Abrupt treatments of hysteria during World War I,1914–18

Introduction

Case reports and clinical anecdotes regarding the management of hysterical symptoms of soldiers of World War I mention rapid, miraculous, cures. While there was probably a publication bias with respect to such dramatic treatments – with negative results being unpublished – there was also firm medical opinion regarding the apparent effectiveness of such abrupt cures. The wastage of manpower from psychiatric disorders was threatening to all the armies, hence the desperate need for quick and effective interventions. Some of the case reports involved acute symptoms and many persisting symptoms. As pointed out by Mai and Merskey (1980), Paul Briquet had recognized in his 1859 book on hysteria that if hysteria lasted a short time, if it had left no after effects, and if the original cause was no longer present, a complete recovery could occur. But this was not so, he maintained, in chronic cases. This clinical observation is mirrored in modern practice. Achieving therapeutic responses in cases with chronic symptoms remains notoriously difficult, and the burden of care for such patients is considerable.

Shell shock – the lay term for the war neuroses of that war, and a term that transiently gained formal medical recognition – referred to a myriad of psychiatric conditions. These were predominantly neurasthenia and hysteria (conversion disorder in modern terminology), though the latter diagnosis was applied to only about 10% of the mental casualties. Retrospectively, it is not possible to estimate accurately the prevalence and incidence of conversion symptoms, and diagnostic accuracy was probably variable. Hysteria was infrequently seen ‘in the firing line’, and typically the symptoms emerged only once safety was assumed (Roussy and Lhermitte, 1917: xxviii). If simple reassurance and rest did not relieve symptoms at the front, multicomponent treatment strategies were introduced at Casualty Clearing Stations (including NYDN (Not Yet Diagnosed Nervous) Neurological Centres) and Base Hospitals. These typically involved isolation (to prevent contagion), suggestive psychotherapies, physiotherapeutic and vocational supports, and a firm military expectation of a return to duty. If such patients were evacuated to their homeland, inevitably more concerted treatments were instituted, including persuasive therapies. Melodramatic reports and theatrical film footage of chronic institutionalized conversion disorder patients dominate historical recollections, but such intractable cases were relatively uncommon.

There were several differing forms of the so-called abrupt treatments, and obvious laxity in the definition of the term. This article attempts to identify common threads to the case reports of abrupt cures. Sudden cures fell into several clusters, namely, circumstantial, psychotherapeutic, hypnotic, feint or trickery, fright, alteration of consciousness, and persuasive management.

Circumstantial recovery

The natural history of most acute conversion symptoms is for spontaneous resolution, usually within hours or days of the onset. Charles Myers wrote: ‘It may be argued that mutism, rhythmical spasms, anaesthesia, and similar purely functional disturbances disappear over time without specific treatment’ (Myers, 1916). In some such cases, when the recovery is sudden, a simultaneous event or circumstance can be attributed to the therapeutic influence. Smith and Pear (1917: 11–12) cite the cures of a mute soldier on hearing Romania had entered the war, and of another on seeing the antics of the comedian, Charlie Chaplin. An Australian soldier buried by a shell blast at Gallipoli was rendered mute and deaf. He was, however, able to convey his wishes by replying to questions in legible writing. Once repatriated, his symptoms persisted, yet examinations revealed no organic lesion. One day at a convalescent home picnic he killed a snake, became very excited and that evening he was able to hear and speak (Jones, 1916). Dr Frederick Mott reported a deaf-mute who recovered his speech upon hearing a man in the hospital say ‘Rose’. The patient at once sat up and repeated the word, proving, as he said, ‘I could both speak and hear’. Another similarly affected patient was heard to sleep-talk, and was told of this by a colleague. The patient was so astonished that he responded by saying ‘I don’t believe it’ (RSM, 1916). Mute for two years, another soldier, according to a report in a morning paper, recovered his speech when someone stood on his favourite corn in a crowded tramcar, and another suddenly recovered his speech at the cinema (Editor (Lancet), 1919). Mott (1917) recalled the case of a patient who, when informed that he spoke in his sleep and advised he would certainly recover, subsequently fell out of bed and recovered his hearing and speech. Mott also reported that a serendipitous cure was apparently achieved for a blind, deaf and dumb grenadier, who was noted to be very sensitive to touch. He experienced an acute episode of abdominal pain and suddenly regained his sight, and then a few days later, after another emotional outburst, regained his speech and hearing.

