During 1915 and the early months of 1916, as Myers toured the CCSs and Base Hospitals and examined some 2000 patients, debate continued to rage about the causes of the multitude of conditions. Frederick W. Mott, a neurologist at the Maudsley Hospital in south London, had not been to the front but had studied patients evacuated to London. He argued in a series of lectures that exposure to shell fire had a pathological effect on the body’s nervous system, possibly caused by concussion to the brain from the impact of an explosion. But he also agreed that psychological factors played a part and that a man’s state of mind before an explosion might well affect his reaction to it. Some people were more disposed to suffer from the horrors of trench life than others, Mott believed. He argued that fear was a biological instinct and the anticipation of death or mutilation was a major cause in what he called the neuroses of war.11
Another view came from Harold Wiltshire, an experienced physician who worked at a Base Hospital in France for a year before concluding that the symptoms of shell shock were entirely of a psychological rather than a physical nature. He observed that men who had lost limbs in shell explosions did not suffer from shell shock. In hospital they were often cheery and supportive of the medical and nursing staff. This contrasted with the morose gloom and lack of hope evident among patients in a shell shock ward. He believed that men suffering from shell shock had been worn down by the prolonged strain of trench warfare into a position where a further sudden psychological shock could tip them over the edge. He cited the example of a soldier who experienced mental shock having been ordered to clear away the remains of a number of comrades who had been blown to pieces by a shell. It was becoming clear to those working with patients that the term shell shock was, as Myers himself later put it, ‘a singularly ill-chosen term; and in other respects... a singularly harmful one’.12 In the vast majority of cases, Myers accepted, shell shock had psychological and not physical causes. But by this point, the term was too well established to be abandoned. It served its purpose in helping to delineate between traditional concepts of courage and cowardice under fire. This was the state of the debate when in the summer of 1916 everything went up a gear.
The Battle of the Somme opened on 1 July. Detailed preparations had been made, as we have seen, for the treatment of the wounded. But the medical authorities were overwhelmed by the number of shell shock cases. In one division the number of ‘Shell Shock W’ cases increased fivefold in a few weeks, amounting to one in six of all casualties. The number of ‘Shell Shock S’ cases were not recorded but Ben Shephard, a historian of military psychiatry, has concluded that the number of official casualties could probably be ‘multiplied by at least three to give a real sense of the scale of the problem’.13 Moreover, it was noticed that the incidence of shell shock in all its forms was much higher in some units than in others. Once again, the War Office became concerned that losses on this level would undermine the army’s ability to continue waging war. It was clear that a tough stance had to be taken, even though Myers had spent a year trying to persuade the authorities to be sympathetic to the sad victims of shell shock. This approach now went into reverse.
One case clearly reveals the hardening of attitude. The 11th Battalion of the Border Regiment was a Pals Battalion recruited by the Earl of Lonsdale from the farm labourers, industrial workers and miners around his estate in Cumberland and Westmorland. On 1 July 1916 the battalion went over the top in the first-wave assault near Thiepval on the Somme, but was massacred by German machine gunners as the men tried to get through barbed wire that the artillery barrage had failed to cut. The unit lost 516 men (out of about 850) during the course of the morning, including its commanding officer, Lieutenant-Colonel Percy Machell, a popular figure with the men who at the age of fifty-four still joined in the assault and was hit as soon as he climbed out of the trench. All but three of the officers in the battalion were killed along with him.
Just over a week later, on the evening of 9 July, the remains of the battalion, about 250 men, were recovering behind the lines when the newly appointed officers were told to select 100 men to carry out a trench raid. The medical officer, Lieutenant Kirkwood, reported that many of the men claimed to be unfit for duty suffering from shell shock and were unwilling to go over the top again. He made out a certificate that explained in some detail why this was the case: the men were still suffering from the demoralising effect of the assault on 1 July, they had spent a week digging out the dead in an atmosphere of decomposed bodies, and they had been under continuous shellfire since going over the top. He concluded that ‘few, if any, are not suffering from some small degree of shell shock’.14 Ignoring this evidence, Brigadier J.B. Jardine ordered that the raid should go ahead anyway. It was a complete failure.
