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No Doubt They'll Soon Get Well

Last updated: 28 April 2016

Recorded on 30 October 2014

Dr Peter Johnston of the National Army Museum explores the British military reactions to the concept of 'shell shock'. He outlines how the British Army in the First World War moved from a position of denial and discipline to one of acceptance, treatment and even exploitation before the war's end.

Transcript

Dr Peter Johnston:

'No doubt they'll soon get well; the shock and strain / Have caused their stammering, disconnected talk. / Of course they're "longing to go out again", / These boys with old, scared faces, learning to walk.'

That's obviously from Siegfried Sassoon's 1917 poem 'Survivors', which describes the shell-shocked soldiers that he encountered during his wartime service, both as an officer serving at the front but also in Craiglockhart.

In 1910 the US Army doctor, Captain RL Richards, wrote that after the Russo-Japanese War, of which he had been an observer, 'The mysterious and widely destructive effects of modern artillery fire will test men as they've never been tested before. We can surely count then on a much larger percentage of mental diseases requiring our attention in a future war.' 

This was a war into which little heed was paid in Europe before the outbreak of the First World War, but it was to prove greatly prophetic. By the end of the war 80,000 psychological causalities had been treated by the British.

This paper will deal with how the British Army dealt with the psychological injuries caused by the First World War. Due to shortage of time I am only going to be focusing on the Western Front, which saw the greatest concentration of psychological casualties. 

Ultimately, it will show that the Army's response moved through three main stages. The first was denial, the second was a grudging acceptance and then the third was finally moving towards an effective treatment.

As we will see, these phases were not entirely chronological or indeed linear, and progression varied in different sectors of the front and back in the UK. Despite these changes, however, it will become clear that shell shock and other psychological injuries were never truly accepted as legitimate wounds of war; certainly not in comparison to physical injury. Any mental injury was associated with cowardice and malingering with interpretations tainted by both Edwardian social values and ideas on race and ethnicity.

Indeed, we will be able to see that the Army's reactions throughout the war were predominantly influenced by the social class, and to a lesser extent the race, of the psychological casualty, particularly in the early stages. Such distinctions greatly influenced the nature and quality of treatment that any casualty received. However, what will become clear is that the assumption surrounding social class and shell shock slowly vanished as understanding improved.

So, first of all, I think it is important to clear up a few misnomers about the term 'shell shock'. From the early months of the war, soldiers from the British Expeditionary Force [BEF] began to report medical symptoms after combat which ranged from amnesia, persistent headaches, nausea, dizziness, tinnitus and hypersensitivity to noise. In the first stage of the war alone, 1,906 cases of behaviour disorder, seemingly without physical cause, were admitted to hospital. By December 1915 this had risen to 20,000, which represented nine per cent of battle casualties for that year alone. Clearly something was wrong.

The term 'shell shock' was actually first used by Dr Charles Myers – there is a picture of him there in the top right – of the Royal Army Medical Corp in a February 1915 article in 'The Lancet'. As the injuries being reported resembled those of physical brain injury, but without the cause of a blow to the head, it was initially assumed that they were therefore the result of the percussive effect of shell fire, which resulted in the physical upsetting of the brain's movements and patterns. 

However, this was only an early diagnosis and explanation. As the war progressed conflicting opinions emerged mixed with official guidelines. This saw an alternative new development that described shell shock as an emotional rather than a physical injury. 

Myers himself soon became convinced of this as his own understanding improved. Evidence for this point of view was provided by the fact that an increasing proportion of men suffering shell shock symptoms had not even been exposed to artillery fire at all, so it could not possibly have been caused by the percussive blast of shells exploding near them. 

Indeed it should be pointed out even the phrase 'shell shock' doesn't actually last the war. It was formally banned by the War Office in 1917 and is never used again in an official capacity.

In 1920 an official enquiry into the condition was appointed by the War Office, which reported in 1922. They acknowledge in their report that the term 'shell shock' was only a temporary name, and I quote, 'born of the necessity for finding at that moment some designation thought to be suitable for the number of cases of functional nervous incapacity which will continually occur in among the fighting units'.

The report also further identified that physical exposure to explosive projectiles was not essential for a patient to be rendered a psychological casualty, and that by 1920 it could be seen the number of cases reporting symptoms that matched this provenance were actually remarkably few. 

