History of Psychiatry

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Hysteria and neurasthenia in pre-1914 British medical discourse and in histories

of shell-shock
Tracey Loughran
History of Psychiatry 2008; 19; 25
DOI: 10.1177/0957154X07077749

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History of Psychiatry, 19(1): 025–046 Copyright © 2008 SAGE Publications
(Los Angeles, London, New Delhi, and Singapore) www.sagepublications.com
[200803] DOI: 10.1177/0957154X07077749

Hysteria and neurasthenia in pre-1914

British medical discourse and in histories
of shell-shock

TRACEY LOUGHRAN*
University of Manchester

Histories of shell-shock have argued that the diagnosis was subdivided into the
categories hysteria and neurasthenia, and that the differential distribution and
treatment of these diagnoses was shaped by class and gender expectations. These
arguments depend on the presentation of hysteria and neurasthenia as opposed
constructs in British medical discourse before 1914. An analysis of the framing
of these diagnoses in British medical discourse c.1910–1914 demonstrates that
hysteria and neurasthenia, although undergoing redefinition in these years,
were closely connected through the designation of both as functional diseases,
and the role attributed to heredity in each. Before the war these diagnoses were
perceived as indicators of national decline. Continuity, as well as change, is
evident in medical responses to shell-shock.

Keywords: anxiety neurosis; degeneration; hysteria; neurasthenia; shell-

shock

Introduction
In recent years, shell-shock has been one of the hottest topics in the history of
British psychiatry. Over the last two decades a number of excellent histories
have appeared, variously situated as contributions to the history of civilian
psychiatry and attitudes to mental health (Bogacz, 1989; Merskey, 1991;
Stone, 1985); military psychiatry (Binnevald, 1997; Jones and Wessely, 2005;
Shephard, 2002); the concept of trauma (Leys, 2000; Young, 1995); and,
loosely defined, the challenge experiences of war posed to established notions

* Address for correspondence: History, School of Arts, Histories and Cultures, University of
Manchester, Samuel Alexander Building, Oxford Road, Manchester, M13 9PL, UK. Email:
[email protected]

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26 HISTORY OF PSYCHIATRY 19(1)

of identity (Barham 2004; Bourke, 1996; Showalter, 1987). These histories

have underscored the social, political and cultural importance of shell-shock,
and have added immeasurably to our understanding of how the disorder
was perceived, experienced and treated. In common with other areas of the
history of psychiatry, however, one aspect of shell-shock remains relatively
unexplored: ‘its languages of diagnosis and prognosis, its classificatory schemes,
its technological concepts, and their internal connexions and evolution’ (Porter,
1991: 278).
This paper, although it deals only indirectly with World War I, is a con-
tribution to filling this gap. It examines theories of hysteria and neurasthenia in
pre-war British medical discourse, with a particular focus on the years 1910–14.
Although hysteria and neurasthenia have generated a large secondary liter-
ature, relatively little has been written on British clinical constructions for the
period covered here (reflecting a more widespread tendency within the history
of psychiatry for the years between 1900 and the outbreak of war to be treated
as a hangover of the Victorian era). The bibliography of nearly four hundred
secondary works on hysteria provided by Mark Micale’s magisterial study of
the disorder lists only a handful of relevant items (Micale, 1995: 295–316).
Most research on neurasthenia has focussed on North America or taken a pan-
Western perspective (Drinka, 1984; Rabinbach, 1990: 146–78; Sicherman,
1977), although the relevant essays in a recent and excellent comparative col-
lection suggest that the diagnosis evolved differently in the British context
(Gijswijt-Hofstra and Porter, 2001). The discussion here has two aims: first,
to draw out some salient features of the diagnoses of hysteria and neurasthenia
in pre-1914 British medical psychology; second, to highlight chronological
shifts in the understanding of these disorders with a view to evaluating the
claim that shell-shock was a catalyst for the reorientation of approaches to
mental health.
A nuanced consideration of the diagnoses of hysteria and neurasthenia in
pre-war British medical discourse is crucial for understanding the intellectual
underpinnings of the category of shell-shock. The one aspect on which most
historians of this controversial topic are agreed is that prior to 1914 hysteria
and neurasthenia were the two main nervous disorders recognized by British
psychiatry, and that the diagnosis of shell-shock was comprised of these
categories. A complex of related and influential arguments regarding the socio-
cultural significance of shell-shock, reducible to three main strands, has been
formed on the basis of this perceived division into hysteria and neurasthenia.
The first of these is that, before the war, hysteria and neurasthenia were dif-
ferentially distributed along class lines, and that this trend continued in war-
time with officers diagnosed as neurasthenic and ranking men as hysterical
(Leed, 1979: 163–4). The second is that these were also gendered diagnoses.
The hysterical ranking soldier was seen in similar demeaning terms as hysterical
females, while the neurasthenic officer was portrayed as closer to an acceptable
male ideal (Showalter, 1987: 175). The third is that different treatments were

