Abstract
Shell-shock has been well examined in literary and wartime works although marginalized in post-war studies into the experience of British Army veterans of the Great War. Attention to the history of the Ministry of Pensions, the British governmental department created to provide for disabled British ex-servicemen, complicates previous criticisms of the department and its supposed inactivity in rehabilitating the mentally ill veteran. Initial attempts to treat the mentally ill veteran were progressive and innovative. However, financial stringency imposed by the British Treasury undermined the Ministry of Pensions’ efforts to cure the shell-shocked veteran as did wider societal attitudes which stigmatized the mentally ill.
Introduction
In Britain, shell-shock remains a culturally and historically resonant symbol of the First World War. 1 Shell-shocked British servicemen have continuously featured in memoirs, novels, and poems. Famous post-war memoirs of shell-shocked ex-servicemen such as Robert Graves and Siegfried Sassoon have influenced the condition’s significance. 2 Pat Barker’s critically and commercially successful Regeneration trilogy only served to reinforce shell-shock as an integral cultural reference point. This popular narrative has arguably been damaging to the historiography; these literary works focus primarily on the officer class, which has led the working-class Private’s torment to be comparatively obscured despite their sizeable majority. 3 It was only in 2002 that Peter Leese offered the first post-war analysis of the shell-shocked veteran’s experience in Shell Shock: Traumatic Neurosis and the British Soldiers of the First World War. While the importance of Leese’s work is undeniable, in a review of this work, Roger Cooter forecast, ‘The final section of the sufferers’ post-war experiences still retains a freshness, though an emergent literature on veterans and state pensions may soon overtake it.’ 4 This ‘emergent literature’ has not been forthcoming. Peter Barham’s work, for example, mainly addresses the post-war experiences of insane English Great War veterans whose mental condition saw them admitted into the post-war asylums. 5 Fiona Reid’s wide-ranging study, Broken Men: Shell-Shock, Treatment and Recovery in Britain, 1914–1930, addresses shell-shock at the Front, the post-war reintegration of traumatized pensioners, the treatment of insane Great War veterans in the asylum, and the role of charities in assisting these men. 6 Reviewing Reid’s work, Jason Crouthamel subsequently claimed ‘the history of mental illness is … still a developing field, and one of the areas that begs more research is the experience of traumatized men after 1918’. 7 It is this ‘developing field’ to which this article contributes.
Any analysis of the disabled Great War veteran faces significant methodological problems. Few physically disabled ex-servicemen left sources commenting upon their experiences. 8 This problem was manifested for those mentally disabled as a result of war service. In the legacy of Victorian masculinity, mental breakdown carried a significant taboo, silencing the articulation of suffering. 9 Consequently, periodic episodes of mental illness would have frequently occurred during the interwar years but were unrecorded. 10 Wendy Holden thus argues, ‘the medical consequences of severe trauma to the moral and mental state on the battle lines were, it seemed, unquantifiable … [and] incalculable’. 11 Holden’s assertion that these men’s post-war experience can only be conjectured is incorrect. This article does not profess to tell the complete story of these men’s lives. Nevertheless, this case study of the Ministry of Pensions, the department which determined policy to help diagnose, treat, and provide a weekly pension to the mentally disabled pensioner, will demonstrate that the post-war lives of the shell-shocked non-officer veteran are neither silent nor untraceable. 12 This article will disrupt previous assertions that the psychoneurotic First World War veteran was forgotten and abandoned by the British state. For example, during the interwar period, Sir Frederick Milner, President of the Ex-Servicemen’s Welfare Society, held psycho-neurotic casualties were the ‘class the government had done the least for’. 13 Such pessimistic discourse directed at the Ministry of Pensions echoes contemporary research into the treatment of the physically disabled ex-service community. 14 While the treatment of mentally disabled First World War veterans during the interwar period may appear unfavourable by contemporary standards, the Ministry’s policy and procedure were more progressive and accommodating than previously considered.
This article ultimately seeks to locate itself within the broader historiographical discussion of whether the First World War was a watershed moment in British society. 15 Influential works by the likes of Paul Fussell have argued the Great War presented a ‘yawning gap’ between pre- and postmodernity eras in Britain. 16 Research has since countered such a thesis by emphasizing the continuities evident in Britain before and after the war. 17 In addition to debates as to whether the global conflict marked a break from the past and ushered in gender equality, working-class rights, and the expansion of the British electorate, a similar disagreement has occurred regarding the ‘goodness’ of the war for medicine in British society. 18 Shell-shock features in this debate. Martin Stone contended that the First World War revolutionized the perception and treatment of mental illness thus legitimizing psychoneuroses into the mainstream of medical culture and ushering in critical progressive reforms. 19 Leading researchers of military psychiatry resolutely dispute this optimistic account. Instead, they counter that the emergence of shell-shock had little impact on civilian and military psychiatry in the United Kingdom and any initial progress quickly evaporated in the aftermath of the conflict. 20 The reality lies somewhere in-between these two opposing theses.
For the first time, the state properly recognized mentally ill ex-servicemen alongside their physically disabled ex-comrades. With regard to medical treatment and financial compensation, the policy and procedure of the Ministry of Pensions surpassed comparative treatment provided to mentally ill civilians, British Army veterans of prior conflicts, First World War veterans who returned to other combatant nations, and similarly afflicted Irish veterans of its revolutionary conflicts. This progression, however, coexisted with continued widespread stigma and discrimination attached to mental illness. While appearing contradictory, these inconsistencies are neither random nor unexplainable. Instead, they need to be interpreted as a concept. As previous research has referenced the paradigm-shifting nature of the First World War on British society, so too was there an entrenchment of Victorian and Edwardian narratives. A study of the mentally ill Great War veteran provides another example of simultaneous change and continuity in UK society in the aftermath of the First World War. 21
‘Crest of a Wave’: Ministry of Pensions’ Policy, 1914–21
Leading researchers of military psychiatry, Edgar Jones and Simon Wessely, write that ‘the idea that soldiers could suffer psychological damage in action was barely acknowledged’ at the start of the twentieth century. 22 It was not until the First World War that the extent war service could have on the nervous and mental system of a soldier was properly recognized. 23 English psychologist Charles Myers officially coined the expression ‘shell-shock’ in a Lancet article published in February 1915. Having worked with a medical unit within the British Army in France, Myers later admitted he did not invent the term, indicating that it had already arisen in popular usage amongst front-line British soldiers. 24 Myers quickly realized the diagnosis was an ‘ill-chosen’ and ‘harmful’ term. Rather than being a result of a shell explosion or ‘shock’, for example, a soldier often required treatment due to a steady mental and nervous breakdown over time owing to the appalling and demoralizing nature of trench warfare. 25 With the shelving of the problematic ‘shell-shock’ terminology, the diagnosis of neurasthenia dominated the medical nomenclature. Like shell-shock, the diagnosis was incredibly broad and included a variety of neuropsychiatric symptoms. 26 By 1921, an estimated 65,000 ex-servicemen were receiving a pension for neurasthenia in the UK. 27 An analysis of the pension files of neurasthenic Great War veterans demonstrates that they experienced a host of subjective symptoms including anxiety, nightmares, insomnia, constipation, irritability, headaches, tremulous limbs, depression, and weight-loss. 28
In catering for the neurasthenic veteran, the first challenge facing the Ministry of Pensions was that of assessment. At the turn of the last century, psychiatry had negligible influence on military medicine before the First World War. 29 This standing start led to a dearth of medico-pensions officials with expertise and knowledge of psychoneurotic conditions to work on Medical Boards to assess ex-servicemen for pensions and make recommendations for treatment. As a result, a hasty process of training staff to carry out such duties ensued. 30 Even authors who published on war-induced neuroses had little experience or knowledge of the subject. 31 Once a system of assessment was produced, interpreting subjective psychiatric symptoms was difficult. One Ministry of Pensions’ official who assessed a neurasthenic pensioner, for example, commented that the assessment of neurasthenia was ‘largely a matter of personal opinion’. 32 Another British military doctor assessed, ‘The symptoms themselves are hardly ever the same twice over.’ 33 An overview of the Ministry of Pensions clarified the problems of treating neurasthenic pensioners:
The diagnosis and treatment of cases of neurosis and psychosis needed much more time, skill and patience. In their more acute forms these conditions presented many novel features, and amidst the various theories and therapeutic suggestions it was difficult at the outset to decide on the most effective form of treatment.’ 34
Despite such challenges, the department established a system of assessment. Unlike many physical disabilities, where pension payments generally followed much more objectively verifiable guidelines, pensions for neurasthenia were dependant on the severity of the ex-serviceman’s psychoneurotic condition (see Table 1). In addition to a weekly pension, treatment for neurasthenic pensioners was confined to specialist Ministry centres. 35
Pension scale and payment in accordance with neurasthenic pensioners’ condition with comparative objective disabilities. 36
As with devising assessment, the Ministry of Pensions had to overcome a lack of experience to establish suitable treatment facilities to cater for the neurasthenic pensioner. Before the First World War, the Lunacy Act of 1890 facilitated discharge from the army, certification, and a transferal to an asylum where British Army veterans shared the ignominy and stigma associated with pauper lunacy.
