Introduction
A discussion of shell shock, whether in books, neurology journals and especially television documentaries, is rarely complete without reference to a twenty six minute film, War Neuroses, by the physician Arthur Hurst, who worked at Netley in Hampshire and Seale Hayne in Devon (Figure 1). Both in medical papers and in this pioneering movie, he made dramatic therapeutic claims. The film showed serviceman, mostly with functional motor disorders receiving treatment with miraculous results: limps were cured, and fixed contractures removed often at a single sitting. Hurst’s methods and claims of successful treatment have been both feted and doubted ever since by clinicians, historians and television and radio programme makers. In a semi-fictional BBC Radio 4 radio series, Home Front, and a BBC TV documentary, Hurst was portrayed as a secretive and deceptive purveyor of temporary symptom removal, in contrast to those who might seek to understand the psychological processes of injured soldiers.1 These debates have often mirrored arguments about whether psychological or physical therapies are most appropriate for functional motor disorders. Concerns have also been expressed about the veracity of some of the footage and a lack of follow up data.
Figure 1 Arthur Hurst (1879–1944)
The rationale for a re-evaluation of Hurst
In the last 15 years there has been a renaissance of clinical and research interest in functional neurological disorder (FND). Some of the treatment initiatives that have developed over this time bear resemblance to those employed by Hurst and other First World War physicians.2 These include a diagnosis based on positive physical signs, rather than a diagnosis of exclusion, and education of the patient about the condition with reference to the nervous system as well as psychological processes. Hurst also championed the use of physiotherapy in a context of re-education, arguably a cognitive behavioural approach, which he combined with occupational therapy in the context of multidisciplinary inpatient rehabilitation. These treatment modalities appear to offer promise for functional neurological disorders in recent randomised trials.3,4
In 1918, the Medical Research Committee had supplied Hurst with ’skilled clerical assistance in tracing and recording the after histories of functional neurological cases’ treated at Seale Hayne.5 Yet, no follow up study was published, and any data that had been collected has not survived. As a result, unless an archive of Hurst’s cases is discovered, it is unlikely that a definitive outcome study will ever be conducted. However, various attempts have been made to trace the histories of Hurst’s patients. In this paper we consider outcome data from his ’in house’ journal, Seale Hayne Neurological Studies (SHNS), and new case studies researched by Raymond Bartlett and Richard Whiteaway, in preparation for a centenary re-examination of Hurst’s work at Seale Hayne.
Within the context of new contemporary approaches, we seek to reassess the treatments offered by Hurst to servicemen with shell shock characterised by functional movement disorders (FMD). This paper explores whether he and other neurologists were exaggerating cures, simply removing symptoms without treating the cause, as suggested by military psychiatrists, or whether Hurst and others had gained new insights into these disorders and their treatment that had a meaningful impact on patient care.
The treatment techniques of Hurst – education and suggestion
Hurst included shots of soldiers before and after treatment in his film War Neuroses to demonstrate recovery. He also included extended sequences of rehabilitation, including graduated exercise, occupation therapy in the form of farming and basketwork, while earlier footage shot at Netley showed physical manipulation and the use of hypnosis to resolve tics.7 In his academic papers, especially in SHNS, written after the end of the war, Hurst described the key ingredients of the treatment regime: ’our method begins with a full explanation of the cause of the symptoms in a language suited to the patient’s intelligence and degree of education, followed by persuasion and re-education, combined in most cases with manipulation, which doubtless acts to some extent by suggestion’.8 The explanation had specific content as Hurst wrote, ’during the whole course of treatment he [the soldier patient] is engaged in conversation and the meaning of each successive step is shown and explained’.9 For example, Private M, who had experienced a paralysed leg for nearly two years, wrote in his diary for 20 February 1918 that ’foot examined, Major Hurst showed me how to move it. I can now walk like a drunken man. All I now require is practice and confidence’. His subsequent recovery was maintained at the point of publication in July 1918.10
The role of suggestion in the therapeutic process was highlighted in the 1944 edition of Hurst’s Medical Diseases of War: ’directly the patient is admitted, the sister encourages him to believe that he will be cured as soon as the doctor has time to see him…. The medical officer… tells him as a matter of course that he will be cured the next day. The patient is made to understand that any treatment he has already received has prepared the way, so that nothing now remains but a properly directed effort on his part for a complete recovery to take place’.11
In a presentation to the Royal Society of Medicine in March 1918, Hurst added that they had only used ’such aids to suggestion as electricity and etherisation in exceptional cases, being convinced that it is greatly to the advantage of the patient that he should co-operate intelligently in his own cure… Our method can be shortly described as vigorous persuasion with the aid of manipulation’.12 William Johnson, who had been Hurst’s chief clinical assistant in neurology at Guy’s Hospital before the war, was an author of the chapter on war neuroses in the official Medical History of the War (1923) and had been supplied by Hurst with statistical data.13,14 Johnson wrote, ’in the cases marked by tremors special measures were needed’. An ’atmosphere of cure’ was established in wards and a new patient shown ’other men rapidly recovering from conditions similar to his own’.15 Having identified suggestion as the key therapeutic agent, Johnson argued that ’the personality of the medical officer is always of greater importance than the particular method. The more convincing the medical officer, the less often should he have to resort to such devices for reinforcing his suggestion as the practice of light hypnosis or application of mild currents of faradism…. For complete treatment, the strong “suggestion” of recovery must merge into persuasion and this finally into methods of re-education, which must include psychic as well as physical measures’.
