The effects of the war would soon become the daily bread of the Girifalco medics. From the report drafted to the director of the provincial delegation in 1918 we learn that in the three years since the beginning of the conflict the hospital had been virtually cleared of ordinary patients to make way for veterans from the frontline. In 1916 due to the inability of other hospitals to take in new referrals, a large number of southern Italian soldiers were redirected to Girifalco forcing the administration to reorganise its space and work schedules. Leafing through the reports, year on year, one can note the gradually dawning awareness of the significance of war trauma;[40] nevertheless, there still remained the lurking suspicion that behind the distressed and disorientated behaviour was a desire to fake insanity in order to avoid a return to the front. This prejudice can be seen clearly in the admissions papers on patients’ arrival at the hospital. An example of this is the case of Michelangelo M.,[41] an illiterate mechanic from Calabria first admitted to hospital on 6 May 1916 and diagnosed as suffering from manic depression, frenzy, anxiety and extreme irascibility. Shortly after his admission the doctors described his account of his experience on the lower Isonzo front as confused and uncertain, and were thus unable to form any clear idea of his pathology. A month later, with an alleviation of his symptoms it was considered of little use to keep him in hospital and the soldier was discharged and sent home on probation. Yet the suspicion that the soldier was faking his illness remained. In the documentation attached to the clinical file there is a letter from Frisco to the Carabinieri in the soldier’s town, enquiring whether the soldier has shown any sign of disturbance while at home. The Carabinieri replied that, although his conduct had been good, the soldier was without any doubt mentally ill. Less than two years later the same patient was once again hospitalised at Girifalco with the same diagnosis and once again the doctors cast doubt on the veracity of his mental illness. In the bulging case file, that appears more like the result of a police investigation than a medical account of a course of treatment, there is a touching letter from a sister of the soldier dated February 1918 addressed to the director of the institute in which she asks for news on her brother’s condition, and, to prove that her brother is genuinely unwell she gives an account of his difficult childhood, orphaned when both his parents were burnt to death in a fire at their small dwelling in the countryside.[42]
The most common pathologies found in the clinical files at Girifalco are the diagnosis of mental confusion or melancholy, which today would be termed depression. From these documents it is plain that very little attention is given to a course of treatment and none at all to therapy. In effect, these pathologies were not considered by psychiatrists in Italy as particularly serious or very dangerous, especially in the case of soldiers. At the root of this conviction was the idea that a slight dulling of the psyche was normal if not desirable in a soldier. It is no coincidence that in 1917 Agostino Gemelli, in his description of the mental state of troops in war claimed that the good soldier, especially if he happens to be a peasant, is one who is capable of sublimating his own personality. In other words, loss of self-control and a lowering of the psychological barriers would help a soldier overcome his fear and favour a suitable level of indifference when faced with the horrors of war.[43] This way of thinking was fully supported by the psychiatric community and would have consequences on the therapies which proved to be wholly inadequate in dealing with the veterans’ suffering. The result of all this was dozens of “alienated” veterans, suffering from amnesia,[44] stupor and depression[45] and idiocy,[46] briefly interned in Girifalco without receiving appropriate care and treatment, and then quickly returned to the front line. For these soldiers, without the chance to receive the treatment they badly needed to cope with the trauma suffered in the trenches, or the possibility to come to terms with the devastating alterations in their world view, a psychological disorientation opened up which would accompany them through the successive years of war (and beyond).
Yet soon it became impossible not to realise that the psychological disturbances, neuroses and other forms of mental imbalance were all signs of a problem requiring a new clinical language. In particular, it was cases of shell shock that forced doctors to study the pathology in depth and lead them to a better understanding of the phenomenon. In the investigations into war trauma two aspects came to take on greater importance: the study of the unconscious and the conflicting demands in the mind the individual soldier in terms of his sense of duty and obedience to the dictates of the army. Cases of soldiers traumatised by poison gas, war wounds or the explosion of grenades were, by this time, analysed as real medical illnesses and not as the behaviour of shirkers pretending to be ill, albeit in the absence of full understanding of the phenomenon or possible solutions. Moreover, there was a tendency to categorise everything under the general heading of “moral collapse”, hence there was no need for any specific course of treatment. The role of the medic therefore was to: “reinforce a soldier’s sense of duty and help him regain his self respect”,[47] by boosting the patient’s self-esteem and trying to limit the loss of dignity which was considered unacceptable, and in a sense immoral, for a country at war. It is hardly surprising, therefore, that in the first phase of the conflict it was the task of the doctors in the field hospitals near the frontline to treat the traumatised victims of trench warfare; these medics congratulated themselves on their success at getting the patients back in action, in the belief that such behaviour was merely expression of a lack of enthusiasm for the fight among the weaker elements of the army.[48] However, once the phenomenon reached a certain level it became clear that the army’s neuropsychiatric service was quite incapable of coping with the problem and many soldiers were referred to civilian mental hospitals. Yet the therapeutic methods used in these institutes were not much different from those employed by the army physicians in the field hospitals, that is to say curing the patient by pumping up his virility. In the numerous cases of shell shock at the Girifalco hospital, the only course of treatment adopted seems to have involved “persuasion” and discussions between the patient and the medical staff. A therapeutic approach, in other words, based on the desire to return the patient to the front as quickly as possible, on the one hand, and on a complete lack of real understanding of the problem and how to deal with it, on the other.