Instead, the report acknowledged that rather than shell shock being a mental illness relating specifically to the war, it was in fact a collection of highly aggravated and widespread nervous disorders that had already been recognised in civil medical practice. The instant and prolonged physical emotional strain of industrial warfare was responsible for the scale to which soldiers had broken down.

The report came to several conclusions about what was actually causing shell shock and attempted to offer a few explanations for why this had been the case, based on a fairly extensive evidence gathering exercise. Among the general predisposing causes that they identified were: inadequate medical screening at the time of recruitment. This problem was also replicated on a grander scale when conscription was introduced in March 1916 and began to pull in those who had already been rejected on medical grounds and been certified as unfit. 

Social class, even in 1922 was still identified as being among some of the predisposing causes as well, which as you will see as the war progresses is slowly eroding but is still present.

And also, interestingly, racial characteristics. The Irish were believed to be susceptible to degeneracy and predisposed to insanity by a lot of the Army hierarchy. Despite their fearsome reputation as soldiers and their widespread use throughout the British Army, there was an assumption that that meant they were slightly unhinged! Not my words, by the way.

Interestingly, as well, one regimental medical officer who gave evidence to the enquiry also stated that the Great War had taught him that, and I quote, 'my experience of the Jew is that he is not worth his uniform'. So, again, as you can see there are some fairly strong assumptions being thrown around.

But back to 1914. How then did the Army react to this new condition during the war? Moving back to the first response I discussed of denial. 

While the small community of Army psychiatrists in 1914 was aware of the potential for psychological casualties, it was the scale of the issue that caught the Army by surprise. And as it grew this forced the wider Army hierarchy to take notice.

 The condition undoubtedly attracted suspicion and hostility in the early stages. Any idea for specialist treatment centres that were proposed were viewed as being mere havens for malingerers. The widely held belief in the Army was that it was pernicious to take claims of shell shock too seriously to prevent what they believed would be a potential shell shock epidemic.

Above all else the Army recognised that discipline and the fighting spirit needed to be maintained. Partly this was born out of the social structures of war in Britain which saw men, and in particular British men, as being unassailable. They were, after all, the men who built the Empire, the greatest Empire the world had ever seen. It seemed unlikely and difficult to assume that they could break down so quickly in a case of war.

Secondly, the Army quite rightly, in my opinion, realised the war could not be won if men were being sent home because they simply weren't enjoying the war, which was the widespread opinion at the time, which made it very difficult to actually class any form of injury or wound or sickness as significant. 

Therefore, those men who seemed to break down were simply dismissed as being weak and lacking the moral fortitude to see the job through. They were, after all, the minority and that must be stressed. 

This was a view endorsed by many of even the medical officers who saw the soldiers initially, even well into the conflict. The Royal Army Medical Corps officers were entirely complicit in the beginning in this process of denial.

Maberly Esler, for example, who was medical officer to the 2nd Battalion, Middlesex Regiment between 1917 and 1918, described one casualty as 'a well known "shell shocker"... He was just a frightened man... I just sent him back.'

Initially, there was a fear that shell shock was infectious and that if it was allowed to spread it would prove debilitating for the entire Army. Dr Gordon Holmes, who was the consultant neurologist to the BEF, claimed that, and I quote, 'The great increases in these cases coincided with the knowledge that such a condition of "shell shock" existed.'

Such a status, it was believed, was essential to prevent some men being excused duty, which would lead to a collapse in the Army. Effectively, shell shock could not be recognised as being this legitimate force if the men were to be kept in the field. 

Such an attitude similarly endured actually throughout the war and never entirely goes away. Lieutenant Colonel Rogers who is the medical officer of the 4th Battalion, The Black Watch, told the official enquiry in 1920, 'I regard "shell shock" or war neuroses as a very contagious sort of trouble when it gets into a battalion.'

Indeed, when examining men reporting the condition during the retreat in 1918, Rogers said in retrospective quotes, 'There was no such thing as "shell shock" wrong with these men at all. They had the wind up and they were frightened and I knew perfectly well it was deadly to allow the contagion to spread. I saw it had to be stopped. I therefore told the men that they had left the front line without permission. I said they were going straight back and would be punished for it afterwards.'