37
The lack of treatment available in the district asylum was recognized by the Ministry of Pensions who regarded these facilities as a ‘cemetery of hopeless cases’.
38
In contrast, the ‘Country House Scheme’, established during the First World War, involved private residences in rural locations donated to the Ministry of Pensions to provide pensioners up to three months of recuperation.
39
These facilities were a continuation of treatment offered during the First World War stemming from the Maghull War Hospital providing psychoanalytic and occupational therapy.
40
The Commanding Officer of Maghull, R.G. Rows, affirmed it was the first military institution to provide ‘definitive teaching in mental illnesses and [where] psycho-therapy was given’.
41
He expanded on the treatment offered: The work of this hospital, therefore had been directed to: – (1) Explaining to the patient the mechanism concerned in mental processes. (2) Discovering the incident or series of incidents on which the disturbance depends. (3) Educating the patient so that he may see the relation of cause and effect between the incident and the associated emotional state in his own case – may be enabled to regard it from a fresh and broader point of view, and so be led to face his problem to solve it.
42
The treatment loosely resembles what would today be labelled Cognitive Behavioural Therapy (CBT), which encourages patients to adjust their thought processes when suffering from ailments such as anxiety and depression, rationalizing negative thoughts and increasing the regularity and magnitude of positive ones. 43 Citing transnational research, both Grafton Elliot Smith and Thomas Pear held that the opportunity for individual and intensive care over a sustained period prevented men’s mental condition from deteriorating. 44 They believed that the treatment represented ‘a great experiment in preventative medicine’, which demonstrated ‘conclusively that the exercise of scientific care during the early phases of mental disorder would save many from such a complete breakdown as would necessitate certification and removal to an asylum’. 45 One patient’s testimony affirmed the benefits of such treatment, with one remarking, ‘I understand now; it is not my muscles which require treatment so much as the mind.’ 46 The treatment offered by staff such as Rivers, Smith, and Pear was described by the Maghull’s Hospital’s Committee as having ‘produced an enormous improvement … the patients now highly appreciate the value of the attention paid to them’. 47 With such instances in mind, the Commanding Officer of Maghull attested that it ‘demonstrates the value of explaining the origin of the disability to the patient. Many have said that they have been able to overcome slight returns of the disability by remembering the explanations that had been given to them.’ 48
The Ministry founded a teaching facility headed by Rows for its medical staff. Practitioners utilized dream analysis, ‘talking therapy’, and hypnosis in the Ministry’s in-patient and out-patient facilities.
49
Ministry facilities, therefore, offered a rare opportunity for the early treatment of mental symptoms. Smith and Pear observed: In our own country, mental disorder is seldom treated in its early stages. Nearly all our elaborate public machinery for dealing with this distressing form of illness is devised, and in practice is available, only for the advanced cases.
50
The perception of the treatable neurasthenic was a far cry from pre-1914 perceptions. 51 Ministry in-patient and out-patient facilities sought to treat neurasthenic pensioners, who were able to admit and discharge themselves from such facilities voluntarily, ‘at the earliest opportunity’. 52 In-patient treatment was provided for ‘chronic cases’ and offered a dual form of therapy: psychotherapy and occupational treatment. 53 Out-patient facilities treated neurasthenic pensioners who had a ‘promising prognosis’, and the treatment, which focused primarily on psychotherapy, was considered beneficial within a 16-week timeframe. 54 Unlike those under treatment in an asylum, who were believed to be a ‘burden on the nation’, Ministry facilities were reserved for ‘nerve shattered soldiers’. Here, there was a focus on ‘immediate action being taken by which these poor men may be treated, and be re-equipped for a fresh start in life’. 55 Such facilities were very much part of the Ministry of Pensions’ philosophy of ‘reconstruction’ which sought to facilitate the full-time employment of a disabled ex-serviceman post-discharge. 56
By 1921, the Ministry established 20 exclusive in-patient facilities and 48 out-patient clinics. Some 3,314 men were receiving in-patient treatment and 9,467 were receiving out-patient treatment throughout the United Kingdom. 57 Unfortunately, in the absence of surviving institutional records, it remains very difficult to verify how individual pensioners responded to in-patient and out-patient treatment. 58 Nevertheless, like the soldier-patient who received treatment in Maghull, it appears that some neurasthenic pensioners benefited from the treatment provided. For example, one neurological expert working for the Ministry of Pensions believed a ‘distinct and definitive reduction’ of a pensioner’s neurasthenic condition ‘was possible’. 59
These Ministry facilities were established at a time when the treatment of mental illness outside of the asylum was very much in its infancy in interwar Britain.
60
As a prominent Minister of Pensions official wrote in 1921: The matter is, as you know well, far from being a simple one, and the present circumstances of the country do not make it any easier. We have been in touch with the best and most eminent opinion of the civil medical profession on the subject for the last four years, and are constantly taking the best specialist’s advice. One difficulty is that the profession itself has come to no final or static view on the subject, and I believe I am right in saying that in comparatively recent times, very various opinions have held the field in turn.
61
While psychoanalysts operated in Britain before 1914, their presence has been equated to a ‘toehold’. The majority of the medical establishment, including asylum superintendents, largely dismissed psychotherapy. 62 As one psychiatrist wrote in 1917, ‘At present, broadly speaking, no person unable to pay its cost can receive adequate treatment until he is certified as of unsound mind.’ 63 The chance for a working-class former ‘Tommy’ to receive costly and personal psychotherapeutic treatment from a trained specialist was, therefore, largely restricted to Ministry establishments. 64
Regardless, the lack of previous medical experience to draw on complicated treatment policy amongst medical officials. Leading neurological specialists working for the Ministry concluded at a conference in 1921: A general discussion ensued on this point and it was agreed that no definitive medical standard could be laid down as to requirements of treatment. Some DCsMS had attempted to work on such a basis but had found it impracticable for it was quite possible that a man with 80% disability was incapable of receiving any further improvement by treatment, While a man with 5% or 10% might be completely cured by appropriate treatment, it was therefore necessary to deal with each case on its merits.
