Incredible as it seems, the War Office had not prepared for the scale of losses that British forces would suffer in a full-scale European war. Each front-line battalion was to have its own regimental aid post near the scene of combat. But events in the first months of the war moved with such speed that these advanced dressing stations were often little more than a temporary treatment centre in a barn or a crater a few hundred yards behind the fighting. Many miles further back were a series of well-equipped base hospitals, constructed first at St Quentin and later at Le Havre, Boulogne, Amiens and Rouen. The wounded were to be evacuated from the front to these base hospitals as quickly as possible. But here was the problem. Although the latest plans within the RAMC included the use of motorised lorries as field ambulances, Sir Henry Wilson had decided they would not be necessary and that horse-drawn ambulances would prove sufficient. The result was that in the first actions it proved impossible to evacuate the wounded quickly enough. As the Retreat from Mons began, some wounded were taken away by horse-drawn ambulance wagons; others remained behind, exposed to shell fire and to capture by the enemy. As one orderly in the RAMC put it, we ‘took 2 wagon loads of them [wounded men] with us leaving two wagons for cases which might crop up along the road … I was sorry to have to leave 14 men behind in the barn, but there was nothing to do as we had no room for them.’46
Medical officers struggled near the front to cope with the numbers of casualties. In addition to the army medical services, various titled ladies came forward to raise funds and even to organise their own private hospitals along the French coast. The Duchess of Westminster set up one such hospital in the old casino at Le Touquet. Out went the gaming tables, and in came two medical wards, a fully equipped operating theatre, an X-ray unit, a pathological laboratory and beds for 260 patients. The hospital was staffed largely by volunteer doctors and surgeons from St Bartholomew’s Hospital in London, with the support of 60 orderlies from the St John’s Ambulance Association. Many upper-class ladies, friends of the Duchess, came to visit and were seen helping to prepare bed linen and bandages. It seemed to provide an opportunity for the wealthy and titled to do their bit to help the war effort. However, there were inevitable tensions with the RAMC, who before long took over and incorporated these private charitable hospitals into the military system.
The French and German armies were the first to experience the shock and awe of modern firepower in August 1914. The French armies who attacked across open fields in Alsace and Lorraine, wearing their blue jackets, bright red trousers and white kepis, were mown down by German machine guns in vast numbers. In a single day, 22 August, 27,000 French soldiers were killed. By the end of the month, the French had lost 260,000 dead and wounded. The German army also suffered terribly in the bloody month of August, having lost about 265,000 men by the time of the Battle of the Marne.
It was at Mons that the British army first encountered the horror of modern firepower. One officer recalled: ‘It was as if a scythe of bullets passed directly over our heads about a foot above the earthworks. It came in gusts whistling and sighing … It seemed inevitable that any man who went over the bank must be cut neatly in two.’47 In fact British losses at Mons were relatively light at 1,850. During the minor action at Le Cateau, the BEF’s II Corps under General Horace Smith-Dorrien suffered 7,812 casualties and held up the German advance for only a few hours. In the series of running battles later called the First Battle of Ypres in October and November, the BEF suffered 54,105 casualties. The battle would be remembered for the destruction of much of the regular professional army. Eighty-four infantry battalions of about 1,000 men at full strength had gone to France in August. After the Battle of Ypres, seventy-four mustered less than 300 men and eighteen of these had fewer than 100 men. By the end of November, total British losses amounted to 89,964 out of an original army of about 100,000 men.48 Brigadier John Charteris, Haig’s intelligence chief, wrote in his diary in early November, ‘The horrible thing about these last few weeks has been to see our battalions dwindling, and no reinforcements arriving to fill the gaps. What we want here now is more men and more ammunition … the casualties are enormous. We can’t go on forever, we must have men.’49 The British, like the Germans and French, now dug trenches and tried to replace the huge numbers scythed down in the first terrible confrontations of the war.