Even those officers who were actually sympathetic to the strain under which men were being placed and were starting to go down from recognised the wider importance of maintaining the war effort.

As Lieutenant Colonel JG Burnett, CO [commanding officer] of the 1st Battalion, The Gordon Highlanders said, and I quote again, 'Although a man's nerves may break down we must look upon it as a disgrace, otherwise you would have everybody breaking down as soon as they wanted to go home.'

However, such a policy was not entirely effective, as Major WJ Adie told the committee, 'All sorts of people got out of the line with so-called "shell shock" and the result was that they evaded their full duty and yet were not punished.' 

So there is a very strong punitive element with which the Army reacts to shell shock and the understanding that perhaps it will just go away. Again, in the early stages of the war there is no forecast that the war will go on for as long as it eventually does, and the assumption is that the British Army must be kept in the field because soon enough they will break through and achieve victory. There is no real strategic long-term planning in place.

Throughout this, class bias remained dominant, both in the early part of the war but also in the year following, in 1915. Lieutenant Colonel Viscount Gore of the Grenadier Guards told the War Office Commission Enquiry again of a need for vigilance and discipline in relation to shell shock complaints since, and I quote, 'a certain class of men are all right out of the line, but as soon as they know they are to go back, they start getting shell shock and so forth'.

However, I think it is quite significant to point out here that the British officer was treated in a very different way. Whilst shellshock afflicted men regardless of their social class, officers suffering the condition were often accommodated as much as possible. 

The manifestations of shell shock among NCOs [non-commissioned officers] and privates, for example, were initially diagnosed as being 'hysteria', a term previously related to a condition suffered only by faint-hearted women and which led to the asylum. 

Officers, however, were not permitted by the Army to suffer anything so lacking in masculinity. They were instead 'neurasthenic', a term with strong connotations of a specific treatable disease rather than those of insanity, as suggested by 'hysteria' and as applied to the other ranks.

Indeed, 'neurasthenic' implied a semi-legitimate injury caused by war rather than personal frailty and failure. This normally resulted in removal from the front line and a less strenuous posting, either elsewhere behind the front, or even to a training establishment in England.

And this is actually where quite a lot of the officers who start to come down with shell shock, and other psychological injuries, end up. As the British Army is rapidly expanding following the huge upsurge in volunteering and then the Military Conscription Act of 1916, huge numbers of men need to be trained by experienced officers, and that is where many of these officers go.

Such a distinction preserved the class structure of British society in the Army. The 'hysterical' soldier was seen as simple, emotional, unthinking, dependent and weak, whereas the complex and overworked 'neurasthenic' officer was much closer to an accepted or even heroic male ideal. 

The work of the famous psychiatrist WHR Rivers actually did much to further this initial interpretation, since it was suggested that neurasthenia was born out of the officer's complex public school-educated mentality, where he put everybody before himself and strived to do the best for his country, which put undue strain upon his own mental faculties.

Interestingly, it would take the British Army nearly two years to admit that a man without visible wounds could be a war casualty and that 'shell shock' was not a synonym for cowardice. 

In 1915 most other ranks cases were still returned to Britain without medical notes and kept in non-specialist wards with soldiers suffering physical injuries. This led to great social stigmatism that actually impaired their recovery, though it may well have been designed to also shame men into pulling themselves together and to simply return to duty under their own volition.

Arguments over the definition, severity and legitimacy of the condition, combined with inaccurate diagnosis, meant that many soldier sufferers were simply lost to asylums throughout the war. The Army lacked the capacity to do anything with them so they were confined in civilian asylums despite their ailments only being temporary. 

Significantly, there was a strong social bias at work in this process. For soldiers and other ranks shell shock was viewed as a form of war-induced madness that led to the asylum, and for officers it was something that could be treated and was almost a noble wound.

Yet this refusal to recognise the condition in the early stages of the war meant that the Army failed to legitimise any treatment for what was a very real problem, and it wasn't going to go away. It was only when faced with a possible pandemic and the disastrous effect that this would have on discipline and morale that the War Office reacted. Which means, as I said, we move into forced acceptance and moving towards improved treatment of forward psychiatry.

By 1916 the British Army was suffering from epidemic of shell shock which, combined with the losses incurred on the Somme, reached a major manpower crisis. It became clear that this was a problem that could no longer be ignored. 