65
By contrast, the treatment of physical ailments often proved more objective and uncomplicated with repair and renewal of artificial limbs and glass eyes and the cleaning and dressing of flared-up wounds providing the bulk of medical treatment provided. 66 The Ministry also had a body of pre-1914 medical practice to draw upon including, for example, many physical disabilities. Previous research into the Ministry of Pensions’ orthopaedic facilities available to physically disabled veterans has also demonstrated that its staff drew extensively on their prior experience of caring for disabled children and those disabled by industrial employment. 67 In addition, the infrastructure to cater to Great War veterans suffering from Pulmonary Tuberculosis was already established owing to its frequency in pre-war British society. As a result, there was close cooperation between the Ministry of Pensions, the Ministry of Health, and local authorities, with funding borne by public funds, to treat ex-servicemen in existent civil sanatoriums. 68 Thus, Lisle Webb, the Ministry’s Director General for Medical Services, described the neurasthenic pensioner as ‘one of the most difficult’ aspects within the department’s entire jurisdiction. He believed difficulties were inevitable as it was a process of ‘getting experience’. 69 The difficulties facing the Ministry of Pensions, and the department’s initial establishment of assessment methods and treatment facilities, deserves better recognition than it has thus far been afforded. As Julie Anderson avers, ‘for the most part, mending the body, even if the disability was permanent, was often easier than curing the mind’. 70
The Therapeutic Importance of Employment
The novel and progressive facilities established for the neurasthenic pensioner did not cater for demand. In 1921, despite the Ministry of Pensions allocating 2,670 beds for neurasthenics, there was still a shortcoming of 787 beds. 71 One Ministry of Pensions’ official described this as ‘deplorably inadequate in most regions and is causing grave harm’. 72 The lack of facilities also impacted upon standards with hasty and short-term treatment being carried out to accommodate more pensioners. 73 Another pressing problem was the socio-economic reception of neurasthenic pensioners outside institutional facilities which compromised the effectiveness of the Ministry’s scheme. The therapeutic importance of employment was endorsed during the conflict and in its immediate aftermath by medical research, politicians, senior civil servants, and Ministry of Pensions’ medical staff. 74 Dr John Harry Hebb, who would become the Ministry’s Director General of Medical Services for most of the 1920s and 1930s, wrote that ‘more and more we have become convinced that the work factor is the all-important one with the Neurasthenic’. 75 When employment was available on a pensioner’s discharge, in-patient treatment ‘proved very successful’ in the recovery of neurasthenic pensioners. 76 One widely read self-help publication for neurasthenic Great War veterans, published in 1917, emphasized the importance of work to give men focus and distract them from their condition. 77 Indeed, waiting-list figures for in-patient and out-patient neurasthenic treatment were lowest in Northern England and Wales amongst the 11 district regions administered by the Ministry of Pensions in the United Kingdom. By way of an explanation, Ministry officials held that a large proportion of ex-servicemen worked in the mining industry and were better able to attain employment. 78 This relationship between employability and neurasthenia had transnational reach. For example, at a conference held in Ottawa in December 1936, 22 psychiatrists and neurologists working for the Canadian pension authorities concluded that a ‘social investigation’ of a pensioner’s or claimant’s region was often crucial in inducing or aggravating neurasthenic symptoms. 79
Research into National Health Insurance Records during the interwar period demonstrates that unemployment and mental ill-health were intrinsically linked in British society.
80
This phenomenon has modern-day relevance. Contemporary research into US Army veterans of campaigns in Iraq and Afghanistan has supposed that unemployed veterans may be inclined to incorrectly attribute their feelings of depression, anxiety, and helplessness to Post-Traumatic Stress Disorder (PTSD).
81
Allan Young has equated this phenomenon to ‘method acting’, contending that ex-servicemen experience genuine psychological symptoms but without these being attributable to war service.
82
Thus, while recognizing that PTSD is not an ahistorical condition, there is a fascinating correlation between unemployment and neurasthenia cited by Pensions’ staff during the interwar period.
83
One Ministry of Pensions official, for example, noted the ‘vicious circle’ a neurasthenic pensioner often found himself in where ‘economic stress’ had a detrimental impact on a veteran’s symptoms.
84
The Ministry of Pensions’ neurological expert, Dr E.L. Forward, provides a clear explanation of this socio-psychological reaction: They are of the opinion that the bulk of the cases now being treated are of genuine War Neurosis, but that economic conditions such as unemployment etc., have enhanced the strain under which these men are living and probably rendering these patients worse than they otherwise might have been. It is difficult, if not impossible, to say where the one cause ends and the other begins.
85
A report into neurasthenic pensioners in Scotland also stated that widespread unemployment in Glasgow ensured that a ‘secondary economic neurasthenia’ arose as a result of unemployment and the accompanying financial stress. 86 Indeed, a small number of neurasthenic pensioners were diagnosed as ‘cases due to social and family conditions and financial distress developing subsequent to war service’. 87
An engagement with research methods encouraged in the burgeoning field of disability history is illuminating. Disability historians have argued that disability is not only medically and administratively defined but socially structured. Thus, wider public perceptions and cultural values shape the treatment and experiences of disabled people in past societies. 88 A recognition of this broader context further magnifies the insurmountable challenge facing the Ministry of Pensions in rehabilitating the neurasthenic pensioner during the interwar period. Contemporary prejudices directed towards the mentally ill contradicted the Ministry’s emphasis on the therapeutic importance of medical treatment and employment. Unlike obvious war-induced disabilities such as missing limbs and gunshot wounds, those suffering from psychological ailments were adversely affected by the disputed origin of their disability with notions of hereditary deficiencies and degeneration remaining prevalent in British society during this period. 89 Jones and Wessely argue that ‘there was considerable stigma attached to any form of mental illness’ during the period regardless of its explanation. 90
A transnational study produced by the Red Cross, published in 1919, disregarded medical treatment, pension payments, and employment and instead stated: a necessary feature of any program for restoring the disabled soldier to self-respect and self-support is a campaign of public education to convert the general attitude towards the crippled and handicapped.
In Britain, there was a ‘signal failure to appreciate the value of public education’ to change perceptions of those disabled as a result of war service. 91 This problem was seemingly manifested for those suffering from a psychiatric illness. In The Future of the Disabled Soldier (1917), certain disabilities were believed to be suited for specific occupations. For example, blind pensioners were deemed suitable to be basket-makers; deaf veterans were believed to be appropriate for tailoring; pensioners suffering from tuberculosis were thought to be suited to being golf caddies. By comparison, no career was seemingly appropriate for the mentally ill veteran. 92 Operating in this prejudicial context, the Regional Director for the West Midlands region stated that occupational treatment proved fruitless as ‘difficulty is experienced with the employers, who are often unwilling to accept men after they had heard details of their disability’. 93 Eustace Percy, MP for Hastings, and the future Parliamentary Secretary to the Ministry of Health, held that neurasthenic pensioners carefully avoided alerting contemporaries to their condition: ‘Each becomes a cause celebre in his district … Notoriety … preys on his mind.’ 94 A regional case study of ‘South Ireland’ magnifies the difficulties that these long-standing societal prejudices had on the neurasthenic pensioner.
Between 1919 and 1921, ‘South Ireland’ was in the midst of the Anglo–Irish War between British forces and the Irish Republican Army. During such an irregular period, the region lacked investment and infrastructure to facilitate investment employment opportunities. As a result, waiting lists for in-patient and out-patient treatment for neurasthenia in the region were the highest in the UK. 95 Nevertheless, on inspecting ‘South Ireland’, Forward downplayed the necessity of increasing facilities. He believed that ‘no amount of psychotherapy’ could alleviate the ‘super-imposed anxiety’ of unemployment owing to the conditions in the region. This observation is important. While the dearth of treatment facilities was unfortunate, Forward felt that the decisive factor was the experience of neurasthenic pensioners outside departmental facilities. Forward reasoned that the Ministry of Pensions would achieve little in increasing facilities to cater for neurasthenic pensioners in the region due to the existing socio-economic and political climate. 96 The situation in ‘South Ireland’ amplifies more extensive institutional problems. The dearth of employment opportunities, influenced by cultural values and the existing social stigma, served to undermine the innovative treatment policy the Ministry of Pensions pursued.