Psychotherapeutic (suggestive, abreactive) recovery

Sometimes recovery was rapidly responsive to medical reassurance and the confident prophesying of a cure. This was routine practice at the front and was probably often effective, although no precise records were kept. The History of the Great War says:

To explain to a man that his symptoms were the result of disordered emotional conditions due to his rough experience in the line, and not, as he imagined, to some serious disturbance of his nervous system produced by bursting shells, became the most frequent and successful form of psychotherapy. (Macpherson, Herringham, Elliott and Balfour 1923: 9)

Suggestion, this process of gaining the patient’s confidence and impressing upon him the idea that he will recover, was involved to a greater or lesser degree in all successful treatments. The post-war Prideaux Report suggested that this required a firm and authoritative, but sympathetic, attitude on the part of the medical officer (Shephard, 1999). Such an intervention could evoke a rapid recovery. A typical case, reported by the German doctor Voss, was a soldier with astasia-abasia who miraculously started to walk after it was emphatically explained to him that there was no reason why he could not stand or walk (Southard, 1919: 791). Myers (1919) made the point that ‘Different physicians attain different degrees of success according to their particular mode of use of the same treatment’. Dr Mott admitted that a great tonic was to tell the patient that it was not likely that he would ever be sent back to active service, for he would be of no use, but that he wanted to discharge him from the service in a state fit to resume his previous occupation (Mott, 1917). It was widely acknowledged that the physically wounded only rarely experienced hysterical symptoms (Buzzard, 1916). This was attributed to the soldier’s distraction by their physical plight and the prospects of it being by a ‘blighty’ or harmful wound.

William Brown, who was in charge of an advanced neurological centre in France from 1916 to 1918, claimed to return 70% of 2000–3000 cases of psychoneurosis to the line; he claimed a cure ‘In every single one of these cases’ (Brown, 1918). As an advocate of psychological treatments (after Joseph Dejerine) and the fostering of self-knowledge (he called his treatment autognosis), Brown considered abreaction was the essential therapeutic process. He thought this was easier and more effective if performed in the field, shortly after exposure to trauma, rather than later in Great Britain.

Feint and trickery induced recovery

Various deceptive strategies were employed. The crude tactic of offering rewards was one. Mott (1917) claimed that several mutes recovered after he had spoken loudly to relatives in the patient’s hearing, offering rewards for recovery. As an example, he quoted his proposition that ‘This man must be kept on a No.1 diet, and when he can ask loud enough for you to hear, he can have a bottle of stout and a mutton chop’. Dr Farquhar Buzzard recalled that, in the presence of a mute officer, he told the nurse in charge that no visitors should be allowed until his speech returned. This effected a cure, although the man attributed it to knocking his head against the rail of the bed (Buzzard, 1916). Dr Max Nonne, a German psychiatrist, recalled a case of a soldier with complete paraplegia and anaesthesia of lower extremities: after receiving the news that he was awarded an Iron Cross, his legs worked perfectly well, though he still suffered astasia-abasia (which later responded to hypnosis) (Southard, 1919: 682).

The authoritative use of a stethoscope (to reassure), a tongue depressor (to provoke an utterance), a mirror (to evoke a visual response) or a tuning fork (to evoke an auditory response) could be helpful. Dr Wilfred Harris encouraged an Irish jester to force his aphonic patients into fits of laughter and thereby regain speech (Harris in RSM, 1916: xxxv). These strategies could be elaborate and orchestrated. Dr Walter Jessop, in his cases of temporary blindness following the explosion of shells, claimed the best results followed wearing dark glasses for a fixed and accurate time – say 3 days, 6 hours and 29 minutes. A patient who did not respond to this treatment was cured when the night nurse woke him up suddenly at 2 a.m. with the remark ‘Now you can see’, and he replied, ‘Yes, as well as I ever did in my life’ (Jessop in RSM, 1916: xxxvi). Mott (1917) commented that in cases of motor paralysis he would tell the patient to get up, support him physically, then engage him in conversation while gradually relaxing his hold, then announce ‘Now you did not know that you have been standing about 5 minutes without any support’. It was not uncommon for mutism to be partially responsive to interventions, leaving residual stammering and stuttering. Dr Dundas Grant commented on the ‘little tricks’ he used to divert these patients’ anxiety, in addition to breathing exercises and relaxation. He was referring to twirling a button, snapping the fingers or making some muscular movement before speaking. Dr Grant was very aware that, for these patients, ‘The more he strives the less he is able to succeed’ (Grant in RSM, 1916: xxxviii).

