If an MO could avoid sending a man ‘back down the line’ to a CCS or base hospital for specialist treatment, he would do so. Charles Wilson, MO with the 1st Battalion Royal Fusiliers, was in his dugout alone in the spring of 1915 when one of his stretcher bearers staggered in, in a dreadful state. A corporal accompanying him explained that the bearer had been in a party of four ‘carrying a man on a stretcher when a shell caught them and literally splashed him with bits of the other three bearers. He himself escaped without hurt. Now he seemed done.’ Wilson sent the corporal away and decided to keep the bearer where he was until things were quieter. ‘I got him to lie down on the stretcher on which I slept. Almost at once to my great wonder he fell asleep. It occurred to me that there might be an outside chance of saving this fellow the mishap of going to the base [hospital] with shell shock. I dropped a blanket down so that he was hidden and made him some hot stuff to drink. He slept for nearly twenty-four hours. When he awoke he seemed all right. He went out with me next day and never looked back again. Fatigue, loss of sleep and the shock of witnessing the death of the other bearers had for the moment used up his will power.’3 Will power was repeatedly stressed as being at the centre of the cure for shell shock.
The Official Medical History recorded that in about 75 per cent of cases the patient could be classed as ‘mildly confused’. To describe such men, MOs used phrases like ‘appears dazed’, ‘looks strange’, ‘is inclined to behave foolishly’, ‘is dull and takes no interest in anything’. Often the patients could answer simple questions regarding their name and age but were unable to give a clear account of what had happened to them. Usually they could remember being in the line, but at a certain point amnesia would set in and they could recall nothing that followed.4 This was clearly the point at which the trauma, perhaps witnessing a horrific incident or being buried under the earth thrown up by an explosion, had occurred. Often this confused state lasted only twelve to twenty-four hours; after a few days of complete rest the patient’s memory returned and he appeared to suffer no long-term residual effects. Most men suffering from shell shock also felt a strong sense of shame, of having let their mates down, and so were usually keen to return to their battalion as quickly as possible.
However, certain more severe cases were diagnosed as suffering from some form of hysteria. Such patients often lay down with their head under the blanket, wanting to hide, and were resentful of interruptions. A man so affected would appear to understand an instruction but would not carry it out. He would be unresponsive and his face would be full of contortions. Often the symptoms would become more serious after a day or so and he would start to tremble, become mute or his limbs would start to shake. In this state, a patient would sometimes shriek if disturbed or even burst into tears if prompted to recall the moment of trauma. This state would continue for at least a week or ten days. There was no alternative but to send such victims back down the line to a CCS or base hospital, some of which from late 1916 began to specialise in treating nervous patients.
Before the Somme, if a man was sent to a CCS or a base hospital with a severe case of shell shock, he was almost certainly returned to England and would be out of action for some time. Between April 1915 and April 1916, some 1,300 officers and 10,000 men had been admitted to special hospitals in Britain suffering from shell shock.5 A major problem that arose with these cases was that often a patient’s medical notes would be lost as he was sent further down the line from one hospital to another. Initial descriptions of what had happened, or of a man’s physical symptoms or diagnosis, were mislaid in CCSs or base hospitals that were struggling to cope with a huge influx of patients. As a consequence, doctors in Britain complained that they were having to start the process of diagnosing and treating a patient all over again.
By the middle of 1916, the general attitude to treatment for shell shock had changed. It was felt that treating men in an environment in which military discipline was loose, or even non-existent, was not appropriate in terms of returning them to the fighting front. Instead of sending a shell shock victim back to Britain it was thought best to keep him in ‘Army areas’, as they were called. Military prejudice was never far from the surface, and one doctor spoke of the hospitals in Britain being far too ‘soft’ and of female nurses showing too much sympathy to the men, who were ‘petted and given nothing to do’. In these circumstances, he argued, ‘I found they got worse. What they required was to remain under strict discipline and that was the only way to get them well quickly.’6 Another physician argued that if a man found himself in ‘an atmosphere of sympathy, consideration and comfort’, his anxieties would not go away but were more likely to become fixed. If friends and family members regarded the illness ‘as absolutely equivalent in disabling power to a severe wound’ then the patient was more likely to believe it and so would be unlikely to make a recovery.7
This strange military logic was widely accepted at the time. Charles Myers took the same view when he became Consulting Psychologist to the Army in August 1916, arguing of shell shock victims that ‘the Regimental Medical Officer’ in the front line aid post ‘may still combat their condition by the aid of moral suasion, and he may thereby successfully induce them to return to duty’, whereas if they were sent ‘farther down the Line, it may take many weeks or months before they are again fit for duty’.8 Today, it remains a fundamental principle in the care of traumatised soldiers that treatment is provided as quickly and as near to the combat scene as possible. Labelled PIE – ‘Proximity, Immediacy, Expectation’, the theory is that psychiatric patients should be dealt with close to the front, as quickly as possible, and should be treated as soldiers not like patients, in order to maximise the expectation of recovery. The ideas laid down by Myers and other First World War neurologists have become the basis for military psychiatry ever since.