There was a desire within the Ministry of Pensions to increase the availability of resources. In June 1920, the Ministry requested an increase of 7,000 beds to provide in-patient facilities for various disabilities and to accommodate the 9,797 pensioners awaiting treatment. The British Treasury declined the department’s appeal to finance the policy because ‘it is common knowledge that Civil Hospitals are urgently in need of funds and that wards are being closed in many parts of the country’. 97 It was the British government’s wariness to set a precedent and initiate demands to increase and improve civilian medical facilities that prevented the increase of Pensions’ facilities. The reply to the Ministry’s request for an increase of in-patient facilities affirmed, ‘In these circumstances it appears indefensible that any Government Department should acquire and equip new hospital accommodation of its own.’ 98 The Ministry’s demands led to a more modest increase in facilities to cater for a further 1,800 in-patients. 99 This restriction on Ministry requirements is important. The initial post-war years have been described as ‘the crest of the wave’ of the Ministry of Pensions’ treatment policy. 100 However, the Treasury’s desire for a reduction in financial outlay became further magnified during the depression of the early 1920s. This economic imperative brought a curtain down on the Ministry’s novel and progressive infrastructure.
‘Pension them off and leave them alone’: Ministry of Pensions’ Policy, 1922–36
In 1921, the British Treasury wrote to all pensions departments urging austere economic policies. In 1921, the outlay of medical costs stood at almost £15,000,000 with this annual figure shrinking to £1,600,000 by 1930. Overall spending for the department was reduced from £106,600,000 in 1921 to £54,100,000 in 1930. A reduction in medical facilities induced the saving. While 332,000 disabled pensioners were undergoing treatment in 1921, this figure stood at just 41,000 by 1930. 101 There was a similar decline in national staff from 21,685 central and local employees in 1921, reduced to just 3,795 one decade later. 102 These restrictions were an ingredient of the infamous ‘Geddes’ axe’ which enforced a host of tax increases and economic cutbacks in the public sector. 103 Coinciding with this reduction in financial and medical resources dedicated to war-induced psychoneuroses, was the fading out of ‘shell-shock’ from the mainstream medical discourse. 104 These cut-backs in financial, medical, and discursive resources impacted on neurasthenic pensioners. Between 1925 and 1930, the Ministry reduced institutions treating neurasthenic pensioners from 15 to 7. Subsequently, pensioners undergoing treatment decreased (see Table 2).
Numbers of neurasthenic pensioners receiving in-patient and out-patient treatment in the UK, 1921–30. 105
The Ministry’s own records attest to their administration being ‘very carefully watched’ post-1921 with a constant desire for economy placed on their operations. 106 The impact the Treasury’s austere philosophy had on the availability of in-patient facilities is evidenced in the correspondence between H. Sugars, Commissioner of Medical Services in South Ireland, and Webb. In May 1921, the former’s request for Leopardstown Hospital in Dublin to be increased by 200 beds was turned down by the latter who stressed that the finances were not available and wrote, ‘although the provision of accommodation for neurasthenics is an urgent and indeed a vital one, still we have to balance this necessity with the economic and financial conditions of the country’. 107 Such instances buttress previous research which concludes that underfunding fatally compromised Ministry facilities. 108 It was noted that public sentiment regarded the Ministry of Pensions as bureaucratic, unsympathetic, and miserly. Nevertheless, even historians critical of the Ministry accept that the department faced the unenviable task of being sandwiched between public scorn for their perceived meanness and constant restriction from the Treasury. 109
Importantly, however, despite their highly stigmatized position, these cut-backs did not single out the mentally ill ex-service community. The reduction of available treatment facilities for disabled pensioners was a universal experience regardless of ailment. Jay Winter has previously claimed that shell-shock provides a cultural metaphor for the war itself. 110 Shell-shock’s aptness as a metaphor also extends to the Ministry of Pensions’ policy and procedure regarding rehabilitation and compensation. Initial innovative and progressive efforts to rehabilitate pensioners were replaced by a ‘pensioning off’ of veterans from 1921 onwards as financial stringency became the modus operandi of the Ministry of Pensions. 111
Hiding in Plain Sight: The Neurasthenic Pensioner in Civil Society
By 1935, 74,905 veterans in the United Kingdom were receiving a pension for neurasthenia. 112 Just over four hundred neurasthenic pensioners were receiving in-patient or out-patient treatment during this period. 113 The Ministry contended that the majority of those who received treatment improved during their residencies. 114 Nevertheless, the majority of neurasthenic pensioners seemingly attempted to resume civil life without receiving medical treatment for their mental illness. An analysis of one member of this ex-service community again highlights the complex and difficult situation facing the Ministry of Pensions but, also, its relatively liberal and supportive outlook. P.J. O’Ryan received a pension fluctuating between the 80 and 100 per-cent grading for neurasthenia and a gunshot wound to the leg following four years of service as a Lieutenant in the British Army on the Western Front. 115 Despite his severe mental torment, O’Ryan was seemingly able to conceal his torment from wider society.
Anxious to keep his mental illness a secret, O’Ryan had to be assured by the examining officer that the contents of the assessment would remain confidential. Sympathetically, the assessment pensions officer wrote, ‘I did not regard his perturbation as significant of malingering but rather as indicating his fear that the barrier of reserve that he had built around himself was to be broken down’. The inspecting officer was ‘satisfied that he is in a highly unstable mental condition although his behaviour may appear quite normal. As regards actual Neurasthenia there are few signs.’ O’Ryan was not totally incapacitated by his condition as he was able to drive himself to one board meeting unattended ‘and was obviously quite accustomed to this sort of thing’. 116
Percy believed that these attempts to reintegrate into civil society were fraught with difficulty. He held that a pensioner’s life would be disrupted due to ‘the almost invariably intermittent character of symptoms’. This also made it increasingly difficult for medical staff to assess pensioners accurately and recommend adequate treatment. 117 Percy’s observation was evident in O’Ryan’s pension file. For example, previous conceptions of shell-shock, where sufferers were associated with a ‘powerless femininity’, were evident. 118 One inspection on 22 August 1932 described O’Ryan having a ‘complexion and appearance rather feminine’. In contrast, another report, written six years later, defined him as having a ‘gentlemanly appearance’. The fluctuating descriptions of O’Ryan were dictated by his well-being during assessment. During one inspection in March 1933, a more composed O’Ryan told officials his neurasthenic ‘feelings come in cycles’. A Board’s report one year previous noted his ‘attention, intelligence concentration and memory [were] up to normal standard’. This fairly tranquil state, however, relied on a conversation matter unrelated to his condition. 119 Arguing ‘the men feel that they are being suspected and analysed and investigated and re-investigated’, Percy believed the repeated medical board’s assessment of veterans to decipher pension rates had an adverse impact on a pensioner’s mental condition. 120 Again, Percy’s criticisms are evident in O’Ryan’s pension reports. One report noted that he exhibited ‘morbid flushing, which can be produced merely by looking steadily at him when questioning him’. During another assessment, it was noticed that O’Ryan ‘broke down during examination and wept profusely’. 121 It remains impossible to ascertain the extent O’Ryan’s experience correlated with the wider neurasthenic community in the UK. In many ways, the everyday lives of mentally disabled veterans remain a hidden history. 122 The contrasting descriptions of O’Ryan during the interwar period portray a man with little evidence of progress or recovery. 123 Percy stated, ‘the state is spending large sums of money on these cases with no result whatsoever’. As such, he attested that ‘the Ministry’s present policy is definitely wrong’. Yet, Percy had little idea as to what policy was ‘definitely right’ conceding ‘at the present the only common-sense treatment is to pension them off and leave them alone’. 124 This is the policy the Ministry followed.
Joanna Bourke argues that British neurasthenic veterans of the Great War gained little from the shell-shock episode. 125 This thesis underplays the significant and novel financial compensation and, albeit limited, psychodynamic outlook available to a previously unacknowledged community. As has been demonstrated, the treatment was heavily reduced as a result of Treasury pressure. The Ministry of Pensions were even sympathetic to neurasthenics addicted to alcohol. Official correspondence recorded, ‘alcoholism may rightly often be regarded as a symptom of mental instability’. As a result, alcoholic neurasthenics were not uniformly penalized for their addiction even if it potentially worsened their condition. 126 In addition, during the economic Depression of the 1920s and 1930s, pension rates for all disabled pensioners in Britain, including the mentally ill, remained unchanged despite cutbacks in unemployment benefits and a reduction in wages for government employees. 127 Contextualizing the neurasthenic British Great War veteran with similarly afflicted veterans of contemporary conflicts and those who returned to other combatant nations further magnifies the liberality of the Ministry of Pensions.