The army ordered a court of inquiry, which blamed the brigadier for not knowing the state of the men in one of his battalions. He, in turn, blamed the non-commissioned officers for failing to set a good example in the absence of officers. General Sir Hubert Gough partly blamed the men, saying it was ‘inconceivable’ that British soldiers could ‘show an utter want of the manly spirit and courage which at least is expected of every soldier and every Britisher’. But the full weight of his wrath fell on the medical officer, Lieutenant Kirkwood. Gough said that ‘so long as he is allowed to remain in the service he will be a source of danger to it... [and] it is not for a MO to inform a CO that his men are not in a fit state to carry out a military operation.’ Kirkwood’s sympathy for the mental state of his men had hit a nerve. Although the 11th Battalion had suffered badly, it had by no means endured the worst losses on the first day of the Somme. Martin Middlebrook lists thirty-two battalions that had suffered casualties of more than 500 men on that day.15 But the senior command realised it had to take a stand to prevent the collapse from shell shock becoming an epidemic and getting, in its eyes, out of hand. Kirkwood was dismissed from the army in disgrace.
Sir Arthur Sloggett, head of the RAMC in France, came to Kirkwood’s defence, claiming he was a ‘scapegoat’. He persuaded the authorities to reassign Kirkwood from his front line MO role to a humble position in a Base Hospital. But without doubt, the word would have got around. The army was going to take a hard line on anyone who was not tough on shell shock.16
In early August, GHQ issued new demands to reduce ‘wastage’ and cut down on the numbers of shell shock cases being evacuated back to England. This was a chance for Myers once again to argue that men with mental disorders should be treated as quickly as possible near the front. For the first time his own views coincided with those of the high command. Appointed to the senior position of Consulting Psychologist to the Army, he toured the front meeting generals and inspecting aid stations. For the first time a special treatment centre for shell shock cases was set up in a CCS and Dr William Brown, a former pupil of Myers, was put in charge of it. But Myers’ star crashed as quickly as it had risen. The belief of senior commanders in his work had never been very genuine and with the Battle of the Somme over, in January 1917, he was summarily removed from his senior position. Myers returned home to England on two months’ sick leave, frustrated and embittered by his experiences on the Western Front and his failure to change the views of the generals.
Myers’ replacement was Gordon Holmes. The son of an Anglo-Irish landowner, Holmes had read medicine at Trinity College, Dublin and in 1901 started work as a house physician at the National Hospital for Nervous Diseases in Queen Square, London. Here he carried out detailed examinations of the brain and began to realise that its various parts, such as the cerebellum, the thalamus and the cerebral cortex, accounted for different sense perceptions. Holmes soon acquired a reputation as a leading neurologist. After the outbreak of war, he worked for some time at the Base Hospital in Boulogne, where he came to the attention of Sir Arthur Sloggett. Holmes’ views, it was noted, were far more in tune than Myers’ with the attitudes of senior commanders in the army. He was a disciplinarian who believed that hysteria could easily spread from one soldier to
another and had to be dealt with ‘in no uncertain fashion’, otherwise the army would soon be drained of its fighting spirit.17 He believed the role of the military neurologist was merely to remove the physical symptoms of distressed soldiers rather than try to find their psychological causes.
