholia. An analysis of over 6,200 cases of Chelsea Hospital pensions dating from the late 1880s showed that 37 (0.6%) were for melancholia or mania, while not a single case of nostalgia was recorded.

IRRITABLE HEART AND THE CRIMEA

The Crimean War provided examples of the way in which the hardships of campaigning and the acute stress of combat could exercise an immediate effect on soldiers. Assistant-Surgeon Arthur Taylor wrote from Sebastopol in October 1854: ‘No one can form any idea of the suffering of both officers and men… They have nothing to do but “eat and fight”, and as such is the case, they seldom seem to wash…no one shaves, they are all too tired to take the trouble’ (Taylor, 1994, p. 51). Lieutenant Lleuellyn of the 46th Regiment, who arrived in the Crimea two days after the battle of Inkermann, entered the trenches to join his unit’s survivors. He was unprepared for their condition:

The poor fellows seem half ashamed to claim our acquaintance and indeed it is difficult to recognise in their haggard faces and ragged clothing the gay soldiers who left us the other day. Every general and staff officer in our division was killed or wounded. The people who are left appear dazed and stupefied and unable to give us any idea of our position or chances (Cooke, 1999, p. 34).

These troops appear to be suffering from what would later be described in World War Two as ‘battle exhaustion’ and subsequently as combat stress reaction.

Even less well understood was the idea that the stress of combat could manifest itself in disguised form as a physical disorder. The hardships of the Crimean War saw soldiers admitted for ‘palpitation’, which when investigated showed no underlying cardiac pathology. Recorded in the British Blue Book of the Crimean War (1854–56) and in the Report of the Hospitals of the Army in the East, these cases were characterised by irregular heartbeat, chest pain, shortness of breath and general debility, leading to invalidity and discharge from the forces (Da Costa, 1871).

Dr Handfield Jones, a physician at St Mary’s, reported a puzzling case of ‘Crimean fever’ in a Captain ‘much tasked both in mental and bodily exertion’ (Handfield Jones, 1855). Evacuated to the UK, he suffered from ‘pains in all the limbs, clammy sweats, parched tongue’, irritable heart, dizziness, headache and diarrhoea, while being ‘utterly unnerved and agitated violently by the merest trifles’. All treatments failed until Jones suggested that his patient take the air of Hampstead Heath. This led to a steady recovery completed by convalescence on the south coast. Significantly, Jones explained the officer’s invalidity wholly in terms of physical illness, suggesting that he had succumbed to a succession of diseases including ‘remittent fever with cerebral determination, dysentery and diarrhoea with variations of vomiting, rheumatism and cardiac paralysis’. However, it is difficult to know from the description whether the officer was suffering from a post-combat disorder characterised by medically unexplained symptoms or an agitated depression.

The chronic nature of some post-combat disorders is illustrated by the case of Sergeant Charles Dawes of the Eighth King’s Royal Irish Hussars. He had served in the Crimea for six months and then taken part in the suppression of the Indian Mutiny, subsequently developing symptoms (notably exhaustion, pains in joints and legs, tremor and weakness) that today would qualify for the diagnosis of chronic fatigue syndrome (Jones and Wessely, 1999). A conscientious NCO, he was awarded a permanent disability pension for debility in 1872. The military physicians who examined him concluded that his ‘service of seventeen years in Turkey, India and home, and the general hardships of a soldier’s life during the Indian Mutiny’ had led to his declining health (Dawes, 1872). It was speculated that cold and general exposure in a country in which malaria was endemic could have been the cause, although there was no clinical evidence to suggest that Dawes had contracted the disease. This anecdotal evidence suggests that the stress of combat tended to be expressed in bodily symptoms during the Victorian period, and that neither doctors nor their veteran patients were ready to think in psychological terms.