The extreme rise in shell shock casualties after the Somme campaign provoked this change in opinion. Official figures, for example, suggest that shell shock had reached its height during the second half of 1916 with a total of 16,138 cases between June and December of that year. As a point of contrast the previous highest six-monthly figure before June 1916 was 3,951. So we're looking at a 400 per cent increase.

Many of these men had previously had good military records as well, which challenged perceptions about the cause of their breakdown. As expected, and I quote, 'The Army's perception of shell shock and the treatment it used was most influenced by its own immediate concerns.' 

Therefore, at this stage, when the loss of men to Britain where they disappeared to asylums and risked losing the gains so catastrophically won, this had to be stopped, especially given the shortages faced and the sharp increase in German U-boat activity that meant even getting back to Britain no longer became particularly simple.

Therefore, a more standardised treatment for shell shock was introduced from December 1916, which owed a considerable credit to the work of Myers who had been working throughout this period. 

He had been appointed as a specialist in nerve shock in May 1915 by the Army and by the end of 1916 had created four specialist centres with forward sorting positions at Le Havre, Boulogne, Rouen and at Étaples. These formed the basis of more effective treatment moving forward and were to remain the focus of the treatment of psychological casualties for the remainder of the war.

Army authorities were appeased as strict tests and criteria were applied in these centres, designed to separate genuine casualties from the despised malingerers who it was assumed were still among them. This was part of the new role for medical officers in the Great War, which Joanna Bourke described as being both doctor and detective in their treatment of wounds and illnesses. 

The practice of wartime medicine was not, after all, just about the health and wellbeing of the patient, but the conservation, consolidation and salvaging of military resources. The pressing manpower needs of war combined with the novel nature of shell shock for many non-specialist medical officers contributed to institutional scepticism.

There was also considerable conflict between civilian medical professionals on wartime commissions, such as Myers, who were medically proficient but unskilled in military thinking, and the more entrenched opinions of the regular Royal Army Medical Corps physicians.

Indeed, what you see throughout the war is medical officers who are on short-service commissions sending men back down the line to where more senior regular Royal Army Medical Corps officers decide there is nothing wrong with them and sending them back. 

This leads to considerable conflict and on several occasions some medical officers were actually drawn up before Boards of Enquiry and accused of being unable to do their roles because they are considered too close to the men and unwilling to exercise enough authority and control over them. So, as you can see, these are very dominant attitudes that actually effect how the Army operates on a day-to-day basis.

Back, however, to these forward psychiatry centres. They were established just 15 miles from the front, so they were still within earshot of the guns, so a soldier could not be under the impression he had somehow escaped his duty. Normal Army routine was also maintained, regulated by NCOs, and daily life included discipline, rest, sedation when necessary and the avoidance of stigmatised words such as 'shell shock'. 

The expectation of recovery is continually enforced in these new centres, which is quite a novel thing. It is told to the men that it is temporary, they will get better, all they need is a bit of rest. This stops them debilitating further but also greatly increases and improves their chances of being sent back to front-line duty.

These three main principles of Proximity, Immediacy and Expectation - or PIE, for the acronym - were borrowed from the French experience and appeared to encourage a quick and successful recovery. Indeed of 5,000 cases treated after the First [Battle of] Ypres, more than 4,000 were returned to duty using this method. 

However, such statistics do need to be treated with some caution because the concept of a relapse was never really fully taken into account, and so while men may have gone back for a short period of time and therefore been passed fit, there is no guarantee how long they would have actually lasted.

After their initial progress and treatment, further changes were also made to treatment methods. In 1917, as I alluded to earlier, the term 'shell shock' was official abolished from the official terminology and replaced with the acronym NYDN, or 'Not Yet Diagnosed - Nervous'. 

Casualties of this nature were sent back to a clearing station like any other and there labelled either ‘Shell Shock - W', meaning that their injury was physical and the result of exposure to direct enemy shellfire, or ‘Shell Shock - S', which meant that the injury was emotional and they were sick rather than wounded. 

It is quite an important distinction and also the fact that they have two still shows that the Army has yet to resolve its understanding about what is actually causing these mental casualties and what is causing the psychological breakdown.