Simulated surgery and spinal taps under anaesthesia (the patient believing it to be a surgical treatment) were not infrequently performed by German doctors (Eckart, 2000). Dr Ninian Bruce, attending a blind Gallipoli survivor, explained that the eye had not been injured but was weak; he advised the man that he would give a series of (normal saline) injections to the temple which would restore the sight of the eye, and indeed they did (Bruce, 1916). Henri Claude apparently used intraspinal injections of stovaine (a local anaesthetic agent) for cases of hysterical dysbasia with contractures (Southard, 1919: 778–9). Arthur Hurst reported three cases of hysterical deafness who were advised to undergo an ‘operation’ which was certain to cure the condition. Aroused by a small dose of ether, two small cuts were made behind one ear, and a hammer was banged on a sheet of iron; hearing was miraculously restored (Hurst, 1917). Suggestive interventions could also be augmented by lumbar puncture. Early in the war the French doctor Paul Ravaut treated a man injured in a mine explosion, who was diagnosed with shell shock. The soldier did not appear to understand questions, his stare was fixed, he complained of violent headaches, jumped in response to the slightest noise, and was only able to mutter a few incomprehensible words. A lumbar puncture showed a very slight excess of albumin, and the man’s headache disappeared; he started speaking and understanding again within a few days. Ravaut, possibly incorrectly, attributed his recovery to the psychological benefit of the lumbar puncture (Southard, 1919: 693)

Hypnotic recovery

Hypnosis was used extensively, especially at the beginning of the war, but its use was discontinued by most physicians on account of the frequent relapses and otherwise indefinite results. William Brown was an early British practitioner of hypnosis in the trenches. He stated, from his experience with 5000–6000 cases of shell shock, that cases of hysteria were easily hypnotized, particularly immediately after the onset of symptoms, whereas neurasthenia cases were not. He used hypnosis in only a small number of the cases he attended: 17.3% and 13.2% respectively in two series of 1000 patients. For early cases of functional amnesia, mutism, deafness, tremulousness and paralysis, Brown found light hypnosis useful, provided it was used in conjunction with suggestion and abreaction. He emphasized that hypnosis was only a component of treatment, and not the complete treatment (Brown, 1918, 1920, 1920–1). Another British enthusiast, David Eder, reported on the first 100 consecutive war-shock cases that came under his care, recuperating from the Gallipoli campaign. He claimed the complete, and very rapid, cessation of all the symptoms by suggestion under hypnosis (Eder, 1917: 128–9). Myers (1916) published his results of the 23 patients he had hypnotized, claiming that six were cured and six distinctly improved. However, eight of his cases could not be hypnotized and three showed no improvement, thus Myers cautioned that hypnosis was only the first step in preparation and facilitation of the path towards complete recovery, although there was a tendency for subsequent relapse. Grafton Elliot Smith was in agreement that hypnosis in the early stages of hysteria was useful in the preparation and facilitation of the therapeutic path, but rarely was it sufficient treatment. However, it could help by quickly breaking down the resistances and thus paving the way for re-education and psychological analysis (Smith and Pear, 1917: 38–9).

