By the time Dr Montagu Lomax wrote The Experiences of An Asylum Doctor (1) in 1921, the campaign for lunacy reform had been ongoing for over half a century. There had been some successes such as the 1890 Lunacy Act, designed to reduce the number of unregulated madhouses. However, little had been achieved to improve living conditions for pauper lunatics in the asylums. This was partly because the campaigners were often ex-patients as in the Alleged Lunatics Friend Society, so had little status, and partly because psychiatrists were resistant to change. Dr Lionel Weatherly published his ‘Plea for The Insane’ in 1918. This book was aimed at the medical profession and was largely ignored. Lomax’s book was written for the public. His writing style was clear, and direct, perhaps with an overtone of sensationalism. However, it could be understood by any lay person and more importantly, by members of the Press. The book set in motion a wave of public outrage.
Cleverly, Lomax keyed into public concern over the treatment of shell shocked soldiers. He wrote about the plight of these young men who had been sent back from the trenches with shattered minds only to find themselves incarcerated within the lunatic asylums. Lomax allied himself with the Ex-Services Welfare Society (ESWS), and was a guest speaker at a number of the Society’s public meetings. The aim of the ESWS was to raise public awareness and funds to help these veterans, some 5000 of whom were still in the asylums five years after the end of the war. Lomax was a good public orator and the national press reported his speeches. The wave of public outrage became a tsunami.
It is worth considering what a diagnosis of ‘shell shock’ meant. On 12 December 1914, the British Medical Journal published an article on functional paralysis following shell explosions (2). The author noted that although there was no obvious physical injury, the proximity to explosions was seen as a causative factor and from the winter of 1914/15 ‘Shell Shock’ became a valid medical diagnosis (2).
There was a running debate between the top psychiatrists of the day as to whether the diverse collection of signs and symptoms which contributed to the diagnosis of shell shock were functional (psychological) or had an organic (physical) origin. The psychiatrist, Dr Frederick Mott noted the presence of microscopic brain hemorrhages in post mortems of men with shell shock, and hypothesised that the condition was due to blast trauma. This lead him to believe that shell shock had an organic cause (3). The Maudsley psychiatrists believed that shell shock was due to a breakdown of psychological mechanisms. Doctors could find no identifiable organic pathology in 38% of admissions for shell shock (2). This dichotomy between psychodynamic and physiological explanations for shell shock was never resolved (3). There was however a military classification which attempted to distinguish between men who were physically damaged, categorised as ‘Shell Shock (Wounded)’ and a second category of ‘Shell Shock (Sick)’ (4). The Shell shock (W) cases were entitled to a wound stripe and a pension. If a soldier’s neurosis did not follow a shell explosion, he was to be labelled Shell shock (S) and was not entitled to a wound strip or pension. Many of the 306 British soldiers shot for cowardice would probably have fallen into this latter category, now recognised as Post Traumatic Stress Disorder (PTSD).
At the start of the Great War, the military hospitals absorbed psychologically damaged men, who could be treated by specialist doctors without the stigma of certification. As the war progressed, casualty number rose and young soldiers with shell shock were increasingly shunted into the County Asylums (4). Estimates vary, but one study found 63% of shell shock cases in 1916 were placed within the asylum system (3). These men were officially classified as private patients, so that their fees were paid by the government, but their private status was effectively meaningless in times of war and carried no special privileges for the soldiers. The asylums were understaffed, and overcrowded with patient food reported as ‘starvation rations’ (5). The asylum medical staff were overworked, and had no facilities or specialist skills to treat broken soldiers. For those young men who weren’t insane, there was a significant risk that they would be made insane by their surroundings.
For relatives, there was a very real stigma to having a soldier son in a County Asylum. The asylums were viewed as the domain of the pauper lunatic. Admission was by ‘certification’ under the 1890 Lunacy Act, and a certified pauper lunatic in the family carried with it great shame. This was partly because poverty was a frightening spectre for the working class, but also because of the strongly hereditarian discourse of mental health which dominated through the 1920s (4).
Towards the end of the war, the British public were growing increasingly uneasy that ex-soldiers were being treated as ‘ordinary lunatics’ (4). The Ex-Services Welfare Society (ESWS) was founded in 1919 to support the ex-servicemen who were effectively trapped within the County Asylum system. The aim of the Society was to set up residential homes for traumatised veterans so that they could be released from the totally unsuitable environs of the lunatic asylums. It was an ambitious project which required enormous financial input. Fundraising and a prominent public profile was therefore crucial to the success of the ESWS. The Society appointed Captain Charles Loseby, to speak on its behalf. He was a lawyer by training and had a distinguished military service record. As an MP between 1918 to 1922, he concentrated on veteran welfare, eventually taking a keen interest in the plight of shell shocked veterans detained within the lunatic asylums. He took the ESWS under his wing, organising and speaking at a number of public meetings on their behalf. Dr Montagu Lomax used the ESWS public platforms as an opportunity to drive forward his case for lunacy reform. Unfortunately, the ESWS’s association with the campaign for lunacy reform was subsequently viewed as controversial, and after a series of financial scandals, the Society’s supporters quietly distanced themselves. By the mid 1920s, the British Legion had assumed responsibility for much of the practical support required by veterans including liaison with the Ministry of Pensions, and the ESWS was sidelined.
It is heartbreaking to read Lomax’s account of the shell shocked soldiers in his book The Experiences of An Asylum Doctor. Men such as these were usually ‘other ranks’, whilst the officer class with shell shock were sent to exclusive military hospitals such as Craiglockhart. For the interested reader, Pat Barker’s Regeneration trilogy portrays shell shock amongst the officer class at Craiglockhart.
1. Lomax M. The experiences of an asylum doctor : with suggestions for asylum and lunacy law reform. [S.l.]: Allen and Unwin; 1921.
2. Linden SC, Jones E. ‘Shell shock’ revisited: an examination of the case records of the National Hospital in London. Med Hist. 2014;58(4):519-45.
3. Jones E. Shell shock at Maghull and the Maudsley: models of psychological medicine in the UK. J Hist Med Allied Sci. 2010;65(3):368-95.
4. Reid F. Broken Men: Shell Shock, Treatment And Recovery In Britain 1914-30: Bloomsbury Publishing; 2011.
5. Crammer JL. Extraordinary deaths of asylum inpatients during the 1914-1918 war. Med Hist. 1992;36(4):430-41.