Other Wars and Transnational Comparatives
The opportunity to receive equitable financial compensation and medical treatment for war-induced neuroses was not available to British Army veterans of previous conflicts. 128 Such recompense was also not a transnational experience. While the majority of combating nations pensioned psychoneurotic veterans, France did not. Previous research into the French experience of post-war trauma highlights that state, society, and even veterans themselves saw the mentally ill as a separate and less-deserving community of disabled ex-servicemen. While substantial pension outlays and medical infrastructure were implemented to cater for physically disabled veterans, there was little inclination to provide similar treatment to the mentally disabled veteran. Unlike their former comrades who were physically disabled as a result of war service, mentally ill veterans were not provided free consultation, examination, and boarding to help demonstrate that their disability was attributable to war service; received no free state-aided medical and pharmaceutical care; and faced almost insurmountable challenges to prove to pension authorities that their condition was war-related. 129 The situation in Germany was more complicated. Despite generous pensions and rehabilitative assistance offered by the Weimar government, mentally ill veterans were singled out by the Nazi regime whose doctrine of degeneration and hereditary traits influenced their decision to retract their pensionable status in the mid-1930s. 130 Soldiers who served in the respective Dominion Forces were eligible for disability pensions and treatment by their national governments under administrative infrastructures broadly similar to that offered by the Ministry of Pensions in Britain. 131 However, this was not universal. There were no special provisions for neurasthenic pensioners in the Union of South Africa. Pensioners were, instead, sent to Military Hospitals which offered little in the form of specialist psychotherapeutic treatment. Advanced cases were admitted into nursing homes or underfunded, cheerless and poorly run mental hospitals with little expectation of recovery. 132
The post-Armistice boundary changes in the Balkan states, and their cessation from the Austro-Hungarian Empire, had a detrimental impact on mentally disabled veterans residing in affected regions. With a reduction in social insurance from the late 1920s onwards to cater for these communities in newly formed Yugoslavia, mentally ill veterans found it increasingly difficult to receive rehabilitative treatment and compensation. 133 By contrast, the Ministry’s connection with the Irish Free State continued in the aftermath of its official establishments in 1922 following the bitter guerrilla conflict between paramilitary Irish republicans and British state forces. 134 The Ministry’s remit and infrastructure included the continued pensioning and treatment afforded to psychologically damaged veterans. 135 Regarding Ireland, the British Government’s treatment of mentally disabled Great War veterans also surpassed the Free State Government’s treatment of Irish veterans of the revolutionary conflicts. Both the Anglo–Irish War, 1919–21, and the Irish Civil War, 1922–23, caused psychoneurotic conditions amongst combatants. 136 Nonetheless, there was no equal care for mental disability under Free State pension legislation. The lack of provisions led one Irish politician to deduce in the Irish Parliament that it was ‘not an Army pension at all, but only a farcical sketch of a pension’. He further complained, ‘the British Government, as bad as it was, treated their ex-servicemen who are living in the Saorstat [Irish Free State] well’. 137 Placing the Ministry within transnational boundaries helps to foreground the progressiveness of its treatment of mentally disabled British Army veterans of the First World War.
Conclusion
This article does not seek to disprove previous research that establishes the impact that public opinion, rather than a moral obligation to the disabled veteran, had in dictating the policies of the Ministry of Pensions. 138 Nor does it deny the certain prejudices which existed within Ministry of Pensions’ officialdom. 139 It has, instead, sought to recognize better the efforts made by the British state to cater for the mentally disabled First World War veteran. The treatment of the mentally ill ex-serviceman during the interwar period must be contextualized by considering the contemporary understanding of mental illness and the broader socio-economic and cultural context. For the first time, British Army veterans suffering from psychoneurotic ailments were properly recognized, compensated, and afforded the opportunity for treatment outside the highly stigmatized asylum. Attempts to fully rehabilitate the mentally ill veteran were fatally compromised by the increasing financial stringency dictated by the British Treasury and the continuation of social stigma attaching itself to psychologically damaged veterans.
It may be that, while flawed, the efforts of the Ministry of Pensions were far more influential than has been previously assumed. In 1936, reflecting on its efforts, the Ministry of Pensions congratulated itself on being a ‘pioneer’ in the early and voluntary treatment of mentally ill citizens. 140 Indeed, citing the establishment of a small number of publicly available outpatient clinics in interwar Britain, Joanna Bourke writes, ‘the lessons learnt during this war were certainly instrumental in the growth of psychiatry as a discipline’. 141 The shell-shock episode may have influenced medical culture in Britain. For example, in the closing stages of the war, asylum staff working in nearby regional district facilities arranged for observations of the psychoanalytic treatment of soldier-patients at Maghull Hospital with the aim of learning more about the nature and extent of the treatment provided. 142 In dealing with medical conditions on a mass scale, the Ministry attested in 1930 that it had ‘unrivalled opportunities of witnessing the progress of many types of diseases’ such as neurasthenia, and had been the ‘first to blaze the trail of exploration’ in understanding causation and inducing a cure. The department further hoped the extensive medical and clinical documentation it had collected would be of value to the wider medical community. 143 During the same year, Britain’s Mental Treatment Act was passed. In addition to ‘Mental Hospitals’ displacing the stigmatized terminology of ‘District Asylum’, the legislation increased the function of out-patient treatment and allowed the voluntary admission and discharge of mentally ill patients with the aim of facilitating early treatment before a person’s condition worsened and became chronic. This article seeks to encourage the further potential that the Ministry of Pensions’ efforts discussed above had on the legislators of this national act and wider psychiatric care.
While the disparity of the Ministry of Pensions’ progressive but defective rehabilitative infrastructure, in a society continuing to hold prejudiced views towards the mentally ill veteran, appears contradictory, these inconsistencies are not random or unexplainable. Instead, they here have been interpreted as a concept. Previous research has referenced the paradigm-shifting nature of the First World War on British society. So too, however, was there an entrenchment of Victorian and Edwardian narratives which evidently proved hard to alter. The same paradoxical principles applied to the treatment and reception of mentally ill British Army veterans with both change and continuity simultaneously evident in the aftermath of the First World War.
Footnotes
Acknowledgements
The author wishes to thank Professor Diane Urquhart for her feedback and comments on previous drafts of this work.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research is the result of PhD funding provided by a University of Liverpool PhD scholarship.
1
Jay Winter, ‘Shell-Shock and the Cultural History of the Great War’, Journal of Contemporary History 35 (2000), pp. 7–11.
2
Robert Graves, Goodbye to All That (London, 1929); Siegfried Sassoon, Siegfried’s Journey, 1916–1920 (London, 1945).
3
Leading military psychiatrist researchers, Simon Wessely and Edgar Jones, went so far as to argue, ‘To an extent, shell shock was hijacked by the literary fraternity’; Edgar Jones and Simon Wessely, Shell Shock to PTSD: Military Psychiatry to the Gulf War (New York, 2005), p. 58; Peter Barham, Forgotten Lunatics of the Great War (London, 2004), p. 5.
4
Roger Cooter, ‘Review [untitled]’, Journal of Modern History 76 (2004), pp. 955–6.
5
Barham’s work has been subsequently expanded upon by Alice Brumby who analysed two British rehabilitative facilities set up in Britain for insane Great War veterans of ‘the hopeful type’. Established in annexed buildings on asylum grounds, these hospitals largely operated along mental hospital lines with ex-servicemen provided limited opportunity for recovery and discharge. The hospital was closed in 1931 with the remaining patients subsequently transferred back to civilian hospitals; Alice Brumby, ‘A painful and disagreeable position’: Rediscovering Patient Narratives and Evaluating the Difference between Policy and Experience for Institutionalized Veterans with Mental Disabilities, 1924–1931’, First World War Studies 6 (2014), pp. 37–55.