The most prominent of the practitioners of hypnosis in the trenches was the Hamburg neurologist Max Nonne, who claimed to have treated 1600 German military hysterics during the war, thus gaining a national reputation for his quick and dramatic cures (Lerner, 1998). This magic healer travelled throughout Germany and Austria promoting his method, and even made a film of himself performing the treatments. He was credited early in the war with rediscovering hypnosis and making it an indispensable component of wartime medicine. War neurosis was considered by many German doctors to be fundamentally a disorder of will. Therefore, by taking advantage of the patient’s submissive state while hypnotized, positive willpower could be instilled to overcome the psychogenic symptoms. Nonne cultivated a stern, superior, authoritative attitude, not even bothering to gain permission from the patient. Convinced of the psychogenicity of the condition, he enforced unfailing obedience and suggested, or rather demanded, recovery. Nonne claimed excellent success rates. He concluded that 65% of his patients suffering from gross hysteria were cured or relieved of their symptoms, 29% of these within one sitting (though he subsequently amended his cure rate to 50%, only to later claim 80–90% success) (Editor (BMJ), 1917). A single session, minimal induction techniques and even the suggestive atmosphere of his clinic were all that seemed to be necessary. Nonne reported a soldier with a persisting paralysis of his right hand after a rifle shot to the forearm had healed, who was cured ‘indecently quickly’ within a single hypnotic séance (Southard, 1919: 742–3). It took him two séances to resolve the psychogenic astasia-abasia of another patient (p. 747), though many colleagues found they were incapable of producing his rapid and reliable results. Nonne continued to practice, train other doctors and promote his instantaneous cures, but he was criticized by some other practitioners, including Simmel (1921), for ‘violating (raping) the psyche’, and they doubted the ability of hypnosis to sustain a cure. Germany’s health officials became concerned about the nation’s slip into moral collapse, the mass hysteria induced by stage hypnosis, and the alleged dangers of public demonstrations of hypnosis (Lerner, 1998). The French were categorically opposed to the use of hypnosis as a treatment of war neurotics. Its association with occult and unscientific practices at the turn of the century led to a prohibition against its use in its army (Roudebush, 2001). Russian authorities also looked with disfavour on hypnosis, though it was occasionally used (Southard, 1919: 740). The Americans never used hypnosis on the Western Front (Bailey, 1918). As the war progressed, the medical use of therapeutic hypnosis declined.

Fright and startle induced recovery

Phylogenetic theories concerning evolutionary responses to fear were well recognized at the time (Loughran, 2007). Roussy and Lhermitte (1917: xxviii) maintained that the emotional reaction registered and hysterical symptoms did not become manifest until after a place of safety had been found. Only after survival did the instinct of self-preservation lose its inhibiting or restraining influence over the emotional response: ‘Then the emotion is brought back to the mind’ and the associated fear symptoms such as tremor and mutism are fixated by an individual unable to contain their emotions voluntarily. The contrary was also acknowledged, and a medical journal book reviewer commented: ‘We all know that hysterical symptoms, previously rebellious to every form of treatment, disappear in the moment of peril: the paralytic recovers movement of limbs, the dumb regains his speech, the blind his sight, etc.’ (Adams, 1918).

The London neurologist, Charlton Bastian, had noted prior to the war, in regard to hysterical mutism, that ‘Its onset is generally sudden and often after a fright or some strong emotional disturbance … Recovery may occur suddenly: perhaps after a fit or a recurrence of some strong emotion, or it may be gradual’ (Bastian, 1898: 126–7). Dr Mott had noted the trivial circumstances that could be curative, but thought the element of surprise and unconscious effort seemed essential: ‘One of the peculiarities of the functional neuroses e.g. hysteria, is not only the sudden manner in which emotional shock may cause loss of function, but likewise the sudden manner in which it may be unexpectedly restored by a stimulus of the most varied kind, provided there is an element of surprise’ (Mott, 1917). Like Bastian, Mott believed that conscious effort did not help recovery and that the more the patient wished to recover the less likely they were to do so. One of his mute patients went out of the ward and, to his surprise, met an orderly who asked him what he was doing there. The patient replied that he did not know he was doing wrong. Another patient was pitched out of a punt on New Year’s Eve, recovering his speech in this accident (Mott, 1917). The Lancet (Editor, 1915) printed an Italian correspondent’s report of a mute (and named) officer stricken absolutely dumb by a violent explosion of an Austrian grenade at his feet. Several days later King Victor Emmanuel arrived unexpectedly at the hospital, and the lieutenant exclaimed: ‘His Majesty the King.’ This emotional shock apparently restored the paralysed function of his tongue.

Hydrotherapy was a medium in which surprise and fright could be therapeutically manipulated. Cold douching was a relatively easily orchestrated strategy. Roussy and Boisseau commented that suggestion afforded by a cold shower may ‘act quasi miraculously’ (Southard, 1919: 688–9). This method of shock could be cruel and abusive.