Both of these terms are designed to remove malingerers since it could in theory be easily ascertained by officers whether soldiers really had been under fire at all and therefore more deserving of the 'wounded' classification than 'sick', which obviously entitled them to at least more recognised treatment. 

However, this system was also abolished in September 1918 when it was discovered that up to 95 per cent of 'Shell Shock - W' cases (or wounded) had in fact been emotional in origin anyway. These changes were little more than a series of improvised reactions and revisions, inadequate measures formulated because having recognised shell shock the Army could therefore no longer ignore it and had to do something about it.

What we do see, however, is that this is the beginning of a more standardised and effective pattern of treatment for those suffering, both officers and other ranks. Yet the form this treatment would fully take would be regulated entirely by the social class of the patient.

This moves us onto the third response, which is going to focus on specialist hospitals in the UK as we look at moving towards a more effective treatment pattern. 

As mentioned, the Army was desperately trying to prevent a drain on manpower, but for some the only option for treatment was to return to Britain. The Army resisted this as much as possible. The best statistics available suggest that if men were treated in France they probably had about 60 per cent likelihood of being returned to duty, whereas if they were returned to Britain that dropped to about 30 per cent, so you can see the significance. 

The Army was desperately trying to keep people in France, near the guns with the expectation of going back. The mental separation from the front meant that they were desperate to keep these men close.

However, by moving these men back and into Britain and integrating them into wider British society this did quite literally bring the issue of shell shock home for the British people and politicians began actively questioning the Army's treatment of shell shocked soldiers in parliament with constituents writing to them saying, 'Is it right that Private X has been shell shocked yet has been sent back to duty?' These are common questions that the Secretary of War actually needs to begin to answer from this period onwards.

In terms of their treatment in Britain, once they return the psychological casualty was faced with a tripartite structure, which we can see here on the screen. 

At the base level were 18 non-specialist wards throughout Britain in general war hospitals such as 1st Southern General in Birmingham. Here, shell-shocked patients were widely dispersed and freely mixed with the physical wounded and cared for by non-specialist civilian personnel. 

Again, it is very important to realise that because of the nature and the scale of this problem, many of the practitioners who were dealing with these men had absolutely no understanding of psychological casualties at all: what caused it, the best plans of treatment, they hadn't read the literature and indeed much of the literature that has formed the basis of some of the work that is done today was written in the First World War. So it is very much a learning curve for all concerned, especially if these personnel are civilians as well, which they are in the non-specialist wards.

Later research would actually show the detrimental impact placing psychologically wounded men in general wards would have on the chances of recovery. The outcomes for these men are tiny; they are about three or four per cent to return to any form of duty at all. 

The majority of these men, as I said, are therefore invalided from the Army and are completely lost to the war effort. Some end up in asylums, some end up at home, broken and relying on pensions. And overall the Army is losing out.

Above this, however, what you have are the more specialist neurological sections of the general war hospitals. At this time neurologists could actually also mean the treatment of neuroses, so in this regard there are some civilian experts who had been brought in to offer their experience on the growing shell shock problem. 

This begins to plant the seed that actually what the Army is dealing with here is not a new phenomenon at all, but simply the larger scale occurrence of disorders that occur in civilian life as well, which means that the Army can therefore rely on these civilian experts who are far more experienced than they are to help formulate patterns of treatment and offer their experience in the growing shell shock issue.

The top tier of this structure, however, was occupied by the specialist hospitals, which were open very specifically to treat war neuroses in an attempt to conserve military resources and return men to some form of duty. These include the Maudsley Hospital at Denmark Hill in London which was run as a specific shell shock subsidiary of No 4 London General. And as soon as this was opened in 1915 it was taken over specifically to be a shell shock hospital. 

So that shows that the Army is waking up to some of these issues. Even if they don't necessarily have the tools to effectively treat them, at least they have buildings in which to do it. To a considerable extent it must be pointed out that actually where a man ended up in this tripartite structure depended quite heavily on his social class.

For those working in the specialist hospitals established to deal with the condition, the haphazard approach of the British medical faculty and the Army prioritisation of the cause over the individual produced two very distinctive schools of thought on how to best treat shell shock. 

One was the disciplinary theory practiced most prominently by Dr Lewis Yealland at the National Hospital for the Paralysed and Epileptic in Queen's Square, London. 