Yet however much the army would have liked to return its shell shock victims to the firing line as soon as possible, doctors had to admit that some cases were too severe to treat so close to the front. Some patients were too troublesome for standard hospital wards to deal with. Patients were sometimes so wild and excitable that they needed tying to a bed. They would think they were still in the trenches and would interpret normal hospital sounds as those of artillery or machine guns. Sometimes they would call out to the other patients in the ward using the names of mates in their platoon. They would accuse doctors of being Germans in disguise, out to kill them. They would hallucinate and become fearful or terrified. One 21-year-old patient was sent to a CCS where, having been restless for three days, he started wandering away from the ward. On the fifth day he announced that he was going to see his father, who was outside. The slightest noise would terrify him. On the tenth day he came before a medical tribunal, but ‘his expression was staring and anxious. He talked rubbish in answer to questions.’ He went back to bed and lay there for hours, muttering to himself. By the fourteenth day he had brief attacks of weeping but would then become quite cheerful and talkative. On the eighteenth day, his doctors noted: ‘Complains of headaches; his attention is very poor, his cerebration much slowed and he still exhibits terror, both in appearance and behaviour.’ His hands still shook. A few days later he escaped from the CCS and found his way almost back to the front line before he was discovered and evacuated to a specialist hospital at the base.
Another patient, a 23-year-old of ‘solid and robust appearance’, was brought in presenting a ‘dazed, lethargic condition’. He lay in bed staring aimlessly and rarely changed his position. He could be persuaded to open his eyes but appeared to recognise nothing. After five days all he would volunteer was to say ‘I feel better’, and he was totally passive regarding anything that happened around him. After eleven days he began to wander aimlessly up and down the ward, ‘but took no notice of other patients and never spoke to anyone’. He was put on a pure milk diet for some days but made no protest. Taken to a concert in the hope of cheering him up, he exhibited no change. On the seventeenth day the doctors stil
l reported a ‘strong frowning expression which is persistent’ and slight tremors. He would reply to the simplest of questions only after several seconds and ‘no account of his history, recent or remote, has been obtained from him’. His habitual position was to sit with his head ‘buried between his hands’. After four weeks he was sent to a base hospital.9 It is not difficult to imagine the nightmares that the poor man must have been going through. Sadly, there is no record of whether he ever recovered.
As there was still no consensus as to the cause of war neuroses, many different cures were tried. It all added up to a great laboratory of the mind. Hypnosis, a tool of French psychologists since Jean-Martin Charcot in the nineteenth century, was sometimes used. Where a shell shock victim had no idea what had happened to him or even which unit he belonged to, doctors could sometimes extract all the details they wanted under hypnosis. Being interested in the concept of lost memory, Myers was among those who treated patients using hypnosis. When the patient awoke, Myers would immediately discuss his experience with him. He claimed that when patients recovered their memory the physical symptoms, the paralyses and tremors, disappeared automatically. Myers recorded excellent results with this technique and in at least one case reported a full recovery.10 He wrote in 1916, ‘No one who has witnessed the unfeigned delight with which these patients on waking from hypnosis, hail their recovery from such disorders, can have any hesitation as to the impetus thus given towards a final cure.’11 But Myers did not find hypnosis easy and was never happy using the technique. Moreover, most army doctors not only had no familiarity with hypnosis but indeed, they were deeply suspicious of it. It probably seemed very mysterious and foreign to them. Even fifteen years after the war, it seems, the mere mention of hypnotism could raise ‘a jolly masculine laugh in RAMC circles’.12
So, while by mid-1916 the vast majority of shell shock cases received treatment in France, many seriously afflicted patients were still evacuated to Britain. Here, as the term ‘shell shock’ covered a myriad of medical conditions, so a myriad of forms of treatment were on offer. Dr Ronald Rows (pronounced Rowse) took charge of Maghull, the first hospital given over to the treatment of shell shock. As an asylum manager for some years before the war he had taken the conventional view that all mental patients should be kept in their beds unless they became troublesome, in which case they should be given ‘bath treatment’, in other words locked into a wood-encased bath of cold water to calm them down. But just before the war Rows had discovered the work of Freud and Jung. Transformed, he became a great reformer of mental hospitals and now used Maghull as an opportunity to develop his interest in psychoanalysis. Rows would look for the emotional origins of a soldier’s problem. He encouraged a caring approach to the shell shock victims who soon filled the long rows of metal beds in his hospital. Photographs show the patients proudly wearing the smart blue uniform of the wounded soldier, with white lapels and red ties.