The war in the west had turned to stalemate. Lord Kitchener wrote to Sir John French in January 1915 that ‘the German lines in France may be looked on as a fortress that cannot be carried by assault and also cannot be completely invested.’50 The British army had gone to war in 1914 planning for a war of manoeuvre and of dramatic flanking movements. But they now found themselves on a static, defensive battlefield with an enemy front line akin to a fortress running for 450 miles from the sea to the Alps. For the first time in its history, there was no flank for the army to turn. The Allies could lay siege to the German lines, but they would find it nearly impossible to assault them successfully. This type of warfare could have been predicted from previous conflicts like the Russo-Japanese War and possibly even the American Civil War. But it had not been. Both sides now had to get used to facing a foe equipped with massed artillery and machine guns by settling down in deep, sometimes waterlogged trenches. This would be a new experience for the armies of Europe and would bring unexpected consequences. The medical authorities were almost immediately faced with an extraordinary challenge that hardly anyone had anticipated.
3
The Shell Shock Enigma
In late October 1914, the 1st Battalion Royal Fusiliers, an elite unit within the regular British army, were out of the line in rest billets near Armentières in north-eastern France. They had been through a period of fierce fighting in the so-called ‘race to the sea’ and had taken part in digging the first trenches that would bring the stalemate characteristic of the next few years of war. One morning a company commander alerted his medical officer to the fact that one of his sergeants was ‘out of sorts’. The MO, as he later wrote, found the sergeant ‘sitting staring into the fire. He had not shaved and his trousers were half open. He seemed a morose fellow; I could get nothing out of him.’ His company commander did not want the sergeant sent away from the battalion sick, as he did not appear to be ill and the company could not afford to lose an experienced NCO at a critical point. But the next day, when the rest of the battalion were moving back up to the front, the sergeant took a revolver and ‘blew his head off’. The battalion was immediately involved in more intense fighting and the MO wrote, ‘I thought nothing of this at the time; it seemed a silly thing to do. I knew nothing then of the tricks war can play with men’s minds. In those early days … we did not bother about men’s minds; we did what we could for their bodies. We did not ask if a man was wearing well or if he would last. Of course he would last, why shouldn’t he.’1
Throughout November and December 1914 the situation grew more puzzling as an increasing number of men with strange and bizarre injuries began to arrive in the Casualty Clearing Stations (CCSs) behind the newly dug trenches of the Western Front. The men showed no visible signs of physical wounds. They had not been hit by machine gun bullets, nor had they been struck by shrapnel. They did not have damaged limbs. They had no apparent wounds to the head. Some of them had minor cuts and bruises but nothing more severe. But they all seemed to display similar strange symptoms that mystified the MOs. Most were suffering from peculiar forms of paralysis. Many were described as having ‘the shakes’. Some could not stand up or walk normally. A few did not appear to be able to speak coherently and were stammering badly. Others had been struck completely dumb and could not speak at all. Most appeared to be in a state of stupor and a few had completely lost their memory. Others seemed to find it difficult to see clearly. Many had lost their sense of taste or smell. Some vomited repeatedly.
The MOs who tried to attend to them had not seen such strange symptoms before and were not sure how to respond. As many were sent back to England with ‘nervous and me
ntal shock’, the War Office began to grow alarmed at the numbers of men being evacuated home. The British Expeditionary Force had already lost a high proportion of its strength and could not afford to lose otherwise fit men due to nervous problems.2
It was the mysterious physical symptoms that seemed so puzzling. One MO described what he witnessed: ‘The eyes pop out of their sockets, the expression becomes fixed and glassy, the facial skin loses all of its red colour, the skin becomes yellow, the cheekbones protrude. The lips are shut tight and sticky spittle tacks up the tongue to the roof of the mouth. The heart works in short, convulsive beats, breathing becomes slower … From time to time a cold shudder runs through the body and the teeth chatter.’3 Another physician attached to a hospital in London wrote that ‘Men in this state may break down in tears if asked to describe their experiences at the front.’4 This was decidedly unsoldierly behaviour. How was the army to react to this strange new phenomenon that no one seemed to understand? The RAMC had no experts in this field. They had to find someone to explain what was happening.
