Neurasthenia and Shell Shock

[Robert Dunlop]

'Shell shock' is a term that is often used in the context of the Great War. Neurasthenia was a diagnosis that is less familiar. This thread is devoted to collating clinical information about these conditions. The information will come from books, journals and other sources that were published before or during the Great War. The goal of this thread is to enable readers to understand better what information was available at the time.

Although some information will be medical, other perspectives should be included.

The first contribution is from Mike (skipman), who kindly referenced a book on neurasthenia that is available online here.

Robert

[PhilB]

In my childhood, the term neurasthenia was in use among GPs but I suspect it was a catch-all term for vague or non-specific complaints that didn`t fit anything else. The following extract is of interest:-

Neurasthenia

In the 19th century, there was a disorder called neurasthenia, which was described as a disease in which the patient experienced severe fatigue. It was believed to be more common among the educated than the unskilled, and the cause was thought to be environmental - it was brought on by what are today regarded as stress factors such as emotional upset, bad experiences and over work. The cure was said to be rest.

Neurasthenia is still diagnosed in Oriental countries such as Hong Kong and Taiwan. In the west, however, fatigue is seen to be a symptom of some other disorder rather than a disease in its own right.

It has been noted by some psychiatrists that what is currently known as chronic fatigue syndrome (CFS) bears a strong resemblance to what the Victorians called neurasthenia. CFS used to be termed 'yuppie flu' because it was first identified as a problem experienced by those who were striving to climb the ladder of success and it often occured after the person had a viral infection, such as flu. It was also known as ME, but chronic fatigue syndrome is now regarded as a better name on account of the symptoms.

The term was introduced into psychiatry in 1869 by G. M. Beard, an American neurologist. Used by Freud to describe a fundamental disorder in mental functioning, the term was incorrectly applied to almost any psychoneurosis and has been largely abandoned.

What are the synonyms of Neurasthenia?

Neurasthenia is also known as Primary Neurasthenia, Cardiac Neurosis, Chronic Asthenia, Da Costa's Syndrome, Effort Syndrome, Functional Cardiovascular Disease, Soldier's Heart, Subacute Asthenia

http://www.depression-guide.com/neurasthenia.htm

[Robert Dunlop]

Thanks, Phil. It is good to have recent context for the term neurasthenia. The focus should be on the understanding at the time of the Great War. While the potential overlap with CFS is interesting, it is not something we should pursue in this thread (which is not to say there can't be another thread on the subject). The extract mentions Freud's use of neurasthenia. This aspect is worth pursuing, as Freud's work around this subject was published before the war (in the late 1890s).

Robert

[Guest]

Thanks for starting a thread that I'm sure will be useful to many.

More from archive .org here page 1 and 2

Mike

[PhilB]

I think my basic point is that neurasthenia was probably not, in general WW1 use, a precisely applied term. Medical people (especially busy or uncertain ones!) do like catch-all terms and neurasthenia would have been a most useful term for those patients with the kind of symptoms outlined above.

[truthergw]

I thought I might give a reference to a work which is often quoted in this context. " The Anatomy of Courage", Lord Moran. Published in 1945, written by Churchill's doctor, it draws on both world wars. It deals with psychological effects of war.

[truthergw]

I think my basic point is that neurasthenia was probably not, in general WW1 use, a precisely applied term. Medical people (especially busy or uncertain ones!) do like catch-all terms and neurasthenia would have been a most useful term for those patients with the kind of symptoms outlined above.

I think that it is more likely that non-medical people used the term loosely. It sounds much more impressive than shell shock. Neurasthenia has exactly the scientific resonance which would appeal to a reporter trying to impress his editor.

[Guest]

'Shell shock' is a term that is often used in the context of the Great War. Neurasthenia was a diagnosis that is less familiar. This thread is devoted to collating clinical information about these conditions. The information will come from books, journals and other sources that were published before or during the Great War. The goal of this thread is to enable readers to understand better what information was available at the time.Although some information will be medical, other perspectives should be included.The first contribution is from Mike (skipman), who kindly referenced a book on neurasthenia that is available online here.Robert

By coincidence I just received a copy of the definitive study: "The Medical War - British Military Medicine in World War One" (346pp and available here) by Mark Harrison (Professor of History of Medicine and Director of the Wellcome Unit for the History of Medicine at the University of Oxford). It has a a whole section on shell shock. Interestingly he does not refer to Neurasthenia, which might indicate it was not a term widely used at the time. The book is meticulously researched and has a massive bibliography. Some of the books that Prof Harrison refers to in the section on shell-shock are listed below;