Ironically, improvements in the treatment of wounds and disease in the Crimea may have inadvertently increased the potential for chronic psychiatric disorders. During the Napoleonic Wars, Sir James McGrigor, Director-General of the Army Medical Department, kept the sick and wounded with their regiments against the wishes of Wellington, who favoured their rapid evacuation (Howell, 1924). This prevented base hospitals from becoming overcrowded and forced combat units to recruit surgeons. However, the Crimean War showed that facilities in the field were often inadequate and that hygiene and diet could be more effectively controlled in purpose-built base hospitals (Reid, 1911). A report on British medical services in the Crimea, published in 1855, concluded that ‘the sick and wounded should, with the exception of very slight cases be at once removed from the field to the rear, the practice pursued by the French’ (Cumming, Benson Maxwell, & Sinclair Laing, 1855, p. 47). While this was, and is, the basis for good practice for the treatment of physical wounds, it is far from certain that some psychological disorders responded equally effectively. During the Russo-Japanese War, for example, it was observed that evacuation to a base hospital served to reinforce symptoms and impeded the natural process of recovery (see p).

THE LUNATIC HOSPITAL, CHATHAM

To treat servicemen invalided to the UK suffering from mental illness, the army medical services set up a small specialist unit at Fort Pitt, Chatham. Its size restricted admissions to an average of two months. In the year to March 1859, 159 soldiers (including four officers and 13 NCOs) were admitted of whom 28 (17.6%) were returned to unit fully recovered (Anon, 1859–1871, p. 2). Luke Barron, the staff surgeon at the hospital, observed that:

The vast majority of the men sent here for treatment with a character for great violence, or as dangerous to their fellow patients and attendants, rarely after the first day or two give much trouble, many indeed are quiet from the beginning. This difference and change in habits can only arise from freedom from restraint, proper management and probably from the absence of all violence towards them by the attendants (Anon, 1859– 1871, p. 2).

‘Moral’ treatment was employed and took the form of warm baths, cold applications to the head and aperients, and ‘as a rule, little medicine is prescribed or indeed necessary’. Patients were encouraged to work in the hospital garden, undertake other forms of occupational therapy or take exercise. Most admissions were diagnosed as amentia (59 in 1859), melancholia or mania. On discharge, most servicemen went to live with friend or family, although a few were referred to civilian asylums (see Table 1.1).

In essence, the Chatham hospital treated cases of psychosis, depression and some men who probably had severe personality disorders or extreme learning difficulties. In the absence of detailed case notes, it is impossible to say whether servicemen with post-combat disorders, characterised by unexplained medical symptoms, were also admitted. The various vignettes included in its annual reports suggest that they were probably few in number. Corporal Francis Harkness of the 3/60th Rifles may have been a case in point. Aged 23 with five years’ military service, he became melancholic while in India. On admission, he was re-diagnosed as suffering from ‘hypochondriacal dyspepsia’: ‘His physical condition was good and when discharged [he] had apparently recovered mentally’ (Anon, 1859–1871, p. 41).

The return-to-duty rate remained low. In 1860 only 28 (12%) of 240 admissions went back to military service, 144 (60%) being discharged to friends and 42 (18%) were referred to Grove Hall Asylum at Bow. By contrast, Dr J.Balfour Cockburn, who succeeded Barron as medical officer of the Lunatic Hospital in March 1865, believed that only in rare exceptions was it possible to send men back to active duties. Subjected to banter from their comrades and the pressures of overseas service, he believed that most relapsed within two years of their return to India (Anon, 1865–1871, p. 337).

Because so many patients were referred from India and tropical postings, climate was identified as a common cause. Barron speculated whether ‘a man who has suffered from severe concussion or from sunstroke is ever safe for any length of time in an extremely hot climate. Many patients coming from India…assert themselves that they have had what they term “a touch of the sun’” (Anon, 1865–1871, p. 245). Yet, because of the lengthy voyage home, some soldiers had recovered by the time they landed at Fort Pitt.

TABLE 1.1
Servicemen treated at the Lunatic Hospital, Fort Pitt, 1858–1865

With such limited space at Chatham, Balfour Cockburn lobbied a new building that could accommodate at least 150 patients ‘with an amount of land attached sufficient for exercise and cultivation’ (Anon, 1865–1871, p. 306). The beginnings of the specialist military psychiatry may also be identified as he also argued that ‘a good school for the instruction of the young medical officers of the army in lunacy [sh]ould be opened’ (Anon, 1865–1871, p. 308).