The army assumed at first that the men were suffering some form of epileptic fit. So the War Office asked Dr Aldren Turner to go to France as a ‘consultant’ to investigate. Turner, a highly regarded neurologist from the National Hospital for the Paralysed and Epileptic in Queen Square, London, was a doctor in the Territorial Force. An expert in epilepsy, he had given a major series of lectures on the subject in Edinburgh in 1910 and had written a textbook on nervous diseases. Turner confirmed that from the Battle of Ypres in October 1914 onwards a stream of men had come out of the line suffering some form of paralysis under shell fire. But after a couple of months he had to return to his practice in London. To try to treat these men further the army turned to a doctor who was already in France, working as a volunteer in the Duchess of Westminster’s former hospital at Le Touquet.
Dr Charles Samuel Myers was an unlikely figure to come to the aid of the British army. He was from a family of wealthy Jewish cloth merchants and had grown up in Bayswater, west London. He never fitted easily into the commercial world into which he was born and, having inherited from his mother an interest in music and culture, he became a gifted violinist. He resisted pressure to go into the family business and instead went up to Cambridge to read Natural Sciences in 1892. There he became a pupil and an admirer of William Halse Rivers, a pioneer of experimental psychology in Britain. After Cambridge Myers went to St Bartholomew’s but did not go into medical practice. Instead, in 1898, he decided to join an anthropological expedition to the Australasian islands of the Torres Strait with a group of Cambridge friends including Alfred Haddon, William McDougall and his tutor William Rivers. It was a strange decision, but the expedition was groundbreaking in trying to find a scientific basis to record the psychology, the music and the cultural rituals of the local population. At its heart the expedition’s purpose was to study the anthropology and psychology of the locals to investigate if there was a difference between the brains and intelligence of these ‘natives’, as they were then called, and ‘civilised’ men.
After nearly a year abroad Myers caught a fever in Borneo and returned home to take up his post as house physician at St Bartholomew’s. But he soon decided to return to Cambridge and to pursue the study of psychology alongside Rivers. He wrote a standard textbook on the subject in 1909 and raised funds to open a new experimental laboratory for psychology at Cambridge in 1912, the first of its kind in Britain.5
When war was declared, Myers was at work in his laboratory in Cambridge studying phonographic recordings of ethnic music produced by Australasian tribes. But before long he could no longer concentrate on the task and decided that he must put his professional skills at the service of the army. However, the War Office turned him down, not wanting to recruit medical officers over the age of forty (Myers was forty-one). So he pulled some strings with his contacts at St Bartholomew’s and got the job of registrar in the Duchess of Westminster’s war hospital at Le Touquet. When the RAMC decided to bring the hospital under its own wing in November 1914, Myers was commissioned in the corps as a captain. While he was at Le Touquet, three soldiers were brought in suffering from various forms of war neuroses. As someone who had devoted his life to the study of the mind, he was the obvious doctor to treat these sad cases. Other doctors turned psychiatric cases away; Myers welcomed them. As he later wrote, ‘it was clear to me that my previous psychological training and my present interests fitted me for the treatment of these cases.’6
The first cases treated by Myers included a soldier who had been trapped for several hours in the barbed wire of No Man’s Land. While he was stuck on the wire, several eight-inch shells had burst nearby. The man, who had been cheerful and positive before this terrifying experience, was eventually brought back to the British lines in a pathetic state, crying and shivering in a cold sweat. His mates described his escape as ‘a sheer miracle’. He appeared to be suffering from blurred vision and felt a burning sensation in his eyes, making him panic that he was going blind. Myers concluded that although the soldier was not physically wounded, he had suffered some form of physical concussion from the proximity of the shell explosions and that ‘the high frequency vibrations’ from the shell had caused ‘an invisibly fine “molecular” commotion in the brain’.7 Myers believed that the man was now displaying the symptoms of this physical damage. When he wrote about this and the two other cases in the doctors’ journal The Lancet in February 1915, he described the condition, adopting a term used by the soldiers, as ‘shell shock’.8
This first use of the term ‘shell shock’ in medical circles suggested that the cause of the mental disorder was concussion of the brain from the bursting of a shell nearby – physical damage to the nervous system is exactly what the words ‘shell shock’ were intended to signify. However, the term was soon in use to describe a wide range of physical symptoms that doctors could not easily explain. It was a simple term but one that had instant resonance for those who saw the strange cases coming in from the front, and doctors began using the words to describe almost every sort of nervous breakdown, trauma or anxiety neurosis. Although the stalemate of trench warfare had only existed for a few months, the military authorities quickly realised that this form of immobile war was a new phenomenon. Men cowering in a trench with shells constantly landing all around them, unable to exercise the instinctive human response to run away, were suffering from extreme forms of anxiety or stress. The shells were far more lethal than those used in previous conflicts, consisting of high explosives that could be fired in rapid succession from miles away. Sudden, horrific, seemingly random death or mutilation became a feature of trench life that every soldier had to live with.