Rows encouraged his doctors to talk to patients and to use their dreams (or nightmares) to try to understand what was at the root of their fears. According to Freud’s approach, the cause of the physical symptoms of shell shock was likely to be a traumatic incident that had been repressed but could be revealed sometimes in a patient’s dreams. The men were therefore offered one-on-one sessions for an hour at a time. But there were lots of barriers to break down. The men, mostly from working-class backgrounds, were not used to discussing their feelings in an open, relaxed fashion. Some grew suspicious that their dreams were being used in some way they did not fully understand to decide whether or not they should be sent back to France. A lot of men simply clammed up.13 But for many patients, finding the cause of their problem and talking it through helped to make the fear disappear, in a form of psychotherapy. Millais Culpin, an army surgeon who transferred from surgery to psychology, wrote with some amazement on arrival at the hospital that ‘a new world opened up, when under the influence of the Maghull teaching I began to treat shell-shocked men by the apparently simple plan of getting them to talk of their experiences.’14
One of the most senior figures who went to work at Maghull was Dr William Halse Rivers. He would become probably the most famous of the Great War psychologists. Rivers had studied medicine at St Bartholomew’s in London, where he became the youngest graduate in the hospital’s history. Having worked as a physician in the National Hospital for the Paralysed and Epileptic in Queen Square, he went on to become a clinician at the Bethlem lunatic asylum and in 1897 helped to establish the new Psychology Department at Cambridge University. Among his students was Charles Myers, and in 1898 the pair took part in the anthropological expedition to the Torres Strait, during which Rivers carried out painstaking research on the kinship patterns of the local tribesmen.
From 1902 Rivers returned to his career at Cambridge while at the same time continuing his pioneering ethnographic work, both in southern India and in Melanesia in the south Pacific. In 1915, when he arrived at Maghull, Rivers must have seemed an unusual figure, bringing an academic feel to his treatment of shell shock victims. He was then aged fifty-one, a bachelor who rarely smoked or drank. He was shy, had a mild stammer, did not mix easily and was still obsessed with his ethnographic studies. Very serious in manner, he did not easily engage with the rank and file soldiers being treated there. But he was familiar with the work of Freud and Jung and slowly became drawn into a community in which the interpretation of dreams and the discussion of topics relating to the mind was an everyday activity. He began to realise that Maghull offered him a unique way of understanding the minds not of distant tribesmen but of his fellow Britons.
Maghull soon attracted a rush of bright young academics from the universities who saw work there as a brilliant opportunity to look into men’s minds and to apply the ideas of Dejerine, the great French psychotherapist, 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.’15
The work at Maghull achieved some renown and the RAMC began sending doctors on three-month courses there to study psychotherapy, dream analysis and the treatment of shell shock. The establishment was rare among British hospitals in showing real sympathy and understanding for its shell shock patients. The men were treated with respect and offered forms of occupational therapy like playing cards or billiards, or working on the hospital farm. It was a classic case whereby the war created a human laboratory for some of the brightest young psychologists of the day to come and experiment and to help solve the problems thrown up. Maghull became a hotbed of ideas that would shape new British psychology after the war. And, ironically, this was all done at the expense and with the encouragement of the War Office.
The Maudsley Hospital in south London was built to treat civilian patients but was requisitioned by the War Office and opened its doors to the first shell shock victims in January 1916. Lieutenant-Colonel Atwood Thorne, a Territorial medical officer, was put in command, while Frederick Mott set up his laboratory there, his influence determining the hospital’s line of treatment. He emphasised the need to create an opportunity for the ‘quiet repose’ of patients, in a place where ‘nourishing, digestible’ food was on offer. He did not believe that hypnosis or psychoanalysis were ‘necessary or even desirable’ when it came to the treatment of ‘psychic wounds’. But he did believe in occupational therapy and patients were encouraged to grow vegetables in the hospital gardens and work in the poultry house. He built a workshop where men could practise carpentry and metalwork, and donated a piano around which they could gather and practise choral singing. Mott wanted to create an ‘atmosphere of cure’ by ‘promoting cheerfulness and healthy recreation’ in order to generate ‘that sense of well-being so essential for mental and bodily recuperation’.16
At the other end of the treatment spectrum was a violen
t physical technique called electric shock therapy. Electricity had been used to treat mentally disturbed patients since the end of the nineteenth century and was politely known as the ‘faradic battery treatment’. Most of the armies of the First World War used electric shock therapy and in the German army, neurologist Dr Fritz Kaufmann made his name by the severity of his treatment in a hospital near Mannheim. He insisted on a strict regime, hoping that word would spread about the harshness of the conditions in his hospital and thereby deter soldiers from malingering. Kaufmann believed that if a man had experienced a shock, the best way to treat him was to administer another, physical shock. He would give his patients an electric shock lasting between two and five minutes, while shouting at them that they should be ashamed of themselves and should snap out of their condition. Extraordinarily, in many cases this brutal approach seemed to work. Not only did some men recover but they were enormously grateful for their treatment. Sadly, in a few cases, men died undergoing electric shock treatment. About twenty German victims died during the war, while others committed suicide rather than face the treatment.
Understandably, patients greatly feared electric shock therapy. But that was part of the intention. At the National Hospital for the Paralysed and Epileptic, Lewis Yealland from Toronto, who had worked for a short time in asylums in Canada, took up the use of electric shock therapy with a fervent zeal. He believed that hysterical patients were weak willed but had convinced themselves that the physical symptoms from which they were suffering were permanent; therefore they had to be persuaded by the use of an electric shock that they could get better.
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