Alterations of consciousness inducing recovery

Manipulating the level of consciousness, either by surreptitious alcohol use or anaesthesia, were reported occasionally to be effective. The Canadian Dr A.P. Procter described a soldier buried in a dug-out at Ypres who suffered hearing and speech difficulties necessitating his repatriation. He was at times resistant to nourishment, and remained in bed until allowed to visit the village where he became intoxicated and ‘found his voice’ (Procter, 1915). The BMJ (Anon., 1916) reported a case of mutism who after two weeks of symptoms was given work in the local vineyard. This involved plenty of wine to drink and hard work. His speech suddenly returned (Southard, 1919: 683). Another soldier, who had been partially buried by a mine explosion, had subsequently lost his hearing and voice. His speech returned after a day of ‘making merry with friends’ while on leave, and later he recovered his hearing under the influence of an ether anaesthetic (Dawson, 1916).

On occasions, anaesthesia could be curative. Abraham (1917) detailed the case of a private, who was rendered paraplegic when a shell burst near him. It was noted that when he was under nitrous oxide anaesthesia his legs moved, and on arousing he was told of this; he gradually regained movement. Procter (1915) also reported the cases of two aphasic soldiers who, during the stage of excitement of an ether anaesthetic, were successfully encouraged to speak. Smyly (1917), in Ireland, documented an ether cure and commented that the patients’ dumbness had not previously responded to the removing of teeth without an anaesthetic. Ninian Bruce (1916) induced a slight loss of consciousness in cases of deafness and mutism, and then suddenly aroused the patient to the realization that he was speaking. He reckoned that ether was better than chloroform for this purpose, suggesting that the recovery from chloroform was too slow. Milligan (1916) reported that, after chloroform administration but before the involuntary struggling stage, there was a period when the patient was believed to be highly susceptible to suggestion. In this state of light anaesthesia and impressionability, suggestive techniques were pursued. But there were critics, such as Colin Russel who disapproved of anaesthesia on the grounds that it made no attempt to establish genuine pathogenesis and that these cases had a tendency to recur (Southard, 1919: 775).

Adjunctive mechanical methods

It was widely accepted that some form of physical stimulus encouraged suggestive and persuasive psychotherapies. The Parisian neurologist Felix Babinski stated ‘We cannot fight hysteria in trench warfare; manoeuvres are necessary’ (Southard, 1919: 723). He considered it advisable ‘to strike their imagination by employing a material method as well [as persuasion]’ (Babinski and Froment, 1918: 228). Wilfred Harris cured persistent hysterical sciatica of nine months’ duration in a soldier who had become wet during the retreat from Mons and developed hip pain. Within five minutes of the application of strong faradism, applied by a small electrode of wire brush to the moistened skin, sufficient for the patient to feel it and ‘break down the psychical auto-suggestion which produces the hysterical anaesthesia’, the soldier was able to run across the room (Southard 1919: 785). According to Harris (1915: 121), verbal suggestion in the presence of the paraphernalia of machines and the mystery of electricity was a necessary component of the treatment. The English pioneer of electrotherapy, W.J. Turrell, believed that ‘One or two vigorous (electrical) séances’ resulted in speedy cures of particularly those who had lost all power in their lower limbs. This treatment ‘convinces them that they still retained some contractile power in their muscles and they could soon stand and walk without support’ (Turrell, 1916). The French method of faradism, which was carried out by the physician alone, involved the patient lying naked on a bed in a recumbent position (then progressively in sitting, standing, walking and running positions). Initially, a feeble current was passed through a spool of fine wool to the affected parts of the skin surface, such as the limbs, the ears, the scrotum, or the sole of foot. As the current was increased, the spools were replaced by revolving cylinders and then a metal brush. This might be continued for several hours until the patient was finally ‘mastered’. Some required only two, perhaps three, séances (Roussy and Lhermitte, 1917: 159–71). Success with a single psycho-electric treatment was reported for a French territorial soldier suffering a disorder of gait and camptocormia (Southard, 1919: 795), and another report by Morestin claimed absolute success in the treatment of mutism by applying a faradic current to the pharynx simultaneously with a signal given to the patient to make an effort to pronounce the letter A (p. 723).