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T. LOUGHRAN: HYSTERIA, NEURASTHENIA AND SHELL-SHOCK 27

applied according to diagnostic label. Hysterical soldiers were punished by

disciplinary therapies, but neurasthenic officers were sympathetically treated
with ‘talking cures’ (Leed, 1979; Shephard, 1999: 35–6). These arguments
accumulate force from the historiographical construction of hysteria and
neurasthenia as separate and opposed categories, in which various dichotomies
are attached to each diagnosis: body/mind, female/male, nature/culture, lower/
upper class, ancient/modern disease. This construction is often presented as
the established background against which shell-shock can be interpreted, rather
than as an equally contestable rendering of evidence (Shephard, 2002: 8–10;
Showalter; 1993: 321–7).
The above précis is unavoidably reductive. Not all historians agree with every
aspect of this three-pronged analysis; recent scholarship has undermined each
to some degree; and the latest histories do not accord hysteria and neurasthenia
supreme prominence in their analyses. Nevertheless, because no revisionist
account has directly tackled the use of the hysteria/neurasthenia divide in
contemporary constructions of shell-shock, the sociocultural interpretations
outlined above still cast a powerful shadow over recent histories. The language
and intellectual content of diagnoses in pre-World War I British psychological
medicine are peripheral to these works. This paper suggests some ways in
which closer attention to this aspect of the history of shell-shock might alter the
established historiographical narrative, and aims to contribute to the deepened
understanding of wartime psychiatry which previous historians of shell-shock
have provided.
Hysteria and neurasthenia were staple topics for discussion in the pre-war
British medical press, and this material forms the bulk of evidence for the pre-
sent study. Neurasthenia was commented on by specialists from every branch of
the medical profession, including gynaecologists, neurologists, ophthalmologists,
paediatricians, general practitioners and private consultants. As might be
expected from such a motley crew, every shade of opinion on the definition,
aetiology, symptomatology and treatment of the disorder can be found within
the pages of these journals (Anon., 1913a; Anon., 1913b; Wilson, 1913: 1677;
also, Practitioner, special issue on neurasthenia, 1911). The situation with regard
to hysteria was similar, although with one crucial point of distinction. Although
neurasthenia was admitted to be a relatively recent and foreign invention, com-
mentators were quick to create a native body of opinion on the disorder. In
contrast, although hysteria was discussed by an equally wide cross-section of
the medical community, it was readily acknowledged that Britain had produced
‘comparatively little of an authoritative character’ on the disorder, and so most
discussions centred on the welter of psychologically-oriented theories emanat-
ing from the Continent (Anon., 1911a: 951; Ormerod, 1911: 270). In articles,
in published papers, in reports of papers received and discussed by regional
medical societies, these theories were endlessly debated (Anon., 1911b; Anon.,
1913c; Anon., 1913d; Brown, 1913a, 1913b; Fowler, 1911; Glynn, 1913; Hart,
1911; Wilson, 1911). Just before the war broke out, the Lancet ran yet another

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28 HISTORY OF PSYCHIATRY 19(1)

exposition of these theorists over three issues (Ormerod, 1914). As will be seen
presently, these discussions are essential to understanding the stance of British
medical opinion towards psychological theories, given the frequent assumption
of widespread hostility before the war forced a reconsideration of Freud.
Certain crucial aspects are, with regret, omitted in this paper: notably, class,
gender, treatment methods, and the dynamic role of the patient in shaping
diagnosis. (I have dealt with some of these aspects elsewhere: Loughran, 2006:
35–69 and 97–124.) As the aim here is to sketch out some broad areas of
medical consensus on hysteria and neurasthenia, differences between various
sections of the medical community have also largely been skated over. This is
in many respects an old-fashioned top-down approach, and one which cannot
hope to do justice to the full richness of pre-war British medical views of
hysteria and neurasthenia. However, it may be justified with the view in mind
of recreating, to some extent, the knowledge that the doctors who were to
treat shell-shock from 1914 onwards brought to their clinical encounters.
These doctors were also recruited from a remarkably wide cross-section of the
medical community, many with no previous experience of treating nervous or
psychological disorders (Loughran, 2006: 240–89). It is not unreasonable to
assume that many of these doctors, grappling with such problems for the first
time in their careers, were guided as much by general knowledge of similar
disorders garnered from the pre-war medical press, or by wide and hastily-
conducted research, as by the distinctive stance that neurology or psychiatry
(for example) had taken towards these disorders.
There are three main parts to this paper. The first examines the status of
hysteria and neurasthenia as functional disorders, arguing with reference to
British expositions of Continental theories of hysteria that the shift from a
predominantly somatic to a psychological paradigm was in evidence before
World War I. The next section demonstrates that although an inherently
ambiguous category, neurasthenia was conceived as in essence a condition
of nervous exhaustion. This is in contrast to the portrayal of neurasthenia in
most histories of shell-shock, which have conflated Pierre Janet’s psychasthenia
and a concept of anxiety neurosis derived from the later work of Freud and
W. H. R. Rivers with the symptomatic content of neurasthenia. Finally, it is
argued that hysteria and neurasthenia were conceptually linked at the aetio-
logical level through the perceived importance of heredity. Through the notion
of the ‘neurotic temperament’ the pathologies of individual and environment
were linked to discourses of nation and race. Hysteria and neurasthenia were
therefore highly charged, politicized categories on the eve of the war. These
arguments suggest that the relationship between hysteria and neurasthenia,
portrayed as opposed categories in most histories of shell-shock, must be
rethought. Moreover, as both disorders were in a state of flux in the immediately
pre-war years, with psychological and somatic elements of the diagnoses in
continual interplay, extension and retreat, the extent to which the experience of
shell-shock acted as a catalyst to modern modes of psychological understanding

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T. LOUGHRAN: HYSTERIA, NEURASTHENIA AND SHELL-SHOCK 29

must be measured with a renewed awareness that British psychological medicine

was not statically and uncompromisingly organicist before 1914, but open (in
often contradictory and always complex ways) to many different theories, ideas
and influences.

Functional disease
In pre-war British psychological medicine, hysteria and neurasthenia shared one
basic feature: both were classified as functional diseases. Functional disorder
was, according to one definition, comprised of phenomena ‘which result from
some disturbance or change in the functions of an organ without presenting any
definite organic lesion by which the disease may be distinguished’ (Hack Tuke,
1892: 518). This classification provides the key to understanding the shifting
relations of psyche and soma in conceptions of hysteria and neurasthenia before
the war. The transposition of the concept of trauma from the physical to the
psychological sphere during the late nineteenth century is now well established
(Micale and Lerner, 2001). The same process, a related event, occurred to the
concepts of hysteria and neurasthenia (Neve, 2001: 141). The category of
functional disease facilitated this development. The concept originated as a
convenient designation for disorders for which no organic cause could be found,
and thus described effects without ascribing first causes. It was therefore a
fundamentally ambiguous category (Bastian, 1893: 2). Although the dominant
somatic paradigm of British psychiatry meant that initially the first point of
reference within the concept of functional disease was the body, this ambi-
guity also provided a space within which psychological theories could develop
(or be transplanted into) when the right set of historical conditions arose. It is
therefore the necessary background against which the shifting roles attributed
to psyche and soma in hysteria and neurasthenia should be discussed.
Today, the meaning of ‘functional’ is often loosely interpreted as equivalent
to describing a disorder as ‘psychologically based’. But in the late nineteenth
and early twentieth centuries, British psychiatry lacked a purely psychological
paradigm, and so what remained when organic change had been excluded
was not automatically referred to the mind. The concept of functional disease
was predicated on the notion of an organic non-event. However, this non-
event was also positive: functional disease was defined as such by the presence
of an organic absence. The body was not merely the first, but the only point of
reference within the definition of functional disease. One way this is shown is in
the stated allegiance of British commentators to an as-yet undiscovered organic
basis for hysteria, the archetypal functional disease. In the 1890s, it was still
possible to suppose that when ‘examined by the light of improved knowledge
and experience’, many of the symptoms of hysteria would be revealed as of
organic origin (Buzzard, 1892: 1163). The optimism faded slightly in subse-
quent years, but it was still insisted that hysteria was ‘as real as smallpox or
cancer, and that it has a physical basis’, and that psychological theories were only