The idea of using suggestion to treat FMD was not new. Whilst Charcot had observed that functional movement disorders could be both produced and removed under hypnosis, it was his pupil, Babinski, who argued that such symptoms could be effectively treated by targeted suggestion. In a paper delivered to the Neurological Society in Paris in 1901, he sought, although failed, to replace the term ’hysteria’ by ’pithiatism’ meaning curable by persuasion.17 Hurst owed an intellectual debt to Babinski. In 1907 as a Radcliffe Fellow, he had studied in Paris and there, twice a week, attended Babinski’s outpatient clinic at La Pitié Hospital. ’I have ever since been profoundly grateful,’ Hurst subsequently wrote, ’for the insight he gave me in the causes, recognition and treatment of hysteria’.18 Babinski’s ideas had informed the setting up of a network of military neurological centres in 1915.19 They were crystallised in his 1917 book, Hysteria or Pithiatism and Reflex Nervous Disorders in the Neurology of War, written with Jules Froment which was translated into English in the following year.20 Other clinicians including Gustave Roussy and Jules Boisseau in Salins-les-Bains and Clovis Vincent in Tours developed similar treatment centres to Hurst with many features in common with Seale Hayne: isolation from other hospitals, a picturesque location distant from the battlefields and a charismatic senior clinician.
The treatment techniques of Hurst – rehabilitation
In his film and writings Hurst was explicit that treatment did not end with improvement or removal of the motor symptom. Indeed, he emphasised that in chronic cases further rehabilitation was necessary. For example, someone with longstanding ‘hysterical’ paraplegia needed to be ’made to walk, perform exercises whilst lying and sitting, and swing his legs… for at least a quarter of an hour three times a day. Exercise on a rowing machine or tricycle is also useful’.21 In SHNS, physical therapies were described in detail, including the graded use of physiotherapy to restore movement and balance, a practice that mirrors treatment recommendations made in the last ten years by experienced practitioners.2 Speech and language therapy for acquired functional stuttering was described using long treatment sessions combined with breathing and education classes run by Hurst’s wife.
Occupational therapy was a core feature of treatment at Seale Hayne. Some patients worked on the farm, and took part in basket making, drawing, painting and making clay models (Figure 2). Others were clerks or assisted with the production of Hurst’s medical journal. War Neuroses depicts group exercises as well as a military enactment, the ’Battle of Seale Hayne’. Lieutenant Rupert Lee, an officer patient, had trained at the Slade School of Art and was admitted with tremor and anxiety. He commented, ’I liked Hurst very much and was able to help him by organising and conducting an orchestra and running a model making workshop and generally organising things for patients to do’.22 After discharge, Lee had a successful career as an artist although continued to experience nightmares for the rest of his life. Hurst was not alone in developing rehabilitation programmes. Frederick Mott, author of the term ’atmosphere of cure’, introduced carpentry classes, choral singing, social events and turned the Maudsley Hospital grounds into a market garden with a poultry house to supplement the War Office diet.23
Figure 2 Stills from the film War Neuroses demonstrating recovery of Percy Meek (top row) and Private Pudmore (bottom row). The film also focused on the importance of occupational therapy such as basketwork and work on Seale Hayne farm. Hurst is the medical officer examining Meek’s right ankle