Dundas Grant did not support the use of violent treatment measures of mutism, such as faradism, at least in the early stages of the disorder (RSM, 1916). But as the war progressed and the psychological casualties mounted, the medical profession, particularly those attending the chronic and seemingly intractable cases, opted for more desperate measures to elicit quick cures of the damaged soldiers. The real target of electrotherapies and adjunctive mechanical methods became not the symptom, but the patient’s will. The practitioners appealed to the honour, duty and moral of their patient (Leed, 1979: 175).

Persuasive recovery

Unlike suggestion, persuasion psychotherapy depended on clear logical reason. The concept, originally formulated by Paul Dubois (1847–1918), was a highly rational and cognitive philosophy which involved tugging the patient towards betterment. The goal was for the patient to regain self-control. It was enthusiastically adopted by Dejerine, who elaborated it by highlighting that, in order for the patient to accept a reasoned explanation, he required to be in an emotional, trusting relationship with the doctor. Roussy, Boisseau and d’Oelenitz (1918: 13) described the method as used by the French: first, the patient was prepared by being instructed that he was curable and sure to be cured; next he was treated at the right moment by persuasion, eked out if necessary with faradization; finally the cure thus affected was fixed or consolidated. Dr Lortat-Jacobs reported that he had obtained good results in Paris with shell-shocked soldiers merely by appealing to the ‘individual’s sense of honour and by publically administering an oath’ (quoted in Dercum, 1919). It was a method not entirely counter to the authoritarian military style of enforcing obedience. Dr Hurst at Seale Hayne Hospital in Devon treated chronic bent back (camptocormia) of soldiers within hours, and on one occasion within a quarter-of-an-hour, by means of persuasion and re-education. He abandoned hypnosis, electricity, massage and plaster jackets as treatment options, relying on psychotherapy alone. He merely explained the posture was ‘bad habit’, introduced some relaxation and straightening exercises with a ‘back board’, and gave firm reassurance (Hurst, 1918).

Persuasive techniques became a standard component of shell-shock treatment regimes. The History of the Great War acknowledged that ‘For complete treatment (of hysteria), the strong “suggestion” of recovery must merge into persuasion, and this finally into methods of re-education’ (Macpherson et al., 1923: 35). It noted that very little harm could be done at this stage, even by misapplied forceful persuasion to a non-responsive case; in comparison with the stress of actual battle, the most forceful methods of persuasion or suggestion were negligible as regards their capacity for producing any deleterious results. Physical cruelty was used to augment verbal persuasion. Dr Mott recalled a private who was going to pick up a wounded comrade when a shell came and blew his comrade to pieces. The private recovered consciousness within half-an-hour but found he was deaf and dumb. Some weeks later in hospital his fellow- soldiers adopted energetic measures to make him shout out for help by leathering him with a slipper and nearly throttling him. He struggled and shouted ‘help’. Another was tied down and his feet tickled until he spoke (Mott in RSM, 1916: xvii). William Bailey, a British psychiatrist, commented that the infliction of pain was permissible, on condition that it happened during a war fought to preserve and defend civilization (Leed, 1979: 169). The administration of a painful stimulus in association with shouted commands, isolation, restricted diet and a promise of relief upon abandonment of symptoms was practised by the doctors of all the belligerent nations. Suspicions of malingering encouraged aggressive treatments. Dr Ferrand, who attended an infantryman with hysterical contractures after a wound to his calf, ‘brutally conquered’ and re-educated him by means of fatigue induced by violent exercises (Southard, 1919: 788–9).

Electricity was considered the most powerful agent to stimulate nerves. In hospitals in France, Germany and Great Britain, electricity would become a tool of torture (with therapeutic intent). The modalities for applying the electric current were refined, culminating in the invention by the French neurologist Clovis Vincent (1879 –1947) of torpillage (Tatu, Bogousslavsky, Moulin and Chopard, 2010). Torpedoing, or torpillage, was a term chosen by the soldiers because they likened the electrical part of Vincent’s therapy to being hit by a shell. It was a radical extension of an approach used in peacetime. Vincent viewed the treatment as a battle, the doctor needing to be the victor, though he did recognize that during the painful phase the soldiers would shout and insult the doctor. He claimed spectacular results. Similar treatments were being practised in Germany, Austria and Britain. The ‘Kaufmann technique’ in Austria consisted of four components: first, the patient was informed that the treatment would be painful, but successful; second, the patient experienced a series of painful sensations caused by electricity, followed by physical exercises; third, military subordination was enforced; and fourth, the doctor’s conviction that treatment, once started, would not be terminated before a complete remission of symptoms was achieved, for if the doctor relented the symptoms would become fixed and irreversible. Referring to a case of dysbasia treated in six weeks by this method, it was described as a ‘highly logical and brutal method’ (Southard, 1919: 792–3). The Überrumplung (hustling) technique in Germany raised the same issues, as did the ‘Quick cure’ or ‘Queen Square’ practised by Drs Adrian and Yealland in London.