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30 HISTORY OF PSYCHIATRY 19(1)

a useful stop-gap measure for treating the disorder until its organic foundation
could be discovered (Ormerod, 1914: 1169; Stewart, 1906: 307; Wilson, 1911:
336–7). In the event, when improved diagnostic techniques revealed that some
of the symptoms traditionally associated with hysteria did have an organic
basis, the result was the contraction of the disorder rather than the provision
of a physical explanation for it (Micale, 1993: 504–10).
The list of disorders under the heading of functional disease in textbooks of
nervous and mental diseases also demonstrates that this category was under-
stood by reference to bodily rather than psychical processes. In one example,
we find epilepsy, chorea, tetanus, aphasia, muscular spasm, writers’ cramp,
facial hemiatrophy, exophthalmic goitre and various kinds of paralysis (Nagel,
1905: 138–90; see also Potts, 1908: 385–437). Most of this list is utterly at
odds with modern notions of functional disorder, but makes sense when placed
against the background of the predominantly somatic paradigm of pre-war
psychiatry. Functional disorder was a crucial way in which diseases that did
not fit the somatic paradigm could be understood through reference to it. This
is demonstrated in the work of Joseph Ormerod (1848–1925), a specialist in
nervous disorders with a particular interest in hysteria. Ormerod frequently took
pains to reiterate the physiological meaning of function in order to introduce and
make plausible the notion of disruption of psychological function (Ormerod,
1911: 275; 1914: 1238–9). Psychological concepts became comprehensible only
when filtered through the lens of physiological (and thus concrete, knowable
and scientifically palatable) processes.
So far, this would seem to suggest more strongly than ever that British
psychological medicine remained stubbornly, even dogmatically, wedded to
somatic explanations. Yet the example of Ormerod’s rhetorical strategy hints
at an unexpected development: perversely, the very strength of the somatic
paradigm enabled the infiltration of psychological ideas into mainstream
British medical discourse. During this period, hysteria was mainly discussed
in the British medical press in relation to the theories of Babinski, Janet and
Freud. These theorists had ‘to a great extent superseded the doctrines of
Charcot, though […] none of them has passed into the region of accepted fact’
(Anon., 1910a). British commentators overwhelmingly (re)presented these
theories via reference to the somatic paradigm, in the process normalizing them.
This approach undoubtedly proceeded in part from an inability to comprehend
psychological theorization. The nameless doctor who alluded to Babinski in
the course of a discussion at the Liverpool Medical Institution but confessed
himself unable to ‘fully follow this distinguished French physician’ probably
articulated the secret sentiments of many (Anon., 1910b). However, precisely
because they were unable to think far outside the somatic paradigm, for the
most part the doctors discussed here greeted these theories with a surprising
degree of openness.
Discussions of Freud demonstrate this trend. Older (but still frequently-
cited) histories of shell-shock often argue that the British medical establishment

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T. LOUGHRAN: HYSTERIA, NEURASTHENIA AND SHELL-SHOCK 31

was almost uniformly hostile to Freud before World War I (Showalter, 1987:
189; Stone, 1985: 243). Yet when his theories were not presented in an
evangelical fashion, many members of the medical community cocked an
interested ear. In the pre-war medical press, Freud was most often viewed as
just one of many thinkers who had contributed to the study of hysteria, and
like these others, his theories did not have to be swallowed whole. For example,
Ormerod thought the idea that the expression of repressed emotion could help
to relieve symptoms was extremely useful, if somewhat overrated by Breuer
and Freud. Although he could not stomach the inductive basis of Freud’s
theories – described as ‘very unsubstantial, and literally such stuff as dreams
are made of’ – he was still able to appreciate some of the general insights it
offered (Ormerod, 1911: 285–7).
This magpie approach was typical of the British commentators. They not
only picked and chose those theoretical aspects which they perceived as useful,
but re-inflected and tamed the whole as well. Paradoxically, this openness to
new ideas was only possible because of their allegiance to the somatic para-
digm. As long as it was accepted that hysteria had an organic basis which had
not yet been discovered, psychological theories could be viewed simply as
useful adjuncts to this supposed foundation. The outcomes of this process –
perhaps described more accurately as welding than assimilation – can appear
incongruous to the modern reader. Robert Cole (1866–1926), a specialist in
mental diseases, incorporated new psychological theories into the account of
hysteria in his well-received 1913 textbook of nervous and mental diseases. This
referenced Babinski, Janet and Freud, and initially defined hysteria as ‘a disorder
of the subconscious mind; it is a peculiar mental state in which the psychical
and physical symptoms are largely due to auto-suggestion’. Only a few pages
later, however, he proposed some possible physiological explanations: perhaps
hysteria was caused by an alteration in the state of nutrition of the cortex, or a
secondary derangement of the lower nerve centres (Cole, 1913: 216–19).
This was not how Babinksi, Janet or Freud intended their theories to be read.
There is clear evidence of misunderstanding, such as when Cole referred to
Janet’s theory of ‘neuronic dissociation’ or attributed to Freud the view that the
‘generative organs’ always had ‘direct aetiological influence’ in hysteria (Cole,
1913: 217, 219). But it would be a mistake to view either these misapprehensions,
or the plucking of certain features of Continental theories from their context,
simply as misappropriations which distort their ‘true’ nature. They are evidence
of a now-alien interpretative strategy available to contemporaries: not only
because they did not perceive psychological and physiological categories of ex-
planation as irreconcilable (and this is one of the respects in which they had an
open-minded approach to the former, even if it was limited by final adherence
to the latter), but because they sought in these theories practical solutions to the
problems of diagnosis and treatment rather than intellectual satisfaction.
Therefore it is possible that the frequent substitution of ‘subconscious’ for
‘unconscious’ in discussions of Freud (Anon., 1911a; Thomson, 1911: 77–9)

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32 HISTORY OF PSYCHIATRY 19(1)

was not made only because the former concept was comprehended and the latter
was not, but because these commentators afforded the difference little weight
in comparison with those aspects of the theory they felt could be used. The
consequence of such re-castings was the piecemeal incursion of psychological
theories into the somatic framework of understanding. The groundwork had
been laid for the acceptance of psychological paradigms before shell-shock
burst onto the psychiatric scene.