6
Fiona Reid, Broken Men: Shell Shock, Treatment and Recovery in Britain, 1914–1930 (London, 2010).
7
8
Meaghan Kowalsky, ‘Enabling the Great War: Ex-Servicemen, the Mixed Economy of Welfare and the Social Construction of Disability, 1899–1930’ (PhD thesis, University of Leeds, 2007), p. 48.
9
Reid, Broken Men, p. 5; Barham, Forgotten Lunatics of the Great War, pp. 5–6.
10
Eric Coplans, ‘Some Observations on Neurasthenia and Shell-shock’, Lancet, 31 October 1931, p. 960.
11
Wendy Holden, Shell-Shock: The Psychological Impact of the War (London, 2001), pp. 7, 66.
12
In 1931, Ministry of Pensions’ officials described its archival collection as ‘unique in character and pregnant with possibilities for research’; T.J. Mitchell and G.M. Smith, Medical Services: Casualties and Medical Statistics of the Great War (London, 1931), p. 350.
13
Joanna Bourke, ‘Review of Broken Men’, History Today (November 2010), p. 56.
14
Deborah Cohen wrote that, in comparison to the German disabled veterans’ treatment by the Weimar Republic, the disabled British Great War veteran received little in material compensation from the British government; Deborah Cohen, The War Come Home: Disabled Veterans in Britain and Germany, 1914–1939 (Berkeley, 2001).
15
A succinct overview of this literature is provided in Jessica Meyer and Alison Fell, ‘Introduction: Untold Legacies of the First World War in Britain’, War and Society 34 (2015), pp. 85–6.
16
Paul Fussell, The Great War and Modern Memory (Oxford, 1975); Samual Hynes, A War Imagined: The First World War and English Culture (New York, 1991); Eric Leed, No Man’s Land: Combat and Identity in World War I (Cambridge, 1979).
17
Adrian Gregory, The Last Great War: British Society and the First World War (Cambridge, 2008); Dan Todman, The Great War: Myth and Memory (London, 2005).
18
Roger Cooter, ‘Medicine and the Goodness of War’, Canadian Bulletin of Medical History 7 (1990), pp. 147–59.
19
Perhaps the most prominent reform was the introduction of the Mental Health Treatment Act, 1930, which allowed the mentally ill population in Britain to voluntarily admit and discharge themselves from psychiatric institutions; Martin Stone, ‘Shellshock and the Psychologists’, in The Anatomy of Madness: Essays in the History of Psychiatry. Volume 1: People and Ideas, ed. W.F. Bynum, Roy Porter and Michael Shephard (London, 1985), pp. 242–71.
20
Edgar Jones and Simon Wessely, ‘The Impact of Total War on the Practice of British Psychiatry’, in The Shadows of Total War: Europe, East Asia and the United States, 1919–1939, ed. R. Chickering and S. Förster (Cambridge, 2003), p. 129.
21
This article bolsters the so-called ‘half-way house’ theses of shell-shock offered by Mathew Thomson and Tracey Loughran; Tracey Loughran, Shell-Shock and Medical Culture in First World War Britain (Cambridge, 2017), p. 214; Mathew Thomson, Psychological Subjects: Identity, Culture and Health in Twentieth Century Britain (Oxford, 2006), p. 185; Barham, Forgotten Lunatics of the Great War, p. 325.
22
Edgar Jones and Simon Wessely, ‘Psychiatric Battle Casualties: An Intra-and Interwar Comparison’, British Journal of Psychiatry 178 (2001), p. 242.
23
Wessely and Jones, From Shell-Shock to Post-Traumatic Stress Disorder, p. 17; Barham, Forgotten Lunatics of the Great War, p. 120.
24
Charles Myers, Shell Shock in France, 1914–1918: Based on a War Diary (Cambridge, 1940), p. 11; Reid, Broken Men, p. 26.
25
Myers, Shell-Shock in France, p. 26; Stefanie Linden and Edgar Jones, “‘Shell-Shock’ Revisited: An Examination of the Case Records of the National Hospital in London’, Medical History 58 (2014), pp. 533–4.
26
Myers, Shell-Shock in France, p. 27.
27
Edgar Jones and Simon Wessely, ‘War Pensions (1900–1945): Changing Models of Psychological Understanding’, British Journal of Psychiatry 180 (2002), p. 376.
28
J.F. Connor. Nature of Disability: Neurasthenia, PIN 26/10730; Sidney O’Hara. Nature of Disability: Neurasthenia (PIN 26/22230); T. O’Brien. Nature of Disability: Neurasthenia. PIN 26/10718; A. Peel. Nature of Disability: Neurasthenia. PIN 26/11232, London, The National Archives (TNA).
29
There was negligible medical provision for mental and nervous casualties. Of the 955 beds provided at the Royal Victoria Military Hospital at Netley, for example, the ‘D Block’ provided just 125 beds for such cases.
30
Mitchell and Smith, Medical Services, p. 310.
31
Tracey Loughran, ‘Shell-shock in First World War Britain: an intellectual and medical history, c. 1860-c.1920’ (PhD Thesis, Queen Mary, University of London, 2006), pp. 32–3.
32
O’Ryan, Patrick John. Nature of Disability: Gun Shot Wound/Neurasthenia, 1918–1976, PIN 26/22244, TNA.
33
Mark Humphries and Kellen Kurchinski, ‘Rest, Relax and Get Well: A Re-conceptualisation of Great War Shell Shock Treatment’, War and Society 27 (2008), p. 92.
34
Mitchell and Smith, Medical Services, p. 341.
35
Ministry of Pensions, note, to Regional Director of All Regions, PIN 15/55, TNA.
36
Table formulated from Leese’s analysis of individual pension files in the ‘PIN 26’ collection in the National Archives; Leese, Shell-Shock, pp. 147–54.
37
Leese, Shell Shock, pp. 59, 68; Ben Shephard, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century (London, 2001), p. 6.
38
Barham, Forgotten Lunatics of the Great War, p. 327.
39
Leese, Shell-Shock, p. 62.
40
The wide-ranging psychodynamic programme adhered to at Maghull during the war is discussed in Edgar Jones, ‘Shell Shock at Maghull and the Maudsley: Models of Psychological Medicine in the UK’, Journal of the History of Medicine and Allied Sciences 65 (2010), pp. 368–395.
41
War Office, History of the Asylum War Hospitals in England and Wales (London, 1920), p. 69.
42
War Office, History of the Asylum War Hospitals, p. 71.
43
Christopher Frith and Eve Johnstone, Schizophrenia: A Very Short Introduction (Oxford, 2003), p. 143.
44
Peter Barham describes Smith and Pear as ‘progressive thinkers and practitioners’ in the field of psychoneurosis; Barham, Forgotten Lunatics of the Great War, p. 151; Grafton Elliot Smith and Thomas Pear, Shell-Shock and Its Lessons (Manchester, 1917), pp. 182–4.
45
Smith and Pear, Shell-Shock and Its Lessons, pp. 108–9.
46
War Office, History of the War Hospitals in England and Wales, p. 70.
47
The surviving medical sheets of soldier-patients admitted into the facility indicate an improvement in their condition; ‘Medical Case Sheets’, M614 MAG/1/3; Committee Minute Book, Maghull Military Hospital 7 October 1915, M614 MAG/1/1, Liverpool Record Office.
48
War Office, History of the War Hospitals in England and Wales, p. 70.
49
W.H.R. Rivers, Instinct and the Unconscious: A Contribution to a Biological Theory of Psychoneurosis (Cambridge, 1920), p. 5; Leese, Shell-Shock, p. 87; Wessely and Jones, Shell-Shock to PTSD, p. 132.
50
Barham, Forgotten Lunatics of the Great War, p. 151.
51
Ibid., p. 3.
52
Ministry of Pensions, London, to Regional Directors, Treatment of Neurasthenia, 15 October 1921, PIN 15/56, TNA.
53
Memorandum on Conference, 2; Ibid.