Although a great many cures were effected, there was a high frequency of relapse, a number committed suicide, and at least two patients died during Kaufmann treatment. In France, Vincent had a physical altercation with a patient, culminating in public proceedings, and Roussy was faced with more and more intractable cases and soldiers refusing treatment. The general public supported the patients’ right to refuse treatment, and this overcame the all-powerful medical and paternalistic right to impose treatment – likewise in the Axis nations, where the psychoanalyst Ernst Simmel said ‘They make a torture of the treatment in order to make the neurotic “flee into health”’ (Simmel, 1921: 43). Freud, in his capacity as an expert witness at the enquiry regarding the electrical treatments administered by Professor Wagner-Jauregg, acknowledged the brilliant results to begin with, but conceded that the results were not lasting and, when under fire again, the soldier’s fear of electric current receded, just as during the treatment his fear of active service had faded (Freud, 1955: 214).

Other abrupt treatments could also be draconian. A doctor at Maghull Hospital, near Liverpool, introduced an apparently invariably successful treatment for (functional) limb contractures (Reeve, 1917). Reeve’s treatment by fatigue involved the forced extension of contracted limbs by two attendants (or relays of men) over several hours, and sometimes several days. A man who had been shot through the forearm required six hours of forcible extension of his fixed flexed (bent) fingers, without interruption, until the fingers could be straightened. Another case, that of a bruised back in shell-burst causing thigh adductor muscle spasms and contractures, required forced separation of his legs by attendants for four hours a day on three consecutive days before the spasm was fully reduced. In cases of mutism, Dr O’Malley manipulated the larynx. A corporal had lost his voice after a bullet had passed through his neck and larynx. Examination revealed no intralaryngeal lesion. The tip of the tongue was held, and the patient was asked to say ‘e’ or cough, while a laryngeal mirror was forced into the larynx, producing a protective reflex and retching; speech rapidly followed (O’Malley, 1916). The most dramatic procedure may have been that devised for the treatment of functional aphasia by Dr O. Muck, an Essen neurologist. An instrument with a little ball at the top was shoved into the patient’s larynx, and suffocation was threatened: ‘The result was a moment of fright, in which the patient held his breathe, relaxed his tongue and let out a scream.’ Genuine healing could only be achieved by producing real anxiety, according to Muck (Eckart, 2000: 144–5). Reputedly, if faradism was not available, a Dr Garel gave a vigorous and sudden blow to the epigastrium, simultaneously with the patient’s endeavour to imitate the movement of the doctor’s lips (Southard, 1919: 723–4).

Alarmed by reports of deaths and serious injuries, doctors and the public became increasingly concerned about the misuse and abuse of aversive or ‘active treatments’, and doctors in Germany and elsewhere were directed to perform them with more moderation (Lerner, 2003). By 1918 the use of brutal faradization had gradually disappeared.