Neurasthenia, nervous exhaustion, psychasthenia and anxiety

neurosis
The description of a disorder typified by an underlying, if undiscovered, organic
basis and accompanied by psychological elements fits neurasthenia as well as
hysteria. Here the argument becomes slightly more complicated, however, both
because of the fluctuating status of the disorder itself in the years before the war,
and the way it has been described by historians of shell-shock. A wide-ranging
and shifting set of symptoms were attached to the diagnosis of neurasthenia at
different points and by different commentators. It is therefore impossible to
pin down any one accepted definition of the disorder, but it is argued here that
the dominant view among British commentators in this period was of a somatic
condition of nervous exhaustion which constituted ‘true’ neurasthenia (Clarke,
1905: 191). Psychic elements could exist alongside this nervous weakness, but
only as adjuncts to this somatic ‘essence’ of neurasthenia. In the years before the
war the category was undergoing fundamental changes, as theorists including
Janet and Freud sought to make it more manageable by redistributing some of
its features among new diagnoses such as psychasthenia and anxiety neurosis
(Wessely, 1990: 47). Historians of shell-shock have conflated the contents of
these diagnoses with the older native conception of neurasthenia as nervous ex-
haustion, and this has contributed to the misleading representation of hysteria
and neurasthenia as absolutely opposed categories. It appears instead that within
British medical discourse, neurasthenia was seen as the nervous weakness which
remained when psychic symptoms were parcelled out among other diagnoses,
rather than these new diagnoses impacting on this core definition. Neurasthenia
was still conceptualized primarily as a somatic entity.
This conception of neurasthenia is apparent in textbooks of nervous and
mental diseases, which gave popular synonyms as ‘nervous prostration’, ‘ner-
vous debility’ and ‘nervous exhaustion’. The most prominent somatic symptoms
were listed as nervous exhaustion and fatigue, particularly constant tiredness
and general aches and pains which might affect any or several bodily functions
(circulation, digestion, sexual activity). Attached to these were a set of ‘psychic’
symptoms which were perceived as further manifestations of this nervous
weakness: inability to concentrate, particularly on mental labour, headache,
insomnia, depression, excitability, irritability, introspection and excessive
emotion (Nagel, 1905: 171–2; Potts, 1908: 405–7). This mixture of somatic

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T. LOUGHRAN: HYSTERIA, NEURASTHENIA AND SHELL-SHOCK 33

and mental manifestations contributed to ambiguity in views of neurasthenia.

Some doctors stressed that neurasthenia shared similarities with certain stages
of recognized and undisputed organic disorders, and warned other practitioners
to be alert to the possibility of ‘grave organic affection’ lurking behind the nebu-
lous set of neurasthenic symptoms (Mott, 1911; Russell, 1913: 1453). Few
accounts of neurasthenia insisted on a solely somatic aetiology (Anon., 1911c),
but even rarer were descriptions which retained the label while insisting that
the ‘malady is essentially mental; it is a psycho-neurosis’ (Ferrier, 1911: 11).
Most common was a compromise position, such as the view that there was an
undetected organic lesion in some, but not all, cases of neurasthenia (Oldfield,
1913: 335), or that body and mind ‘may alike be implicated and demand the
same attention’ (Anon., 1912). Philosophical pragmatism was therefore one
way of negotiating the ambiguities posed by a concept as elastic as neurasthenia.
Another was the attempt to delineate different types of neurasthenia according
to whether symptoms were physical, psychical or a mixture of both (Russell,
1913: 1453).
The approach which eventually gained greatest currency was the removal of
psychological symptoms from neurasthenia in order to create new diagnoses
and to strip the old one down to its bare essentials. This process was under-
way some years before the war. In 1911 William Aldren Turner (1864–1945),
a neurologist who was later to publish on shell-shock, stated that ‘several
pseudo-neurasthenic states’, including manic-depressive psychosis, dementia
praecox, psychasthenia and Freud’s ‘anxiety neurosis’ had been eliminated
from the diagnosis. This had left a pure core of nervous exhaustion or ‘true
neurasthenia’, a primarily somatic category which incorporated a psychic
dimension (Anon., 1911b). Although Aldren Turner spoke of ‘the partial
passing of neurasthenia’ as established fact, other commentators were less
confident that these redistributions had succeeded in making neurasthenia
more comprehensible. H. Macnaughton-Jones, a distinguished obstetrician,
argued that it was impossible to draw hard-and-fast lines between the modish
categories of psychasthenia, phrenasthenia and neurasthenia. He suggested that
because these clinical states ‘all at times merge into another’, it might be best
for practical purposes ‘to regard them as constituting a clinical group in which
but shadowy borderlands exist between one member of it and another, and
in which it is occasionally, indeed frequently, impossible for us to delimit by
any boundary line the features peculiar to one or all of them’ (Macnaughton-
Jones, 1913).
In 1914 neurasthenia was therefore a confused and confusing diagnostic
category. The little coherence it ever had as a clinical entity was being gradually
undermined by the redistribution of its symptoms. Those who used the term
could be fairly certain that it signified to their audience at the very least a con-
dition of nervous weakness, but only context could determine which of the
other manifold possible meanings an individual might also intend to convey.
This ambiguity is rarely conveyed in historical accounts of neurasthenia as