54
One Regional Director of a Ministry of Pensions’ out-patient clinic in Oxford stressed the role of psychopathology, and the work of Freud and Jung as heavily influencing the mode of treatment at these facilities; Jones and Wessely, Shell-Shock to PTSD, p. 12; A. Ninian Bruce, ‘The Out-patient Treatment of Early Mental Disorders: The Neurological Clinic, and Some of its Functions’, British Journal of Psychiatry 68 (1922), p. 385; Neurological Cases: Out-patient treatment with or without allowances, and Home Treatment with allowances, PIN 15/2946, TNA.
55
Recuperative Hospitals, 3 January 1917, PIN 15/53, TNA.
56
Anon., ‘Treatment of Disabled Soldiers: Work of the Ministry of Pensions’, Lancet, 16 April 1921, p. 827.
57
Ministry of Pensions Fourth Annual Report for the period 1 April 1920 to 31 March 1921, pp. 9, 32–4; Provision of Treatment for Neurasthenia, 25 November 1921, PIN 15/56, TNA.
58
There has been a lack of research into these facilities. In 1917, Smith and Pear wrote that research into their operatives was ‘urgently needed’. This request remains unheeded over a century later; Smith and Pear, Shell-Shock and Its Lessons, p. 117.
59
Ministry of Pensions, Dublin, to the Ministry of Pensions, London, 13 December 1921, PIN 15/56, TNA.
60
Of course, we know far more about how to treat mental illness today than during the period discussed in this study. For example, the use of anti-psychotic drugs is a relatively modern phenomenon; Frith and Johnstone, Schizophrenia, p. 145.
61
Ministry of Pensions note, 31 May 1921, PIN 15/55, TNA.
62
Stone, ‘Shellshock and the Psychologists’, pp. 242–3.
63
Smith and Pear, Shell-Shock and Its Lessons, p. 79.
64
Leese, Shell-Shock, p. 89; Shephard, A War of Nerves, p. 164.
65
Memorandum on Conference of Neurological D.Cs.M.S. held at Headquarters, 17 June 1921, PIN 15/56, TNA.
66
Ministry of Pensions Thirteenth Annual Report for the period for the period 1 April 1929 to 31 March 1930, p. 2; Ministry of Pensions Twenty-First Annual Report for the period 1 April 1937 to 31 March 1938, p. 8.
67
Jeffrey Reznick, Healing the Nation: Soldiers and the Culture of Caregiving in Britain during the Great War (Manchester, 2011), p. 118.
68
Ministry of Pensions Fifth Annual Report for the period 1 April 1921 to 31 March 1922, p. 13; Treasury to the Ministry of Pensions, 8 October 1918, T 136/2, TNA; Mitchell and Smith, Medical Services, p. 340.
69
Ministry of Pensions, London, to Ministry of Pensions, Dublin, 21 December 1921, PIN 15/56, TNA.
70
Julie Anderson, ‘‘Jumpy Stump’: Amputation and Trauma in the First World War’, First World War Studies 6 (2015), p. 9.
71
Memorandum on Conference of Neurological D.Cs.M.S. held at Headquarters, 17 June 1921, PIN 15/56, TNA.
72
Ethnal Shakespeare to Director General of Medical Services, London, 12 December 1919, PIN 15/55, TNA.
73
Ministry of Pensions, Dublin, to Ministry of Pensions, London, 24 November 1921, PIN 15/56, TNA.
74
Smith and Pear, Shell Shock and Its Lessons, p. 52; Jean Lepine, Mental Disorders of War (London, 1919), p. 193; HC Debates, 12 December 1922, 159, cols 2694–2855; HC Debates, 9 May 1923, 54, cols 56–62; Joanna Bourke, Dismembering the Male: Masculinity, Men’s Bodies and the Great War (London, 1999), p. 118; Leese, Shell-Shock, p. 131.
75
Ministry of Pensions, London, to Ministry of Pensions, Dublin, 21 December, 1921, PIN 15/56, TNA.
76
Ministry of Pensions Fourth Annual Report for the period 1 April 1920 to 31 March 1921, p. 9.
77
Bourke, Dismembering the Male, p. 118.
78
Memorandum on Conference of Neurological D.Cs.M.S. held at Headquarters, 17 June 1921, p. 6, PIN 15/56, TNA.
79
‘Extracts from the Report of a Conference held at Ottawa in December 1936 of a Board of Psychiatrists and Neurologists appointed by the Canadian Government’, p. 136, PIN 15/4200, TNA.
80
Noel Whiteside, ‘Counting the Cost: Sickness and Disability among Working People in an Era of Industrial Recession, 1920–39’, Economic History Review 40 (1987), pp. 228–46.
81
The financial incentive of applying for pension claims amongst unskilled ex-combatants in a time of economic depression has been similarly cited as impacting upon American and Australian veterans of the Vietnam War; Richard J. McNally and B. Christopher Freuh, ‘Why are Iraq and Afghanistan Veterans Seeking PTSD Disability Compensation at Unprecedented Rates?’ Journal of Anxiety Disorders 27 (2013), pp. 524–5.
82
Allan Young, ‘Trauma and Harm’, plenary presented to Cultures of Harm in Institutions of Care: Historical and Contemporary Perspectives, Birkbeck University, 14 April 2016.
83
See, for example, the classic text on the history of trauma and the evolution of PTSD: Allan Young, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder (Princeton, 1995).
84
Millais Cuplin, ‘The Problem of the Neurasthenic Pensioner’, British Journal of Psychology 1 (1921), p. 326.
85
Ministry of Pensions, East Midlands, to Ministry of Pensions, London, 15 November 1921, PIN 15/56, TNA.
86
Joanna Bourke, ‘Effeminacy, Ethnicity and the End of Trauma: The Sufferings of “Shell-Shocked” Men in Great Britain and Ireland’, Journal of Contemporary History 35 (2000), p. 65.
87
William Macpherson, Medical Services: Diseases of the War, vol. 2 (London, 1923), p. 58.
88
Deborah Stone, The Disabled State (Basingstoke, 1984), pp. 26–7; Paul Longmore, Why I Burned My Book and Other Essays on Disability (Philadelphia, 2003), p. 58.
89
Jessica Meyer, Men of War: Masculinity and the First World War in Britain (London, 2009), p. 97.
90
Wessely and Jones, From Shell-Shock to PTSD, p. 133.
91
Douglas McMurtrie, The Disabled Soldier (New York, 1919), p. 105.
92
C.W. Hutt, The Future of the Disabled Soldier (London, 1917), pp. 154–60.
93
Memorandum on Conference of Neurological D.Cs.M.S. held at Headquarters, 17 June 1921, p. 2, PIN 15/56, TNA.
94
Lord Eustace Percy, MP, to Ministry of Pensions, London, 19 December 1922, PIN 15/1632, TNA.
95
Joanna Bourke, ‘Shell-Shock, Psychiatry and the Irish Soldier during the First World War’, in Ireland and the Great War: ‘A War To Unite Us All?’, ed. Adrian Gregory and Senia Paseta (Manchester, 2002), pp. 155–71.
96
Provision of Employment for Ex-servicemen in Ireland, PIN 15/899, TNA.
97
Letter from the Treasury to the Ministry of Pensions, 26 June 1920, T 136/4, TNA.
98
Ibid.
99
Ministry of Pensions Fifth Annual Report for the period covering 1 April 1921 to 31 March 1922, p. 12.
100
Mitchell and Smith, Medical Services, p. 309.
101
One longer-term method by which the Ministry of Pensions achieved a more austere financial policy was in its introduction in 1921 of a seven-year time limit on disability claims and via the ‘Final Awards Scheme’. Until mid-1925, almost half a million pensioners, with around fifty per cent of these in receipt of a pension scaled at twenty per cent or less, were given a final lump sum or gratuity; Helen Bettinson, ‘“Lost Souls in the House of Restoration”? British Ex-Servicemen and War Disability Pensions, 1914–1930’ (PhD thesis, University of East Anglia, 2002), pp. 70–7, 91; Nineteenth Annual Report of the Ministry of Pensions, 1935–1936, Part Two, p. 37.