Discussion

After the cessation of hostilities, the Editor of The Lancet commented on the many ‘in vogue’, diverse and extravagant claims of efficacy of the treatments for hysteria. Noting that the vast majority of war cases were of a comparatively simple type, of relatively short duration, and with causation uncomplicated by the elusiveness of an unconscious motive, he thought it likely that the cures would persist, contrary to the experience of civilian cases of hysteria. Agreeing with Briquet’s prognostic opinions, and accepting the role of psychogenicity in the perpetuation of symptoms, he also admitted that in chronic cases ‘active trophic changes may take place, from disuse mainly’. Acknowledging that hysterical fugues, fits and alternating personalities were more difficult to treat, the Editor proposed that the essence of all the treatments was the influencing of the mind of the sufferer, predominantly by suggestion (Editor (Lancet), 1919). It is not possible to determine the precise therapeutic efficacy of abrupt treatments. Babinski considered that, when combined with isolation, they were far superior to slower psychotherapies, whether the disease was recent or old (Babinski and Froment, 1918: 226). The History of the Great War commented that, on the whole, hysterical cases did well on being returned to duty, but conceded those with generalized coarse tremors or hysterical walk did poorly in contrast to those suffering mutism (Macpherson et al., 1923: 44). Dr Mott claimed that in only one instance had he been unable, by suggestion or other means, to restore function in those with mutism and mutism with deafness (and this case was subsequently cured by Dr Yealland) (Mott, 1917). The majority of chronic psychiatric cases post-war were neurasthenic and not hysterical cases. This is a reflection of the relative numbers of the respective cases seen in the field, but might also affirm that generally the prognosis of hysteria was encouraging. As clinicians have long recognized, spontaneous recovery, perhaps facilitated by suggestion and the addressing of health anxieties, alleviates acute conversion symptoms in many, if not most. But Dr Buzzard left unanswered whether or not sudden cures lasted (Yealland, 1918: vii).

The more intriguing cases are those in which alterations of the level of consciousness (by fatigue or intoxication), the manipulating of survival mechanisms, or facilitating surprise or startle, appear relevant, for these may implicate psychophysiological mechanisms. Although he was unable to find an anatomical lesion to account for hysteria, Charcot had tried to marry the psychological with the physical, believing that hysteria was primarily a neurological (or physical) disorder (Goetz, Bonduelle and Gelfand, 1995: 201). He proposed that the event initiating the illness was a physical blow, and that the emotional and ideational accompaniment to the event carried the pathogenic charge and evoked the symptoms (Micale, 1995: 123–6). Sudden fear or fright was, Charcot maintained, the most potent pathogenic factor. He postulated that this created ‘an intense cerebral commotion’ which caused an ‘obnubilation of consciousness’ and a ‘dissociation of the ego’ (Micale, 1995: 123–6; White, 1997). Drawing functional analogies between this mental state and states of drunkenness and drug intoxication, causing a weakening of mental capacity, allowed Charcot to ‘graft’ a psychological vulnerability onto a background of a prior physical lesion (White, 1997). Charcot’s enduring, but contested, legacy was his insistence upon dual organic and psychological aetiological causation of hysterical conversion symptoms.

Alterations of levels of consciousness, such as drunkenness and anaesthesia, expose a vulnerable and pliable nervous system. The shell-shock doctors believed this state could be therapeutically influenced by suggestion and an ‘atmosphere of cure’. Survival reflexes overwhelm the conscious state. Automatic physiological activity overrides the ‘will’ and ensures fight, flight, submissive and immobilization reactions. Rivers (1922: 52–60) and Kretschmer (1960: 1–20) both hypothesized that some conversion symptoms were re-enactments of these motor responses. A component, albeit a cruel one, of some abrupt cures was to induce survival reflexes by the creation of a potentially fatal condition. Torpillage and Muck’s therapies were undoubtedly associated with risk to life. In this regressed state, the brain and mind may be receptive to adaptive influences, such as commands to function ‘normally’. Landis and Hunt (1939) demonstrated that associated with a startle response is a short period of neurological silence as the system is rebooted into a survival response. During this moment, a naked neurological system may also be vulnerable to impression, and potentially healthy suggestion. The abnormal plasticity induced by persisting conversion symptoms may then be reversed and replaced by normal, or previous, functioning.

The putative mechanisms of these methods may have relevance to the current understanding and management of pseudo-neurological conversion disorders (or Functional Neurological Symptom Disorder in DSM-5). The ethics of modern medical practice would not allow many of the abrupt manoeuvres advocated by Babinski and others to treat conversion symptoms. Consent was not an issue in those desperate times. Pure psychogenicity of conversion symptoms, a relic of Freudian theory, is increasingly disputed. A comprehensive alternative understanding of conversion disorders remains elusive. However, the considerable disability associated with conversion disorders, and our ineffective treatment of persisting symptoms, raises the question of whether or not some of the World War I methods could be adapted safely and without an apparent loss of effectiveness.