A classic example of war trauma is found in the case of Alfonso P.,[49] a bricklayer from Cava dei Tirreni serving in the 48 infantry regiment. On 21 September 1916, he was referred to the Girifalco hospital for observation with the following diagnosis “a syphilitic subject suffering from depression as a result of war trauma”. He was considered fit for release on 27 December 1916. From the case files it appears that he had been sent to the front on two occasions and wounded twice. From the beginning of his stay at the hospital he appeared depressed, confused and prey to terrifying visions. He wore a bandage on his foot to cover a wound contracted at the front. He suffered both from insomnia and from continual nightmares; he feared being alone and constantly asked to stay in company. The therapy adopted followed the usual route: the director and his colleagues had long conversations with the patient, who was also given warm baths in an attempt to alleviate his anxiety, and mercury injections for his syphilis. The desired subject of the conversations with the medical staff was the soldier’s experiences on the front line, but he was confused and unable to give a coherent account of his combat experience. He could, however, remember being wounded, he had severe facial spasms and sometimes burst into tears, symptoms that were aggravated when the prospect of returning to the front was raised, or when he saw his uniform folded on the chair beside his bed.
A similar story is the case of Natale D. A.,[50] a tram driver from Casaminima (BA), who was admitted to Girifalco on 28 July 1916 and discharged on 31 October 1916. The clinical files describe how, while he was on the frontline in Trentino, he was wounded in the auricle of his right ear by a grenade explosion. The patient only realised what had happened while being treated in a military hospital near the front line. After some weeks he was transferred to the military hospital in Catanzaro. Here, after having thrown from his bedroom window a straw mattress and two back packs he picked up a rifle and fired a shot at the Carabinieri barracks next to the hospital. For this episode he was arrested and held in prison, where he was subject to violent convulsions, and subsequently taken to the Girifalco hospital, completely unaware of what had happened. At first the patient suffered from insomnia, hypersensitive hearing, muscular spasms and intermittent bouts of amnesia. From the medical notes one learns that when first admitted any reference to the subject of the war was sufficient to cause a violent alteration in his heart rate and plunge him into a state of depression and feeble mindedness.
The fact of being haunted by war images from which one cannot escape is a common characteristic of many traumatised veterans of the trenches. What does change, however, is the soldiers’ reaction to that sense of crushing defeat that the cries of the wounded, the devastation and the feeling of total impotence in the face of the bloody events on the frontline had generated. Aside from amnesia, stupor, and a retreat into silence, another expression of mental disturbance was the childhood regression of some veterans who lost themselves in a semi-conscious state in which they regressed with even their voices becoming childlike. This is exactly what happened to Vito G.,[51] a bricklayer from the province of Siracusa, who was diagnosed as suffering from “melancholic delirium as a result of trauma and injuries sustained in battle.” Seriously wounded in a grenade explosion on the Carso front, he was taken to a field hospital where – while under treatment – he began to behave in a childlike manner, such as playing children’s games. At the same time, he was haunted by terrifying visions and bouts of delirium during which he would sing musical arias at the top of his voice, even in the middle of the night. As a result, he was referred to the Girifalco hospital in May 1916, where he continued to present the same symptoms. In conversations with the doctors he only remembered episodes from his childhood, which he recounted in great detail, while he made no reference to his war experiences. In order to compel him to talk about these, the medical staff decided to simulate a war scenario by making a series of dull heavy noises resembling a bombardment and to address the patient in the manner of a military superior issuing commands, at which point he became violently agitated.
A similar case is that of an illiterate Calabrian soldier,[52] diagnosed as suffering from dementia, who was taken from the front to the Girifalco hospital. Once again, observing the patient the doctors noted “little somatic development, scare critical capacity and lack of facial hair”. The patient continued to behave in a childish manner, seeming to remember nothing apart from the games played in infancy, which he recounted “in a falsetto voice”. At night, however he was plagued by horrific nightmares, alternating with mystical and religious visions.