This was opposed by the analytical theory practised first at Maghull, Liverpool whose staff included Myers from Autumn 1917 when he transferred back from France. Maghull had been taken over by the Army shortly after the rapid rise in shell shock cases of Spring 1915 and was a place where, forgive the phrase, 'mental' patients could be treated without the stigma of being sent to an asylum. Again, that is the Army's phraseology being used there.

So these are the two schools of thought that emerged. Disciplinary theory consisted of forcing the soldier into rejection of his physical ailments, manifested in conditions such as mutism and paraplegia, through persuasion techniques, 'persuasion' being a bit of a euphemism. These included electric shock therapy, shouted commands and isolation. Therefore, it is quite clear that this treatment holds a very strong element of scorn, and combined treatment and punishment. 

Again, it is about understanding that those men who had shell shock and were in these facilities were not being really considered as truly wounded. It wasn't like a bullet wound or anything of the sort like that. There was an inherent assumption that the man was somehow weak and a flaw in his own character, be that race or class, had led to him being there.

Although it was very extreme, they did actually produce very effective results: around two months before return to health was considered pretty typical. But only those with limited psychological disorder were treated in this way. 

Again, as the understanding of shell shock grows the fact is it is not a simple cause; it is not a simple issue that is like being exposed to shell fire or inhaling too much carbon monoxide from shells exploding. It is far more complicated than that and there are often deep-rooted psychological problems at play that require a lot more than the application of electronic plates and shouted commands.

The National Hospital dealt with 200 cases between 1915 and 1924, all of whom were drawn from the ranks, 33 of whom received electric therapy. 

While Yealland claimed fantastic success, it is interesting that what he did afterwards was effectively... there's a school of thought that one of his more aggressive reasons for using this was to somehow make up for his own shame that he had a relatively cosy posting in London, whereas there were lots of other men out in France who were suffering much more than him. And therefore what he wanted to do was show that the men who came back were weak.

If you contrast that with analytical treatment... Now, analytical treatment is far more what we would probably associate with traditional psychotherapy. That means conversations, one on one, with a therapist, quite detailed case notes, treating people as individuals, working through their issues and it was far more practiced by the school of thought that saw shell shock as an emotional disease.

And increasingly what we have is the infiltration of Freudian psychoanalysis into these practitioners. And it is very much... a lot of the ideas that we use today can be traced back to the First World War and the experience gained there.

This used the discussion of traumatic experiences which overcome them, the bringing out of suppressed memories, for example, and a slow gradual process of re-education and a return to physical and mental health through hypnosis, therapy and physical activity. 

This often took the form of therapeutic activities aimed at building the soldiers' confidence; basket weaving... this is actually where the phrase 'basket case' comes from notably enough because it was one of the activities that the men were given in order to help re-build their confidence.

Maghull treated 3,638 cases but was only able to return around 50 per cent of its patients to active service. This led to some conflict with the Army. Although on the one hand you have the disciplinary theory which is returning men very quickly and in larger numbers, whereas you have the analytical theory which is: a) taking an extremely long period of time; but also not even delivering results. And that regularly led to some conflict between the Army hierarchy and the War Office, and the practitioners there.

Indeed, however, whilst these are the two main schools of thought, it should also be noted there's really no set pattern of treatment in the UK hospitals and instead it depended entirely on what members of staff are where as to which techniques are practiced. 

You will see there's a huge litany of different techniques, causes, types of therapy - some are purely analytical and some are purely disciplinary, some like to mix and match the two in order to achieve their goals. And it is very much an experimental phase for the development of war neuroses. 

Many of the experts who joined the military are therefore drawn to these areas. So you have Rivers, for example, who transfers up to Craiglockhart when it was opened in 1916, you have Myers who comes back with his experience of treating casualties at the front to work exclusively in Britain from 1917. And these men are furthering their own knowledge in very practical terms and formulating new approaches and techniques. 

However, because there is no consensus view at this stage at all, this varies enormously across the country. Also it is interesting here that what you have is because of the nature of the two treatments, you start to have a bit of a blurring now between who ends up where and what social class they are. 

At Maghull, for example, the vast majority of cases are actually privates and NCOs and they're receiving analytical treatment, whereas people who end up at the National are receiving disciplinary theory.