‘D BLOCK’, ROYAL VICTORIA HOSPITAL, NETLEY

In the aftermath of the Crimean medical scandal, the Royal Victoria Hospital, opened at Netley on Southampton Water in March 1863, was designed to offer modern and effective treatment for diseases and wounds. However, in its design no provision was made for psychiatric cases. Inevitably, functional somatic disorders found their way to Netley apparently when investigations failed to find an organic lesion or when disability endured beyond the recovery of wounds. Innumerable cases of DAH were discharged from Netley (Wooley, 1985).

Despite the opening of the Royal Victoria Hospital and perhaps because of fears of contamination, psychiatric cases continued to be referred to the Lunatic Hospital at Fort Pitt. However, in 1869 when the Commissioners in Lunacy decided that the existing facilities at Chatham were overcrowded, it was agreed to construct a purpose-built psychiatric hospital (‘D Block’) in the grounds at Netley. Patients transferred from Chatham on 4 July 1870 (Hoare, 2001). Symbolically, it was tucked away in woods behind the main hospital buildings and surrounded by a 10ft wall (reduced from the original 12ft specification to modify its ‘prison-like’ appearance). Although an improvement on Fort Pitt, Surgeon Major Thomas Blatherwick, the first medical officer of ‘D Block’, was critical of the design. Suggesting that due attention had not been paid to the practical needs of a mental hospital, he argued that the two-storey building had ‘insufficient’ accommodation. In 1871, Blatherwick requested that a day room for violent patients be erected because of ‘the great, chief and prominent defect of the hospital, viz that of instead of ample corridors fitted as day rooms, passages of 7ft width have been constructed throughout’ (Anon, 1859–1871). The aftermath of the Boer War saw increased numbers referred to ‘D Block’, and an extension was finally constructed in 1908. Sadly, the loss or destruction of case notes has prevented an analysis of admissions to discover diagnostic categories, treatments and outcomes.

DISORDERED ACTION OF THE HEART

The incidence of functional heart disorders in the British Army leading to invalidity became a serious cause for concern in 1864 following a presentation at the Royal United Services Institute by W.C.Maclean (d. 1898), professor of military medicine at the Army Medical School, Netley. Having excluded rheumatism, excessive alcohol consumption, heavy smoking, or overexertion as causes, Maclean considered that the weight and distribution of a man’s equipment were responsible: The present accoutrements are highly injurious to the health of infantry soldiers and have a large share in producing many affections of the lungs and heart common among them’ (Maclean, 1864). The marked differences in incidence between units, he explained by esprit de corps, suggesting that ‘in well-disciplined regiments the practice of falling out at drill or on the line of march is discouraged, and men will bear and suffer much, rather than incur the imputation of being “soft”’ (Ibid, p. 111). These observations were supported by Edmund Parkes, professor of military hygiene, who argued that the causal association between equipment and he...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• LIST OF ILLUSTRATIONS AND TABLES
• ACKNOWLEDGEMENTS
• INTRODUCTION
• CHAPTER ONE: PRE-1914 BRITISH MILITARY PSYCHIATRY
• CHAPTER TWO: SHELL SHOCK AND THE WAR NEUROSES
• CHAPTER THREE: MILITARY PSYCHIATRY IN THE INTERWAR PERIOD
• CHAPTER FOUR: TREATMENT AND OUTCOMES DURING WORLD WAR TWO
• CHAPTER FIVE: SCREENING AND SELECTION
• CHAPTER SIX: POST-1945: KOREA, VIETNAM, AND THE FALKLANDS
• CHAPTER SEVEN: WAR PENSIONS AND VETERANS’ PRESSURE GROUPS
• CHAPTER EIGHT: PTSD: INCIDENCE AND TREATMENT IN THE MILITARY
• CHAPTER NINE: WAR SYNDROMES
• CHAPTER TEN: CONCLUSIONS
• GLOSSARY OF DIAGNOSTIC AND OTHER RELATED TERMS
• REFERENCES