Childhood regression is a means of escape into an imaginary world that provides the sufferer with a safe haven from the total chaos of war. The return to childhood becomes the “symbol of a condition of safety and protection and in the regression to a state of childhood the soldier can avoid reality and express his own emotions and weaknesses.”[53]
On other occasions the diagnosis of shell shock was connected to other considerations, in which the border between clinical diagnosis and prejudice was highly suspect. The dramatic tale of Francesco R.[54] is one such case. This soldier was wounded in the arm during the course of a battle on 10 June 1917 and, unable to withdraw with the rest of his comrades, he remained trapped in a trench where, helpless, he endured an intense enemy bombardment. He told the hospital director how he had witnessed the bodies of his comrades tossed into the air and thrown about by the explosions and how he temporarily lost his hearing on account of the noise of the grenades detonating. While he was finding a way to escape from the danger he was thrown to the ground by a detonating grenade and buried under two metres of earth. After being rescued and brought to safety, he manifested extreme excitability, mental confusion and delirium, and was hence confined in a mental institution. The story in itself is enough to explain the origin of the psychosis and the agonised state of mind of this soldier, yet we find, in the case notes, the comments of Frisco who opines that the young man displays evidence of female characteristics in prey to a hysterical crisis, following the trauma of being buried alive. This recourse to the diagnosis of hysteria that located mental illness in the female sphere confirms a preconception commonly held by Italian psychiatrists during the Great War that considered the phenomenon a “constitutional anomaly […] of a personality with psychic malfunctioning.”[55] The cases of male hysteria encountered during the conflict were commonly linked to effeminacy which, especially as regards soldiers, had negative connotations being interpreted as indicative of a lack of character and virility. Also for the Calabrian soldier, there is evidence of the willingness of the medical team to highlight female characteristics, while the terrible trauma of being buried alive is considered of lesser importance. Even when it is recognised that the patient lives “in a pitiful state, wracked by anxiety and fear, and is unable to hide the desire to commit suicide”, all this is still connected with female behaviours without any understanding that “in his bouts of hysteria the soldier affirmed his right to weakness and fragility, […] a form of passive resistance to a war which was experienced passively, with the dominant emotion one of impotence.”[56]
The lack of consideration given to the psychological suffering of those traumatised by their experience in the trenches reverberated in the wider society. In fact, unlike what happened in the case of those who suffered physical injuries, the ‘mentally mutilated’ nearly always had to face the disapproval of a society at war, in which the calls to heroism and sacrifice had become absolute values. The desire to avoid being rejected and stigmatised sometimes had paradoxical outcomes. For instance, the story of Nicola P.,[57] a butcher from Apulia, bears witness to this. This young man of 22 years was so anxious to avoid the shame and dishonour of being considered mentally ill that he claimed he had faked his illness, although he had all the symptoms of war trauma. The refusal to accept his psychological illness by this soldier, who preferred to return to the front rather than be considered mad, fascinated the doctors who gave him particular attention. Nicola’s clinical history begins with a serious head wound received while fighting in the war zone. In 1916 he was first brought to the mental hospital in Udine for treatment, and thence transferred to another in Catanzaro. A document, dated 6 September 1916 and signed by Doctor Captain Riccio, states that while on leave in Apulia, the soldier was in the vicinity of his house when he heard a rifle shot. At this point the patient “went berserk and started behaving violently so that he had to be forcibly restrained and locked in a room for 17 days.” This pathological behaviour was directly traceable to the head wound received while serving at the front. After further treatment in the hospital in Bari, he was again discharged with the following diagnosis, “neurasthenia, suitable for light and sedentary work”. Assigned to his regimental depot he continued to behave in a strange and impulsive manner, and during his convalescence he had little self awareness, was slow to understand things, and excessively aggressive over minor issues. Judged as a danger to himself and others he was referred to the Girifalco hospital, where he underwent careful analysis that led the doctors to conclude that his psychological illness certainly originated with his battlefield head wound and consequent shock. Nevertheless, as soon as Dr Frisco informed the patient that his illness would require a longer stay at the hospital, because his symptoms displayed all the signs of war trauma with transitory bouts of frenzy and convulsions, the soldier reacted violently shouting that “he had behaved in this way to avoid being sent to the front”. He then wrote home and told his father he was the victim of a plot, and his intention was to return to active service as soon as possible. Rather than replying to this letter his father contacted the hospital to ask the director to give his son the best possible care, mentioning that he had already lost a son, who had died some time previously in a mental hospital in Lecce. Attached to the case file is a letter from Bernardo Frisco in response to the patient, after his discharge, dated 9 August 1917, in which he writes: “as you have asked me for an opinion, I believe that in order to preserve your health you should follow the advice of your father. You have need of a period of calm and therefore until your condition has been stabilised for a good length of time, it would not be a good idea to think of marriage because it would certainly put your cure at risk.” The theme of the regeneration of society and eugenics, which are touched upon in this letter, assumed considerable importance in the post-war period, and were widely debated by the psychiatric community. Once aware of the destructive consequences of the war Italian psychiatrists began to reflect on how the new society emerging with the peace settlement could be ‘completely renewed’ in a constructive and biological sense. The war was seen by most Italian eugenicists as the chance to put “on the order of the day the need to ‘regenerate the social body’, as well as to introduce practical and verifiable medical procedures of the ascertainment and selection of a eugenic programme.”[58] The need for ‘social defence’, as stated in the law of 1904 on the setting up of asylums, would become the subject of heated debate the aim of which was to regulate marriages and control couples who intended to procreate.[59] This is another indication of the devastating impact of the Great War on a disorientated society, forced to change its way of thinking and come to terms with the dark side of modernity, in which human life itself had lost every value.