102
Expenditure of the Ministry of Pensions, PIN 15/2601, TNA.
103
Meyer, Men of War, p. 101; Andrew McDonald, ‘The Geddes Committee and the Formulation of Public Expenditure Policy, 1921–1922’, The Historical Journal 32 (1989), pp. 643–74.
104
Loughran, Shell-Shock and Medical Culture in Britain, p. 212.
105
Jones and Wessely, From Shell-Shock to PTSD, pp. 132–3.
106
‘Expenditure of the Ministry of Pensions’, PIN 15/2601, TNA.
107
H.S. Sugars to George Chrystal, 13 July 1921, PIN 15/56, TNA.
108
Bourke, Dismembering the Male, p. 122.
109
Cohen, The War Come Home, p. 26, 57.
110
Winter, ‘Shell-Shock’, p. 7.
111
This universality correlates with the research of Julie Anderson who has urged historians to resist segregating mental and physical disability when discussing the First World War veteran; Anderson, ‘Jumpy Stump’, pp. 9–19.
112
Nineteenth Annual Report of the Ministry of Pensions, 1935–1936, Part Two, p. 14.
113
Wessely and Jones, From Shell-Shock to PTSD, p. 134.
114
By this stage psychotherapy had been largely replaced by a policy of ‘hardening’ which involved physically capable in-patients working for at least six hours a day at associated workshops; Ministry of Pensions: A Report for the Year 1936/1937, p. 26, PIN 15/4200, TNA; ‘Policy and Administration of the Ministry of Pensions’, PIN 15/2601, TNA.
115
The ‘PIN 26’ series is organized by pension type and then by alphabet. With every fiftieth file kept for archival purposes, over 22,000 individual files regarding pension awards have survived, which represents just two per cent of the pensions awarded as a result of disablement. A suitable case study to utilize for the purposes of this article is difficult to extract. A former veteran of the British Army in receipt of a disability pension for both Neurasthenia and a physical disability, and which lasted for the duration of the interwar period, is applicable to just small minority of surviving files. This article is, therefore, fortunate to be able to utilize the pension files of O’Ryan, Patrick J. Nature of Disability: Gun Shot Wound/Neurasthenia, 1918–1976, PIN 26/22244, TNA.
116
O’Ryan, Patrick J. Nature of Disability: Gun Shot Wound/Neurasthenia, 1918–1976, PIN 26/22244, TNA.
117
Lord Eustace Percy, MP, to Ministry of Pensions, London, 19 December 1922, PIN 15/1632, TNA.
118
Jessica Meyer, ‘“Gladder to be going out than afraid”: Shellshock and heroic masculinity in Britain, 1914–1919’, in Uncovered Fields: Perspectives in First World War Studies, ed. J. Macleod and P. Purseigle (Leiden, 2004), p. 198; Joanna Bourke, An Intimate History of Killing: Face to Face Killing in Twentieth Century Warfare (London, 1999), p. 253.
119
O’Ryan, Patrick J. Nature of Disability: Gun Shot Wound/ Neurasthenia, 1918–1976, PIN 26/22244, TNA.
120
Lord Eustace Percy, MP, to Ministry of Pensions, London, 19 December 1922, PIN 15/1632, TNA.
121
O’Ryan, Patrick J. Nature of Disability: Gun Shot Wound/ Neurasthenia, 1918–1976, PIN 26/22244, TNA.
122
As Jay Winter encapsulates, ‘it was in homes and out of sight that their miseries were expressed’; Jay Winter, ‘Families’, in The Cambridge History of the First World War: Volume 3: Civil Society, ed. Jay Winter (Cambridge, 2014), p. 59.
123
O’Ryan was able to better recover from his gunshot wound and his physical impairment. Due to his physical wounds attained on the Western Front, O’Ryan’s initial pension records note that he was unable to walk more than five miles without experiencing pain. By 1924, however, following out-patient treatment provided by the Ministry of Pensions, O’Ryan’s physical ailments improved dramatically; he was described as looking in a ‘good physical condition’ and able to play golf; ‘Special Medical Board’ Report, PIN 26/22244, TNA.
124
‘Special Medical Board’ Report, PIN 26/22244, TNA.
125
Bourke, Dismembering the Male, p. 108.
126
‘Neurasthenia and Allied Disabilities: Memorandum for the guidance of Medical Officers’, PIN 15/2947, TNA.
127
Cohen, The War Come Home, pp. 57–8.
128
Kowalsky, ‘Enabling the Great War’, p. 34.
129
Should a French veteran’s mental illness be so severe as to require institutionalization in an asylum, a meagre pension was provided to cover their treatment; Marrie Derrien, ‘“Entrenched from Life”: The Impossible Reintegration of Traumatized French Veterans of the Great War’, in Psychological Trauma and the Legacies of the First World War, ed. Jason Crouthamel and Peter Leese (London, 2017), pp. 193–214; Gregory Thomas, Treating the Trauma of the Great War: Soldiers, Civilians, and Psychiatry in France, 1914–1940 (Louisiana, 2009), pp. 85–126.
130
Philipp Rauh, ‘Violence and Starvation in First World War Psychiatry: Origins of the National Socialist “Euthanasia”’, in Psychological Trauma and the Legacies of the First World War, ed. Crouthamel and Leese, pp. 261–86.
131
For case studies of Australia and Canada see, for example, Marina Larsson, ‘Families and Institutions for Shell-Shocked Soldiers in Australia after the First World War’, Social History of Medicine 22 (2008), pp. 97–114; Mark Humphries, ‘War’s Long Shadow: Masculinity, and the Gendered Politics of Trauma, 1914–1939’, Canadian Historical Review 91, no. 4 (2010), pp. 503–31.
132
‘Report on the General Administration of War Pensions in the Union of South Africa and on the payment of Pensions made in the Union on behalf of the Ministry of Pensions’, PIN 15/2611, TNA.
133
Heike Karge, ‘Making Sense of War Neurosis in Yugoslavia’, in Psychological Trauma and the Legacies of the First World War, ed. Crouthamel and Leese, pp. 227–30.
134
The Irish Free State, officially established in December 1922, constituted the region previously defined as ‘South Ireland’. It held a status within the British Empire akin to the Dominions of the British Empire such as Australia, Canada, and South Africa.
135
Michael Robinson, ‘‘Nobody’s Children’? The Ministry of Pensions and the Treatment of Disabled Great War Veterans in the Irish Free State, 1921–1939’, Irish Studies Review 25 (2017), pp. 316–35.
136
Bourke, ‘Effeminacy, Ethnicity and the End of Trauma’, p. 68; Dáil Éireann, 13, 11 November 1925, Volunteer’s pension claims; Dáil Éireann, 7, 16 May 1924, Clare soldier’s pension; Orduithe An Lae, 18, 25 January 1927, Orders of the day – Army Pensions (no. 2) Bill, 1926.
137
Dáil Éireann, 7, 20 May 1924, Adjournment Debate – Position of ex-servicemen.
138
Cohen, The War Come Home, p. 24.
139
For example, in addition to assumptions of malingering and degeneration, the aforementioned waiting-lists in Ireland were blamed on an apparent ‘definitive neurasthenic prevalent temperament that was prevalent amongst the South Irish’, which was a long-standing accusation in British medical discourse; Bourke, Shell-Shock, Psychiatry and the Irish soldier during the First World War, pp. 155–71.
140
Ministry of Pensions Nineteenth Annual Report for the period 1 April 1935 to 31 March 1936, p. 19.
141
Bourke, Dismembering the Male, p. 120.
142
Letter from T. Stewart Adair, Resident Medical Superintendent Asylum, Kirkburton Asylum, to Colonel Rows, Maghull Military Hospital, 1 May 1918, M614 Mag/1/3, Liverpool Record Office.
143
Ministry of Pensions Ministry Sheet, 24 June 1930; Letter from Herbert Evans to M. Roberts MP, 13 August 1930; Medical Work of Ministry: general analysis, PIN 15/65, TNA.