Almost everyone who went through such a bombardment during the First World War described in similar terms the effect it had on them. Gerald Brenan was typical of most when he later wrote of being caught in a German barrage: ‘I do not think anyone who has not lived through one of these can form a conception of what they were like. The earth appears to rock and tremble. The air is filled by a persistent rushing sound, broken by the crash of explosions. The mind cannot think, the arms and legs tremble automatically, and the tough man is the one who recovers quickest.’ After enduring a particularly heavy barrage, Brenan looked at the soldiers in the trench around him and ‘saw the shattered looks of the men who had survived, and heard the moaning and the sobbing of a poor fellow who had broken down’.9
Tom Pear, a young academic psychologist who had studied under Myers at Cambridge, wrote a few years later that conditions in the trenches were unique, claiming, ‘Never in the history of mankind have the stresses and strains laid upon body and mind been so great or so numerous as in the present war.’10 But it was not only the younger generation of psychologists who attributed the high incidence of shell shock to the unique conditions of the Great War. General Horne, commander at the time of an infantry division in France, agreed with this view and claimed that shell shock ‘became a serious fact
or in this war owing to the peculiar character of the war [in contrast to previous conflicts].’ He concluded that shell shock could be put down to the high level of ‘explosives and bombardments [that] had never been known before’.11 A medical officer from the Western Front later said that ‘acute breakdown … occurred especially during bombardments when the men, sometimes in large numbers, lost their heads and lost their control.’12
Now that this strange new phenomenon had a name, the army needed to know how to shape its response. However, the problem for the military was that there was no agreement as to how to treat the many different conditions and neuroses labelled as ‘shell shock’. Myers’ diagnosis and use of the term began an intense debate within the medical community in Britain about the nature of shell shock. The study of ‘nervous diseases’ had become fashionable within the medical profession in the twenty years before the Great War. Indeed it had been written in 1909 that ‘Nervous breakdown is the disease of our age’; this was put down to the speed of modern life and the stresses and strains generated by the ‘wear and tear’ of the urban and industrial environment with the ‘constant struggle for a livelihood’.13
However, in the Edwardian era a fundamental class divide emerged between the treatment of ‘poor lunatics’ in mental asylums by psychiatrists on the one hand, and the treatment of wealthy clients by neurologists, on the other. There had been a big increase in the number of registered lunatics in the second half of the nineteenth century, so that by 1913 there were estimated to be 165,000 men and women in largely Victorian mental asylums that were now horribly overcrowded. Relatively little treatment was available for the poor individuals in these wretched places, where each psychiatrist (known as an ‘alienist’) had between 400 and 600 patients at any one time. As a consequence, being sent to an asylum was often a life sentence. The early twentieth-century lunatic asylum has recently been described as ‘a storehouse for incurables’.14 Certainly in the public view admittance to an asylum was a cause for intense shame. The Victorian asylum system had been partly created to lock away and out of sight those who were classed as ‘imbeciles’, regarded as being unable to contribute to society. The doctors who did study these patients concluded that mental illness was frequently hereditary, and it was usually perceived as some sort of weakness. Much debate took place in late Victorian and Edwardian Britain about what was called the ‘degeneracy’ of the race, the growth in the number of lunatics being cited as proof of this. And most people felt that lunacy was incurable. ‘Once a lunatic, always a lunatic’ was a phrase used by London County Council in a report on its mental asylums in 1914.15 This was not a message of hope for the impoverished insane or pauper lunatic.
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