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34 HISTORY OF PSYCHIATRY 19(1)

a component of the shell-shock diagnosis. Historians of shell-shock almost

invariably select anxiety as the dominant symptom of neurasthenia, and
sometimes even use neurasthenia as a synonym of ‘anxiety neurosis’ (Barham,
2004: 76; Binnevald, 1997: 94; Bourke, 1996: 112; Leed, 1979: 163; Shephard,
1996: 435). The historical literature on shell-shock also frequently attributes
to wartime doctors the view of hysteria as a primitive defence mechanism and
neurasthenia/anxiety neurosis as a more sophisticated response to psycho-
logical trauma (Leese, 2002: 80, 95; Shephard, 1999: 36). The unintentional
effect is to distort the concept of neurasthenia as it was employed in pre-war
British medical discourse. The implication is that throughout the war, and
before, neurasthenia both manifested and was understood primarily as a psycho-
logical disorder. The somatic aspect of the disorder which was dominant if not
exclusively emphasized in most pre-war constructions is ignored.
This confusion stems from the conflation of three categories which were
characterized as overlapping yet distinct before the war: nervous exhaustion,
psychasthenia and anxiety neurosis. The conflation is understandable given
the ambiguity of neurasthenia, but the historiography as a whole has tended
to emphasize the attributes of psychasthenia and anxiety neurosis at the ex-
pense of nervous exhaustion. This has resulted in the misleading presentation
of neurasthenia as a psychological construct within pre-war medical discourse.
The discussion here suggests instead that the essence of neurasthenia was under-
stood as somatic, and that this conception had gained further ground as a result
of the removal of psychological symptoms to form separate diagnostic entities.
In Britain, neurasthenia was not being redefined as a psychological disorder:
rather, a process was occurring in which somatic elements were increasingly
becoming the only essentials of its definition.
The term psychasthenia, formulated by Janet as a psychological disorder in
which depression, phobias and obsessions existed with certain somatic symp-
toms (Janet, 1901: 519–21; see Shamdasani, 2001) was increasingly listed
alongside hysteria and neurasthenia in pre-war discussions of functional disease.
It was even occasionally presented as a synonym of neurasthenia (Ash, 1913:
123; Ormerod, 1911: 279). This does not mean, however, that British uses of
the term signified acceptance of Janet’s model of psychological functioning. As
in British reformulations of European hysteria theories, psychasthenia was often
reconfigured to accommodate a physical basis. In one account, psychasthenia
was attributed to ‘some physiological error in the mechanism controlling the
emotions’ (Thursfield, 1911: 118–19). Cole conceived of psychasthenia and
neurasthenia as separate disorders which often co-existed in the same case, and
awarded psychasthenia a physical aetiology, positing ‘a weakened state of health
in a predisposed individual’ which had disturbed the action of the higher cortical
neurons as the main cause (Cole, 1913: 225). Therefore although Janet’s orig-
inal concept of psychasthenia was a psychological disorder, uses of this term in
pre-war British medical discourse cannot be automatically read as conveying
an understanding of this disorder in the terms formulated by Janet.

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T. LOUGHRAN: HYSTERIA, NEURASTHENIA AND SHELL-SHOCK 35

Untangling how neurasthenia has come to be seen as virtually synonymous

with anxiety neurosis is a more complicated matter. The idea of anxiety neurosis
was first formulated by Freud in his 1895 paper, ‘On the grounds for detach-
ing a particular syndrome from neurasthenia under the description “anxiety
neurosis”’ (Freud, 1979a). Freud separated a cluster of symptoms described
as ‘neurotic disturbances’ from the neurasthenia diagnosis, arguing that these
differed in their ‘aetiology and mechanism’ (p. 35). These neurotic disturb-
ances (including general irritability, anxiety attacks, night terrors, vertigo,
agoraphobia and phobias relating to general physiological dangers, digestive
disturbances and paraesthesias) were grouped around the chief symptom of
anxiety (pp. 37–45). The symptoms left over, which comprised ‘neurasthenia
proper’, were ‘intracranial pressure, spinal irritation, and dyspepsia with flatu-
lence and constipation’ (p. 35). The aetiology of both ‘genuine neurasthenia’
and anxiety neurosis was sexual, but the first resulted from an inadequate
release of sexual tension, such as masturbation or spontaneous emission, while
the second was ‘the product of all those factors which prevent the somatic
sexual excitation from being worked over psychically’ (p. 56). In his concluding
comments, Freud also considered the relation of anxiety neurosis to hysteria.
He stated that the two were extremely similar in terms of both symptomato-
logy and aetiological mechanism, but that anxiety neurosis was ‘the somatic
counterpart to hysteria’. The displaced tension expressed in anxiety neurosis
was ‘somatic sexual excitation’ and ‘purely somatic’, whereas that expressed
in hysteria was ‘psychical’, ‘provoked by conflict’ (p. 63). In his paper, anxiety
neurosis was conceived as a purely somatic category which was similar to
the psychological category of hysteria in terms of symptomatic content and
mode of operation of aetiological mechanism. This anxiety neurosis does not
correspond to that invoked by historians of shell-shock, either of itself or in its
relation to hysteria.
The term ‘anxiety neurosis’ was rarely used in the pre-1914 British medical
literature on neurasthenia, either as a synonym for or as a component of the
general diagnosis. Macnaughton-Jones’ (1913) discussion of the redistribu-
tion of the symptoms of neurasthenia made no reference to anxiety neurosis.
The term is not even found in the places where it might appear most likely to
be used, such as an article by the neurologist Gordon Holmes (1876–1965)
on sexual neurasthenia in men. Holmes referred briefly and disparagingly to
Freud’s work on hysteria, but showed no awareness of the concept of anxiety
neurosis (Holmes, 1911: 50). A thorough search of the pre-war literature on
which the present paper is based yields only four uses of the term (Anon.,
1910a; Anon., 1911b; Anon., 1913a: 1470; Mott, 1914: 71). Perhaps most
tellingly, it does not appear in the 1913 edition of Cole’s textbook of mental dis-
eases, although it is given as an alternative term for neurasthenia in the second
edition of 1919, suggesting that this usage was a product of the war (Cole,
1919: 224). All evidence suggests that the term was not common in pre-war
British medical discourse.

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36 HISTORY OF PSYCHIATRY 19(1)