Claire Tisdall, a young volunteer nurse, later recalled the shame and lack of compassion exhibited towards these tragic victims. She was collecting a group of patients from an ambulance train one day when another ambulance appeared unexpectedly. The second train was totally closed up, with all its windows barred and shut. ‘What’s this ambulance coming in?’ she asked. ‘Haven’t we done the train?’ ‘No, sister,’ came the reply. ‘This is for the asylum; it’s for the hopeless mental cases.’ The young nurse later wrote, ‘I didn’t look. They’d gone off their heads. I didn’t want to see them. There was nothing you could do and they were going to a special place. They were terrible.’18
Despite the hardened attitudes, official figures indicate that the incidence of shell shock in the Battle of Passchendaele in the summer of 1917, at about 1 per cent of the men who took part, was far lower than it had been during the Somme. Partly this might have been down to administrative changes. In order to reduce the numbers being classified as ‘Shell Shock W’, the army had invented a new category of ‘NYDN’, meaning ‘Not Yet Diagnosed Nervous’. It is possible that thousands of men were put in this category and waited for long periods before the paperwork was completed to finalise their condition. Regimental medical officers were given much more authority to decide on cases.19 And although there was still no consensus on what caused nervous breakdowns, more and more doctors diagnosed men as simply exhausted. They called for a week or two of rest and sleep, and a few firm words of reassurance. William Johnson, who worked in No. 62 CCS in Flanders, claimed to be able to treat a large number of patients, even restoring speech to those who had become mute or restoring the memories of those with amnesia. He would summon a man into his office, ask him to lie down on a couch, and tell him to rest, close his eyes and give himself up to sleep. In a state of light hypnosis, Johnson would then instruct the patient to return to the trenches and relive his particular moment of shock. At first the soldier would twist and turn and sometimes cry out. But slowly, by describing his moment of terror, he would improve; it was as though describing the problem under hypnosis would lift it from his mind and slowly enable him to work out his neurosis. Sometimes, Johnson could cure a man in about twenty minutes. Getting men back to their unit was, after all, the objective of the military medical officer.
Of course, some cases could not be cured in this way, and men were still evacuated to England displaying the ghastly effects of shell shock. At a hospital in Devon, the freakish behaviour of certain shell shock victims was recorded on film. The short clips show tragic scenes of men who cannot walk and who roll about on the floor, who shake uncontrollably, who leap under the bed at the mere mention of the word ‘bomb’. The filming took place at Seale Hayne Hospital on the edge of Dartmoor. Here, Dr Arthur Hurst practised. A great showman, Hurst made countless claims as to his ability to cure the symptoms of hysteria, which he was able to do using his strong powers of persuasion, sometimes backed with hypnosis, physical manipulation or even electric shock treatment. The expectation that a patient would receive a miracle cure was drummed into him from the moment he arrived at the hospital, while the build-up to meeting the doctor on the day of the treatment made it into almost a religious experience. The purpose of the films made at Seale Hayne was to show victims before and after their treatment with Hurst and certainly, the patients on film appear to be cured. After treatment they walk briskly and confidently by the camera, feed chickens or work happily in the hospital farm. Myers and other critics, however, were not convinced that removing the symptoms of hysteria was the same as curing the problem. There were stories that by the time some patients had arrived back in London on the train, they had developed new symptoms and were almost as bad as before.20
At a hospital just outside Liverpool, a different and far more radical approach was taken in an effort to solve the underlying psychological causes of shell shock. Maghull Hospital (later called Moss Side Hospital) had been built before the war as a large, airy and spacious establishment to treat epileptics. When the War Office requisitioned it, Ronald Rows was put in charge. A reformer of mental hospitals who had an interest in Freud, Jung and psychoanalysis, he encouraged a caring approach to the shell shock victims who soon filled the beds. Doctors were to talk to the patients and to use their dreams (or nightmares) to try to understand what was at the root of their fears. Frequently, finding the cause of the problem and talking it through would make the fear disappear, a form of psychotherapy.
Rows looked for the emotional origins of a soldier’s problem. He soon attracted a rush of bright young academics from the universities who saw work at Maghull as a brilliant opportunity to look into men’s minds and to apply the ideas of Dejerine and Freud. They included Tom Pear, who went on to become a professor of psychology at Manchester University, and Grafton Elliott Smith, Professor of Anatomy at the same university. Pear would tell his patients reassuringly, ‘You are suffering from an illness. It’s called mental illness. You are not mad and you are not a lunatic.’21 Maghull was rare among British hospitals in showing real sympathy and understanding for its shell shock patients. It was a classic case whereby the war created a human laboratory for some of the brightest young psychologists of the day.