History of the Great War based on Official Documents. Medical services: Casualties and medical Statistics of the War

(London 1931) Mitchell T J and Smith G M ...page 73...107

Hysterical Men: War Neurosis and German Mental Medicine 1914-1921

(Columbia University PhD thesis, 1996) by Lerner, Paul F. ...page 8

Mental States and the War - The Pyschological Effects of Fear

(Journal of State Medicine, 25, (1917)) by Robert Armstrong Jones .....part I 238-49, part II 289-99

Forgotten Lunatics of the Great War

(Newhaven & London 2004) by Barham, Peter....p 125

Medicine and Victory: British Military Medicine in the Second World War

(Oxford 2004) Harrison, Mark...p59-60

Shellshock and the Psychologists

by Stone, Martin in

T

he Anatomy of Madness: Essays in the History of Psychiatry Vol II

- Institutions and Society (London 1985) p242-271

War Neuroses and Social Cultural Change in England 1914-1922: the Work of the War Office Committee of Enquiry into Shell Shock

by Ted Bogacz in the Journal of Contemporary History 24 (1989) p 227-256

Shell Shock

by Merksey, Harold.... in German E Berrios and Hugh Freeman (eds)

150 Years of British Psychiatry 1841-1991

(London 1991) ...p 245-267

Shell Shock: Traumatic Neuroses and the British Soldiers of the first World War

(Basingstoke 2002) by Leese, Peter..p. 178

Why are they Not Cured? - British Shellshock treatment during the Great War by Leese

, Peter in M S Micale and P Lerner (eds)

Traumatic Pasts: History, Psychiatry and Trama in the Modern Age 18970-1930

(Cambridge CUP 2001)... p 205-221

Psychology and the Soldier

(Cambridge 1927) by Bartlett F C.........p.196-197

Shell-shock in France 1914-1918

(Cambridge 1940) by Myers C S ........p. 24-48, 40

Instinct and the Unconscious

(Cambridge 1924) by Rivers, W H R....... p 209-210, 214, 217-219, 221

Cases of Nervous and Mental Shock observed in Base Hospitals in France

(JRAMC 14, (1915)) by Turner, William A ...........p 351

War of Nerves: Soldiers and Psychiatrists 1914-1994

(London 2000) by Shepherd, Ben ...............p.41

Shellshock to PTSD: Military Psychiatry from 1900 to the Gulf Wa

r

(Hove 2005) by Jones, Colin and Wessely, Simon

Report on the War Office Committe on Shell-Shock

WO 32/4748

p 122-123

Neuroses and Psychoses of War

by Turner W A , text of the Bradshaw Lecture, Royal College of Physicians 7 July 1918, the

Lancet 9 Nov 1918

p 617

There are a multitude of other unpublished sources quoted in the book, mostly Govt archive material and periodicals. For anyone interested in this subject I would strongly recommend Harrison's book. Regards MG.

[Robert Dunlop]

Interestingly he does not refer to Neurasthenia, which might indicate it was not a term widely used at the time.

Martin, thanks for drawing attention to Professor Harrison's book. You have rightly noted that the two terms, 'shell shock' and 'neurasthenia', cannot be regarded as synonymous. Hopefully this will become even clearer as the thread progresses.

Robert

[Robert Dunlop]

Neuroses and Psychoses of War by Turner W A , text of the Bradshaw Lecture, Royal College of Physicians 7 July 1918, The Lancet 9 Nov 1918 p 617

I should be able to get hold of this reference. The lecture may have been reported in the BMJ at the same time. Otherwise a copy will be available at the Royal Society of Medicine library.

Robert

[Guest]

Interesting and graphic footage HERE

2 more online books

War neuroses and shell shock (1919)

The Treatment of neurasthenia (1903)

Mike

[Sue Light]

'Medical Diseases of the War', Sir Arthur Hurst (Edward Arnold and Co., London 1916), republished in 1940 as 'Medical Diseases of War', which was an updated edition of the original to cover two world wars.