In fact, the three-pronged sociocultural argument regarding shell-shock

outlined at the outset of this article has been influenced by a very particular
concept of anxiety neurosis, which does not derive from Freud’s 1895 paper.
There are two related explanations for this historiographical confusion. The
first is that in 1925 Freud fundamentally revised his concept of the anxiety
neuroses, retaining the term and symptomatology but positing a different set
of causal ideas (including the view of obsessional neurosis as a sophisticated
psychological process compared with ‘true conversion hysteria’) (Freud, 1979b:
265–73; Micale, 1993: 520–2). The second is that the most well known of the
shell-shock doctors, W. H. R. Rivers, used a distinctive concept of anxiety
neurosis as a synonym for neurasthenia and postulated the relationship be-
tween hysteria and anxiety neurosis which historians of shell-shock have retro-
spectively applied to pre-war notions of the disorder. Rivers was aware that his
concept of anxiety neurosis did not correspond to the then-current Freudian
version, and his use of the term in this context did not go entirely unquestioned
(Rivers, 1917: 19, 20). Although one of the most important theorists of shell-
shock from 1917 onwards, Rivers was not typical either in his definition of
neurasthenia/anxiety neurosis, or his views of the causative mechanisms of this
disorder and hysteria.
The term anxiety neurosis was in fact infrequently used throughout the war,
and when employed usually implied nothing more than a condition in which
anxiety was prominent as cause or symptom, without the specific mechanisms
invoked by Rivers or Freud. From a comprehensive analysis of writings on
mental and nervous disorders of war from 1914 onwards, only three authors
using the term (excluding Rivers) can be found before 1918 (Abrahams, 1915;
Ballard, 1917a; Ballard, 1917b: 128; Mott, 1916: vi, xx). On the other hand,
the use of neurasthenia to connote primarily nervous exhaustion, perhaps at-
tended by a selection of ‘psychic’ symptoms, continued in a range of medical
discussions on shell-shock during and after the war (Collie, 1916: 532; Craig,
1917: 254; Forster, 1918: 85; Hurst, 1944: 136–8; Marr, 1919: 46). Authors who
defined neurasthenia in this way usually preferred to designate hysteria and
psychasthenia as separate ‘mental’ conditions (Ballard, 1917b: 124; Hurst, 1917:
409–10; Marr, 1919: 125). As in pre-war British medical discourse, however,
the capaciousness of the neurasthenia concept meant that its psychological as-
pects could be emphasized without occasioning a major re-definition or writing
nervous exhaustion out of the picture (Burton-Fanning, 1917: 908; Fearnsides,
1918: 45). The complex relations of hysteria and neurasthenia, their meanings
in pre-1914 British medical discourse, and therefore the degree of change or
continuity which their deployment in relation to shell-shock entailed, can only
be understood through a precise and nuanced approach to the language of
diagnosis. The reading employed here suggests that the tripartite social-cultural
analysis of shell-shock has little relation to how hysteria and neurasthenia were
conceived in pre-war British medical thought.

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T. LOUGHRAN: HYSTERIA, NEURASTHENIA AND SHELL-SHOCK 37

The neurotic temperament

An examination of aetiological theories of hysteria and neurasthenia further
demonstrates that these disorders were not constructed as opposed or even
entirely distinct categories within pre-war British medical discourse. They were
connected by the crucial aetiological role attributed to heredity or inheritance.
It was through this aspect, which emphasized a dialogue between the individual
body and the environment conceived in various ways (the environment of the
individual body, of the family and of the nation) that hysteria and neurasthenia
took on a social and political dimension. In textbooks, the aetiological fac-
tors of these disorders were usually divided into a wide range of predisposing
and exciting causes, with varying degrees of consensus on the specific causes.
Virtually all, however, agreed on one general predisposing cause: a ‘neuropathic
tendency’, ‘inheritance’ or ‘taint’. This was usually defined as the existence
of some neurosis or neurotic disease in the family (Clarke, 1905: 176; Nagel,
1905: 171; Potts, 1908: 414–15).
Hysteria and neurasthenia were therefore conceptually linked through the
notion of faulty inheritance. The predisposing and exciting causes listed for both
also had another common denominator: the concept of a weakened nervous
system. This was either inborn (the result of heredity) or acquired (the result of
an element in the environment, be it an undesirable mode of life or an accident
such as shock or illness).
Nervous weakness was not only fundamental to the definition of neurasthenia,
but was also perceived as a precondition for the development of hysteria
and mental disorders such as hypochondria and melancholia (Potts, 1908:
411–12). This perception helps to explain neurasthenia’s ambiguous status
as a ‘borderland’ diagnosis. Because nervous weakness was seen as a stepping
stone to disorders with a more pronounced ‘psychic’ element, it was impossible
to demarcate where this element began and ended in neurasthenia. Although
understood as primarily a somatic disorder, neurasthenia therefore always
potentially contained this psychic element. The role of nervous weakness as
the defining factor of neurasthenia and as an aetiological factor in hysteria also
underlines that these were linked rather than opposed categories. This ex-
plains not only the occasional conflation of hysteria with neurasthenia despite
the efforts of most authorities to keep them separate, but also the existence of
otherwise confusing designations such as ‘hystero-neurasthenia’ (Anon., 1910b;
Cole, 1913: 94).
The fact that heredity was conceived as the most important factor in the
aetiologies of both diagnoses also acted to neutralize the perceived import-
ance of exciting causes, and thereby to locate the cause of the disorder in the
individual rather than the social environment. Although it was stated that a
specific, external stimulus was always necessary for the actual development
of hysteria or neurasthenia, the emphasis on heredity as a predisposing cause
meant that once this development had occurred, the disorder was usually

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38 HISTORY OF PSYCHIATRY 19(1)

seen as a pre-existing potential of the individual which had been latent until
the right circumstances for its expression arose. The apparent and immedi-
ate cause was always at most only ‘a coefficient, and often merely serves as the
spark which falls into the explosive matter’ (Mott, 1907). In practice, once
the disorder had been diagnosed the specific stimulus was constructed as only
of secondary importance. This did not mean that the social environment was
insignificant, but that its importance was conceived mainly in terms of its
possible modification to prevent the appearance of outward manifestations of
nervous disorder, rather than in terms of its ability to effect a permanent change
in the nervous individual (see for example Riviere, 1911).
Biological determinism became more entrenched in the years immediately
before the war, as can be seen in changing uses of a recurrent motif in discussions
of nervous disorders: analogies to plant life. In 1892 one contributor to Hack
Tuke’s Dictionary described neurasthenia as ‘to a certain degree the starting-
point of all the more severe nervous disorders, and the soil from which they
grow’ (Arndt, 1892: 840, 842); another, the obstetrician and gynaecologist
William Playfair (1896–1903) argued that the ‘rank weeds of neurotic disease
will only grow and flourish in suitable soil – that is, in a state of depressed
vitality; improve the soil, and the unhealthy growth will disappear’ (Playfair,
1892: 853). The outlook here was essentially positive: although nervous
exhaustion was the ‘bad soil’ which fostered the growth of neurotic disorders,
more serious disorders could be prevented if the right measures were taken.
Nervous exhaustion was portrayed simply as an illness which affected the indi-
vidual, not a pathology which defined her. Only a few years later the metaphor
was being used quite differently: to describe how ‘the seeds’ of neuroses were
‘sown by stupid or ignorant parents or nurses through want of recognition of
the signs of the nervous predisposition and temperament of the child’ (Clarke,
1905: 7; Macnaughton-Jones, 1911: 69). The ultimate cause of the neurosis was
the child’s ‘nervous predisposition and temperament’; the social environment
was implicated only as a factor which allowed and encouraged the disorder to
develop. This was an illness which, like original sin, was embodied rather than
contracted, and the aim was not to cure but to prevent its worst potentialities
from manifesting.
The key term here is ‘temperament’, in pre-war British medical discourse
often conceived as a biological destiny rather than a mere personality trait.
Robert Jones (1857–1943), superintendent of Claybury Asylum, stated that in
the individual temperament was a tendency determined by nation and race, and
which therefore differed according to evolutionary development ( Jones, 1911:
1–2). His colleague, the neuropathologist Frederick Mott (1853–1926), put
forward a similar definition of the ‘neuropathic temperament’ as an inborn
tendency determined by biological inheritance (Mott, 1914: 68–71). This
concept of the neurotic temperament was fundamental to medical accounts
of hysteria and neurasthenia. In discussions of neurasthenia, the notion of