One of those who passed through Maghull, William Halse Rivers, has since become perhaps the most famous of the Great War psychologists. Rivers was in his early fifties at the time and had done a range of work before the war. He had studied medicine at St Bartholomew’s in London, where he became the youngest graduate in the hospital’s history; he had worked as a physician in the National Hospital for Nervous Diseases in Queen Square; he had been a clinician at the Bethlem lunatic asylum; and in 1897 he had helped to establish the Psychology Department at Cambridge University. He was interested in the relationship between mind and body, and at Cambridge he carried out remarkable research with his colleague Henry Head by cutting the nerves in Head’s left forearm and over a period of years mapping its recovery of sensory perceptions. In 1898 he had accompanied Myers on the anthropological expedition to the Torres Strait, where he had carried out detailed and painstaking work into the social and belief patterns of the local tribesmen. He went on from here to south-west India, where he continued his pioneering ethnographic studies.
When he arrived at Maghull in July 1915, Rivers must have appeared an unusual figure. A bachelor who rarely smoked or drank, he was something of a recluse and remained obsessed with his anthropological studies. But he slowly began to realise that Maghull offered him a way of opening a window into the minds not of distant tribesmen but of his own fellow Britons. The interpretation of dreams and the understanding of emotional problems provided new areas of study. In 1916, Rivers was commissioned as a captain in the RAMC, and later that year he was sent to Craiglockhart Hospital for Officers just outside Edinburgh, located in a dilapidated Victorian hydro spa that had formerly been used as a convalescent home. Here he was to play a memorable role in the development of techniques to heal shell shock.
Craiglockhart was a humane, friendly and supportive establishment for officers only. By day, the patients could play cricket, tennis, bowls, croquet or use the hydro-pool. But at night, many were still tormented by nightmares. Rivers went back to study Freud and spent more time analysing his own dreams as well as those of his patients. He increasingly felt sympathetic to the pacifists who saw the war as a great folly, and he grew uncomfortable about his role as a military doctor whose principal duty was to prepare men to be sent back to the front. Then, on 4 August 1917, a new patient arrived at Craiglockhart. His name was Siegfried Sassoon.
The relationship between Rivers and Sassoon became one of the most famous doctor-soldier relationships of the war. It was described extensively by Sassoon in
his own writings and provides the core for Pat Barker’s award-winning 1990s Regeneration trilogy of novels, the first of which was made into a film.22 ‘Mad Jack’ Sassoon had been a brave soldier and had won an MC in 1916, but while recovering from wounds in London in 1917 he had issued a public declaration denouncing the conflict: ‘I am making this statement as an act of wilful defiance of military authority, because I believe that the War is being deliberately prolonged by those who have the power to end it.’23 However, instead of a court martial, influential friends intervened and arranged for him to be sent to Craiglockhart, supposedly suffering from shell shock. Whether or not Sassoon really was suffering from a nervous breakdown is a moot point, but he had certainly suffered from nightmares in which he saw wounded men from his battalion crawling towards his bed.
Rivers met Sassoon and the pair began a long series of conversations. Rivers had suppressed his homosexual tendencies, while Sassoon was becoming increasingly open about his own, and the two men soon became friends. Sassoon described Rivers as a ‘father-confessor’ figure – his own father had died when he was seven. After three months of ‘treatment’ either Rivers persuaded Sassoon to return to the front, or Sassoon himself decided that it was his ‘mission’ to rejoin his battalion. It was an extraordinary turnaround. He was sent at first to Palestine but eventually returned to France, where he was finally invalided out of the army after being wounded again in July 1918. After his experience with Sassoon, Rivers decided to leave Craiglockhart, and he became a psychologist at the Royal Flying Corps hospital at Hampstead in London. ‘Aviators’ Neurasthenia’ was high in the RFC; in the later stages of the war it affected 50 per cent of all pilot officers, although roughly half of those were successfully treated and returned to full flying duties.24 Rivers played his part here as well although it is for his treatment of Sassoon at Craiglockhart that he is best remembered.
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