Many of the chapters are relevant, even where not directly titled as such, but include:

Predisposing causes of war neuroses

Hysterical symptoms in soldiers (hysterical paralysis, contractures, tremor, fits)

Disorders of speech

Stupor and amnesia

Exhaustion resulting in Neurasthenia

Anxiety Neuroses of War

Effort Syndrome (Soldiers' Heart)

Sue

[TEW]

Some time ago I found in the Devon Record Office an account of a 'Shell Shocked' soldier, Pte Percy Meek who was placed in the care of Arthur Hurst in Devon. His approach was apparently radically different to his contemporaries. He claimed a 90% success rate with one session.

One of his techniques was to re-create a version of the trenches out on Dartmoor and introduce the men to the scene and eventually get them to shoot again.

The account I read was I think by Arthur Hurst and showed that Percy Meek was almost catatonic and apparently returned to normality.

Quote from HERE Hurst made the only film in existence about how shell shock victims were treated in Britain. These rare recordings give an insight into Hurst's dramatic techniques. One of the films follows Private Percy Meek who was driven almost mad during a massive bombardment of the Western Front.

The strangest thing in Hurst's account of Percy Meek is that of his supposed comrades. I guess it may be gallows humour or 'There but for the grace of God' attitude but his comrades were actually rather cruel (in my 21stC view) to him.

He lost all connection with words i.e. had no idea what certain things were or what to call things. His comrades kept 'teaching' him incorrectly just for a laugh. They taught him that FOOD was called PUS and various other 'jokes' were played out. All very amusing apparently when Percy Meek asked for more pus at dinner time!!

It has been my intention to re-locate the document and post it in full here, as this thread seemed appropriate I thought I'd include this for the moment.

TEW

[Guest]

Martin, thanks for drawing attention to Professor Harrison's book. You have rightly noted that the two terms, 'shell shock' and 'neurasthenia', cannot be regarded as synonymous. Hopefully this will become even clearer as the thread progresses.

Robert

From the opening of his chapter.... "No aspect of military medicine during the great War has attracted so much attention as the condition known as shell-shock. On the Western Front from 1914 to 1918 there were over 80,000 recoded cases of shell-shock or what were subsequently termed 'war neuroses' amounting to 1.28 per cent of the 6,218, 540 (battle and non-battle related) casualties sustained in France and Belgium.. or 2.97 per cent of those related to battle only..... although these figure probably understate the true extent of war-related psychiatric disorders..."

He also goes into detail on the distinction of 'Shell-Shock "W"' (wounded) and 'Shell-shock "S" ' (sick), and NYDN (Not Yet Diagnosed Nervous).... and does mention Neurasthenic cases (but not in the index) but implicitly this is seen as not being Shell-Shock...p.115 "The DMS of the 5th Army, for example, detailed one CCS as a psychiatric centre for his area, the intention being to use it for the continuous treatment of both 'genuine Shell Shock (W) cases and Neurasthenic cases' "

He also mentions Hugh Crichton-Miller (1877-1957) who was a leading specailist in nervous disorders. See 'Miller, Hugh Crichton (1877-1959) DNB (I assume this is the Dictionary of National Biography) by Loughlin, K.

The books is so well researched; he packs an incredible amount of information on just 10 pages on this subject.

MG

[Robert Dunlop]

Martin, thank you for the further details. You have also touched upon another interesting aspect too. There has been some discussion about 'catch-all' diagnoses. The concept of NYDN is just such a 'catch all'. I would like to come back to neurasthenia as a 'catch-all' later in this thread.

Robert

[Robert Dunlop]

'Medical Diseases of the War', Sir Arthur Hurst (Edward Arnold and Co., London 1916), republished in 1940...

Thanks Sue. Have you had a chance to compare the two editions? The differences would be interesting, I imagine.

Robert

[Sue Light]

Thanks Sue. Have you had a chance to compare the two editions? The differences would be interesting, I imagine.

No, mine is the 1940 edition. However, it seems that most of the chapters named above are relatively unchanged, and refer in the main to studies done in the Great War, and in his preface to this edition does mention what has been updated (abridged):

'The first edition of my book on Medical Diseases of the War was published in November 1916. At that time I had had opportunities of studying the various diseases occurring on active service, first as a physician and neurologist to a number of military hospitals in London and to the New Zealand Hospital at Walton-on-Thames, then as a member of the Medical Advisory Committee for the Prevention of Epidemic Disease in the Mediterranean Expeditionary Force in Lemnos, and subsequently as Consulting Physician to the British Forces in Salonica. The second edition was published in March 1918, when I had had further experience as Neurologist to the third Southern General Hospital at Oxford and to the Royal Victoria Hospital at Netley. During the next fifteen months I was in command of the Seale Hayne Hospital for Functional Nervous Disorders. At the end of 1918 I had collected material from my own experience and from a study of the available literature in English, French, Italian and German for a third edition, but the Armistice made its publication unnecessary.