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T. LOUGHRAN: HYSTERIA, NEURASTHENIA AND SHELL-SHOCK 39

‘hereditary neuropathic taint’ in conjunction with ‘nationality and tempera-

ment’ was presented as crucial to understanding and treating the disorder
(Russell, 1913). In one account, it was even suggested that doctors ‘had fre-
quently to deal with a neurasthenic temperament – not really a disease’ (Anon.,
1913a: 1469). Hysteria and neurasthenia were such large and ill-defined
categories that the concept of a neurotic temperament was the glue which
held each together as a discrete clinical entity in the absence of an identifiable
pathology. The conceptualization of the neurotic temperament as a biologically
determined quality also meant that the actual appearance of hysteria or
neurasthenia was merely the final stage of a preordained process, the disease
itself simply confirmation of a pathological identity. The neurasthenic or hysteric
was not only pathological, but her whole being provided the pathology, literally
embodied it at a level beyond the body, so deep that no autopsy or microscope
would ever uncover it. At the core of these amorphous clinical entities, what was
left when all the extraneous symptoms and abstruse jargon were removed, was
the neurotic temperament.
Hysteria and neurasthenia were both viewed as evidence of the biologically
determined neurotic or neuropathic temperament. The significance of this
perception in the present context is two-fold. First of all, it further highlights
the close conceptual relationship between hysteria and neurasthenia, and
particularly an aspect which is often glossed by historians of shell-shock who
wish to emphasize the construction of these disorders as opposed categories.
In these histories, neurasthenia is frequently presented as a fashionable ‘disease
of civilisation’, a focus which has heightened the contrast with the ancient
disease of hysteria (Barham, 2004: 76–8; Leed, 1979: 63–4; Showalter, 1987:
174–6). The construction of neurasthenia as a malady fostered by the conditions
of modern life was undoubtedly present in the pre-war literature (Clarke, 1911;
Cobb, 1913: 745), but commentators were equally likely to refer more gen-
erally to the increase of all nervous disorders as a concomitant of the ‘rise in
the general level of culture and civilisation in a race’ (Anon., 1911d). In the im-
mediately pre-war years the view that nervous disorders were more prominent
in civilized societies increasingly dovetailed with theories of degeneration
(Fleming, 1911: 32–3), a development which appears to have been common
in Britain and Europe, but not in the North American context (Drinka, 1984:
213–14; Micale, 1995: 205–20). The rise of eugenics, particularly from the
turn of century, meant that any putative claim neurasthenia might have had as
a symbol of status was outweighed by fears that it signalled the beginning of
biological and therefore social, political and imperial decline.
This leads onto the second reason why it is important that hysteria and
neurasthenia were seen as biologically determined: both disorders were
increasingly conceptualized as social dangers. Committed eugenicists argued
that nervous and mental disorders were ‘certainly on the increase’ and
that ‘incipient disease of mind’ would ‘lead to even more disastrous results

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40 HISTORY OF PSYCHIATRY 19(1)

than […] disease of body’ (Tredgold, 1911: 95). Mott framed these fears
of national degeneration explicitly in relation to neurasthenia. He reasoned
that if neurasthenia was both ‘a special outcome of modern civilization’
and ‘the starting-point of an unstable nervous condition in a stock’ which
would intensify under the continued influence of an unfavourable environment,
then modern Britain was in trouble (Mott, 1913: 26–8). The fear of latent ner-
vous and mental instability was apparent even in accounts which attempted
to strike a more optimistic note. Sir George Savage (1841–1921), a lion of the
pre-war psychiatric establishment, warned against believing too much in ‘the
tyranny of the organism’, arguing that the right conditions were necessary for
the development of insanity. In order to make this point he compared heredity
to ‘the mycelium of the mushroom’, which ‘spreads far and wide and is not rec-
ognised till suitable conditions lead to what we call the mushroom which comes
to the surface’. His audience probably took little comfort from his conclusion
that, similarly, ‘the neurotic inheritance spreads far and wide and is deeply
seated, but the occasion for its development may be wanting’ – after all, if this
were the case, what would happen in a national crisis? (Savage, 1912: 1136).
Hysteria and neurasthenia were therefore framed as indicators of national
and political health. An anonymous 1910 comment piece in the Lancet took
issue with the French neurologist Jules Déjerine’s contention that emotional
shock was the main aetiological factor in the development of hysteria. The
author argued that, as individuals and in the aggregate, the Latin races were less
emotionally stable than the Teutonic, linking the prevalence of both hysteria
and social upheavals in France to this fact. It was well known that the Parisian
mob became ‘inflamed by any passing wind of emotion’, while such events
were uncommon in England. These differences could only be explained as the
result of ‘national and racial differences’. As a nation, the English were ‘less
emotional, less exuberant, less gesticulative’ – in short, less hysterical (Anon.,
1910c). The physician and neurologist Samuel Wilson (1874–1937) put
forward a similar argument, pointing to the moment in the 1880s when ‘the
telegraphic announcement of an insignificant reverse at Langson provoked a
fury in Paris and France, and brought about the instantaneous overthrow of
the Government’ when ‘a much more serious reverse undergone by our English
expedition to Khartoum produced only a slight emotion, and no ministry was
overturned’ (Wilson, 1911: 322). Here, hysteria moved from individual to social
and political pathology, and was constructed as a fundamentally un-English
disorder. It is not surprising that hysteria was deemed to be more prevalent
among Jews as well as the Latin races; the former were also seen as more
liable to neurasthenia (Clarke, 1905: 4–5, 175; Oldfield, 1913: 335; Stewart,
1906: 308). By association, English neurotics were not part of the nation, but
aligned with the threatening forces clustered on its borders, awaiting their
chance to attack or, worse, silently infiltrate the body politic.
It is therefore no coincidence that the dialogue between medicine and politics
on the eve of the war featured hysteria and neurasthenia, both as actual diagnosis

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T. LOUGHRAN: HYSTERIA, NEURASTHENIA AND SHELL-SHOCK 41

and as linguistic trope. Historians usually locate three main sources of disruption
to British political life in 1914: the threat posed to industrial productivity by
trade union activity, the militant suffrage campaign, and the crisis around
Home Rule for Ireland (Hynes, 1991: 6–7; Read, 1994: 483–97). As regards
the first of these, the relationship between medicine, the state and the labour
force was still being worked out in the wake of the Workmen’s Compensation
Acts of 1897, 1900 and 1906. One of the most vexed aspects of these debates
was the issue of compensation for traumatic neurosis, in which hysteria and
neurasthenia were clearly implicated (Grant, 1914; Palmer, 1911; Thorburn,
1913). The militant suffragettes, meanwhile, were stigmatized as hysterical
for their ‘unwomanly’ violence to private property, and by extension the state
(Wright, 1913: 166–88). Although the Celtic races were seen as more liable to
hysteria and neurasthenia (Clarke, 1905: 4–5, 175), such labels were not ap-
plied to figures in the debates on the Irish Question. However, when seeking
to explain the mechanism of hysterical dissociation in early 1914, Ormerod
plucked a prescient metaphor from political life: in the hysterical mind, he
wrote, the ‘central government is weak, and there results a turbulent home rule
all round’ (Ormerod, 1914: 1236).

Conclusion
It has been argued here that hysteria and neurasthenia were not fundamentally
opposed categories in pre-war British medical discourse but, rather, linked
through their definition as functional diseases and the crucial role attributed to
hereditary predisposition in the aetiologies of both. The conceptual closeness
of hysteria and neurasthenia undermines the three-pronged sociocultural inter-
pretation of shell-shock outlined earlier. To a certain extent, the demolition
of arguments based on the hysteria/neurasthenia divide is little more than the
completion of a clean-up operation begun by previous historians of shell-shock,
attacking the problem from a different angle. Powerful criticisms of arguments
regarding gendered perceptions of shell-shock and differential treatment
according to class have already been made by Laurinda Stryker (2003) and
Peter Leese (2002: 110–16). The main difference is that here the critique has
been based on an analysis of diagnostic categories, and therefore strikes at all
three arguments simultaneously.
Demolition, however, is secondary to the main purpose of this paper. In
focusing on the clinical categories of hysteria and neurasthenia in the ‘forgotten
years’ of 1900–14, my aim has been to question certain aspects of the con-
ventional historiographical argument that shell-shock forced a transition from
physical to psychological understanding. That there was some shift in this
direction seems unmistakeable: in the post-war years hundreds of doctors
returned to their day jobs with vastly increased experience of dealing with
psychological disorders, thousands of shell-shocked veterans sought psychiatric

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42 HISTORY OF PSYCHIATRY 19(1)

treatment and pensions throughout the 1920s, and in 1930 the Mental Health
Act partially dismantled the asylum system and created out-patient clinics. Yet
the other side of the chasm which is 1914–18 demands equal attention if we are to
judge to what extent and in what ways the war itself was a force for change.
There was not one giant leap from Victoria to Freud via World War I. British
psychological medicine did not stand still between 1901 and 1914.
This paper has pinpointed some of the areas in which small steps were being
taken before that cataclysm. Through the category of functional disorders,
psychological concepts were infiltrating the dominant somatic paradigm, a
development which was paradoxically enabled by the very inflexibility of that
world-view. British doctors were not uniformly deaf or hostile to the clamour
of Continental voices entreating a psychological view of mind. Their eclectic
interpretations of these theories suggests that sometimes they might have been
served well by an ear-trumpet, if not a translator, but nevertheless the pidgin
versions of Freud, Janet, Babinski and others which were disseminated in the
medical press meant that no well-read doctor could claim complete ignorance
of these theorists. The shift from a somatic to a psychological paradigm was
in progress before the war, and it might be more fruitful to look for evidence
of continuity and natural growth in this process over 1914–18 than to assume
radical and abrupt change.
The gradual assimilation of psychological theories proceeded simultaneously,
although not exactly hand-in-hand, with the increasing entrenchment of
biological determinism, signalled perhaps above all by the popularity of moder-
ate eugenic ideas. The biological dimension of hysteria and neurasthenia meant
that both were linked to prevalent socio-political concerns and were thus highly
charged categories on the eve of the war. Before 1914, medical discourse por-
trayed neurotic Britons as not just ill or bad, but unpatriotic. They were enemy
aliens at the most basic biological level, latent lesions on the body of the nation
which might erupt and threaten the health of the whole at the first serious crisis.
There was an enormous difference between representations of the shrieking
hysteric or lurking neurasthenic and the figure of the shattered soldier; but
although shell-shock pushed mental health issues onto the mainstream medical
agenda with unprecedented force, the signs are that this was a move which some
prominent medical spokesmen had been enjoining before the war, albeit for
different reasons. In a ground-breaking, and still indispensable, essay written
more than twenty years ago, Martin Stone argued that shell-shock redefined
‘the boundary of the pathological […] at all its constitutive levels’ (Stone, 1985:
266). This conclusion has rarely been disputed, but it may be premature: as
yet, we do not know nearly enough about how this boundary was delineated in
the crucial years immediately before 1914 to judge. This paper suggests that a
detailed mapping of the pathological in the opening decades of the twentieth
century may yet surprise us by revealing continuities which survived the several
ruptures of the war.

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T. LOUGHRAN: HYSTERIA, NEURASTHENIA AND SHELL-SHOCK 43

Acknowledgements
I would like to thank the Arts and Humanities Research Council and the Institute of Historical
Research for providing funding which made the research for this paper possible. The comments
of Professor Daniel Pick, Professor Michèle Barrett and Dr Matthew Grant on earlier versions
of this paper were also invaluable.

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