... I have tried to bring (this new edition) each chapter up to date in the light of knowledge acquired since 1919. I have omitted certain chapters from the earlier editions dealing with conditions which are unlikely to occur in the absence of an Eastern campaign. I have invited Dr. H. W. Barber to write a chapter on Skin Diseases in War, as no less than 30 per cent. of medical casualties in the British Expeditionary Force in the last war were the result of scabies and pediculosis.

I have also been fortunate in obtaining the help of Dr. T. A. Ross in the section on psychoneuroses. The war gave us great opportunity of studying the varying manifestations of hysteria in soldiers. By the end of 1918 we had been able to demonstrate the hysterical nature of several conditions which had hitherto been regarded as organic, and we had gradually evolved methods of treatment which made it possible to do in an hour what had first required weeks or months. This experience seems worth recording in detail again, as many of the hysterical symptoms which were common in the war are very rarely seen in peace-time, and moreover most modern psychotherapists are accustomed to slow methods of treatment which would be useless in war-time. I hope, however, that Dr. Ross's chapter on anxiety neuroses will help to explain the war neuroses in the light of modern psychotherapy.'

...

Sue

[seaJane]

I think - not quite certain as I am hors de combat with a very sore throat - that both editions are in "my" library. I'll have a look when I get back.

[Druid_Ian]

Here is a link to The Care and Treatment of Mental Diseases and War Neuroses Shell Shock in the British Army

http://www.scribd.com/doc/52614016/The-Care-and-Treatment-of-Mental-Diseases-and-War-Neuroses-Shell-Shock-in-the-British-Army

I have posted a few more manuals on there as well

[Guest]

Harrison: page 13

"

Most historians have concentrated on the Western Front and their principal interest has been in the phenomenon of 'Shell-Shock'. This is understandable in view of the prominence in literature and film, but the amount of attention which the subject has received is perhaps disproportionate to its military significance. Mundane problems such as trench fever and trench foot caused far more admissions to hospital, for example, and yet have found very few historians. After shell-shock, the subjects which have received most attention are medical specialisation, 'venereal diseases', and various aspects of surgical treatment.

"

What Prof Harrison does not address is the high legal, political and social sensitivities to 'shell-shock' and cowardice. Before shell-shock was properly understood, many hundreds of men were incorrectly diagnosed and wrongly accused of cowardice. With apparently able-bodied men, the inability of the Military medical system to clearly differentiate between cowardice and shell-shock led to courts martial and sometimes the death sentence. Despite the fact that well over 90% of death sentences were not carried out, it remained and still remains an highly emotionally charged issue. This is why it is so prominent in literature and films. To my knowledge, mis-diagnosed trench foot or venereal disease would not incur courts martial and a potential death sentence. Mis-diagnosed shell-shock could and did, all too often. It is for these reasons that (I think) shell-shock has "received disproportionate attention" to paraphrase Prof Harrison. One could easily argue that the attention is very proportionate given the potential consequences of mis-diagnosis. Harrison does not consider or weigh this dimension of the debate.

MG

[PhilB]

What Prof Harrison does not address is the high legal, political and social sensitivities to 'shell-shock' and cowardice.MG

Harrison deems shell shock to be militarily mundane but, unlike trench fever and trench foot which the public rarely saw, it left many men visibly stricken, some severely, for years after. Generally speaking, what was the recovery rate from moderate to severe shell shock?

[Guest]

While not a study of Shell-Shock the following book has dedicated considerable space to the subject: "Blindfold and Alone - British Military Executions in the Great War" by Cathryn Corns and John Hughes-Wilson. There are chapters as follows:

Chapter 3: Military Law in 1914: The Manual of Military Law

Chapter 4: Mental Health in Britain in 1914

Chapter 5: The Shock of Battle

Chapter 6: Shell-Shock: A Brief History

Chapter 7: Shell Shock and the Great War

Chapter 14: Cowardice - The Early Years

Chapter 15: Cowardice and the Battle of the Somme

Chapter 16: Cowardice - The last case

Chapter 25: Shell Shock and Discipline

Chapter 26: A Shell-Shocked Officer

Lots more books in the Bibliography which I will post later... MG

[Robert Dunlop]

Thanks Martin. The key references would be anything prior to 1919 please.

Robert

[Robert Dunlop]

I hope, however, that Dr. Ross's chapter on anxiety neuroses will help to explain the war neuroses in the light of modern psychotherapy.'

Sue, thank you for posting the information. This looks like the most fruitful example for more detailed analysis in the 1916 edition.

seaJane, all the very best for a complete and rapid recovery.

Robert

[Guest]

Thanks Martin. The key references would be anything prior to 1919 please.Robert

The post 1919 books contain a mass of information and references to what was available at the time and more importantly what the preconceptions were towards mental illness. The Bibliographies are extensive. There is much that was part of the social and military conditioning of the age that is not in any manual or publication that contributed towards attitudes to shell-shock etc. The social context is arguably as important as the clinical context. Some might argue that it was the most important aspect. As new ideas were introduced there are multiple examples of MOs and senior Officers still hanging on to old perceptions. It took time for new ideas to percolate through the system. From Harrison:

"But in 1914-1918 official recognition masked a considerable variety of attitudes towards shell-shock and its legitimacy as a medical condition....ideas of predispositions to mental illness were not altogether dispelled. A number of psychiatric specialists as well as regimental MOs continued to believe that social misfits and those with 'weak minds' were particularly susceptible to breakdown"

and later

"..But psychiatric medicine was class-orientated in its beliefs about the liability of officers and men to different types of mental disorder. While 'hysteria' appeared appeared among the rank and file, 'anxiety neuroses' were diagnosed more commonly among officers...."

There is a strong case that assessing what was not understood is as valuable as understanding what was understood, even with a 'retrospecoscope'. I will try and extract the pre 1919 references but I think this will not capture the deeply ingrained preconceptions which were (arguably) the biggest single challenge. The chapter in Blindfold and Alone on Mental Health in Britain in 1914 gives a very detailed analysis of the prevailing attitudes at the time.

If you are after a list of literature and manuals available to the RAMC at the time, that will be a very short list. The civilian contribution will expand the list, but there was an explosion of literature post 1919 that analysed and assessed the changes in attitudes and understanding. In the immediate years post WWI the learning curve was still steep as the medical system was still dealing with the tragic consequences for years, decades afterwards.

Edit: It is notable that one of the eminent neurologist Charles Myers when offering his services to the Army in 1914 was initially rejected as being too old (aged 42). He eventually was accepted and coined the term Shell-Shock, although later tried to have the term officially dropped, but by then it was too late. A serious attempt to address war neuroses in the same category as pre-war nervous breakdowns was made by G Elliot Smith and T H Pear's Shell Shock and its Lessons published in 1917.

Pre 1919 References:

1.

Report on the War Office Committee on Shell-Shock

WO 32/4748 TNA

2. W A Turner '

Neuroses and Psychoses of War'

text of the Bradshaw Lecture, Royal College od Physicians London 7 Jul 1918, The Lancet 9 Nov 1918.

3. E B Sherlock:

The Feeble Minded

(London 1911)

4. Thomas Salmon,

Care and Treatment of Mental Disease and war Neurosis ("Shell-Shock") in the British Army

,

Mental Hygiene 1917 Vol 1

5. William A White

Outlines of Psychiatry

(New York: The Journal of Nervous and Mental Diseases Publishing Company, 1909)

6. Charles L Dana

The Future of Neurology

Journal of Nervous and Mental Diseases 1913

7. G Elliot Smith and T H Pear

Shell Shock and its Lessons

(Manchester University Press 1917)

8. Anon

Madness in Armies in the Field

BMJ 1904 Vol 2

9. Capt R L Richards

Mental and Nervous Diseases in the Russo-Japanese War

Military Surgeon 1910 Vol 26

10. Charles S Myers

A Contribution to the Study of Shell Shock

Lancet 1915 Vol I

11. Lewis Yealland

Hysterical Diseases of Warfare

(London 1918)

Regards MG

P.S. John Lewis Stempel's book "Six Weeks - The Short and Gallant Life of the British officer in the First World War" contains some good anecdotal diary evidence as well as some history on attitudes towards shell-shock. MG