However, the Army and the War Office was extremely dissatisfied with the patterns being used and the poor returns and it was only actually the immense professional standing of the staff at Maghull that saved them from the Army's wrath. 

There are calls for the director to resign, for example, for his poor returns and it is only when the faculty threatened to go with him that the Army backs down. So there is quite a lot of conflict going on even in Britain at this stage.

Another reason why officers and enlisted men received different plans of treatment was that as the war progressed more studies were conducted and more effective and formalised treatment was put in place. This resulted in the initial differential labelling attached to physiological casualties - you will remember the 'hysteria' and 'neurasthenic' I talked about earlier - from the ranks and those who were officers beginning to actually reflect the differential symptoms that were being exhibited. 

For example, symptoms of hysteria - such as paralysis, blindness, deafness and mutism - appear predominantly amongst soldiers from the ranks, whereas neurasthenic symptoms - nightmares, insomnia, depression, etc. - were more common amongst officers.

The case notes for the Lennel Convalescent Home for Officers in Coldstream, Scotland, for example, make just one reference to a functional symptom, such as paralysis associated with hysteria, in an officer - in this case a 23-year-old lieutenant who was treated there in September 1917. 

As such, it can be seen that there was actually an evidential reason for classifying these as different forms of casualty, and it was no longer just about social class. Whilst original distinctions were put in place purely due to class, the treatment and the evidential basis actually starts to bear those out.

However, what we can't overlook, and what we shouldn't overlook as well, is that the vast majority of shell-shocked officers were actually treated in Britain. And again, this assumption of being neurasthenic and that a slightly more noble injury required rest and recuperation... Britain was seen as the best place for that. Whereas the other ranks were only returned to Britain with the greatest reluctance from December 1916 onwards. Everything is done to keep other ranks in France, whereas for officers there was far more flexibility in returning them.

Officers, significantly, were also treated in specialist hospitals and wards. Even at places like Maghull that treated predominantly NCOs and enlisted men, the officers have their own ward and they are very much predominantly separate from those other ranks and greater care is also being taken not to mix them with the physically wounded, unlike other soldiers.

The first of these specialist officers' homes was the Special Hospital for Officers at Palace Green, London, which was opened early in 1915 as a convalescent home providing respite. However, as it became clear that mere rest wasn't enough, further specialised hospitals focusing on treatment were opened, including Lennel and the now famous Craiglockhart near Edinburgh.

In these specialist treatment centres, officers were to enjoy a standard of living and facilities that befitted their social status. As we can see if we just moved back quickly to the tripartite system, the vast majority of officers ended up in the neurological wards or the specialist hospitals and always with men of their own social standing. So officers would be messing together. 

For other ranks, for example, far more practical reasons dictated where they were sent, being space and the speed at which they needed to be returned. And also at the same time depending on what was happening in France, if there was a big push going on and big battles were taking place, the men needed to be returned quickly, so that dictated where they were sent as well.

But back to the officers and their more specialist and comfortable. At Craiglockhart, one of its most famous patients, Siegfried Sassoon, was able to play golf every day during his convalescence and mixed his therapeutic hobbies with the opportunity of enjoying a lot of exercise which he had done previously. 

These therapeutic opportunities were seen as a crucial way for officers to rediscover their confidence which they had seemingly lost. Indeed, Sassoon described his own treatment as 'simply an opportunity for marking time and reading steadily', which shows how he engaged with the project.

Craiglockhart stands as a unique institution in the wartime treatment of shell shock. Staffed by a dedicated group of neurological experts and containing just 160 officers, it was small enough to allow the formation of personal bonds such as those between Sassoon and WHR Rivers. 

Again, what you see here is when it comes to the officers' treatment there are far more experts allocated to them on a smaller ratio. You're looking predominantly about 1 to 50, possibly even less. Whereas with the other ranks you are looking more about 1 to 200. So there are quite significant differences going on and that of course impacts on the quality of treatment as well, let alone the type of treatment they receive.

Craiglockhart and the treatment practiced there were products of the social division that marked both British society and the Army. While class distinction was slowly being eroded amongst the fighting men through the shared experience of combat at the front, at home such barriers were still actively enforced and maintained. 

However, I should also point out that despite their more luxurious treatment, even officers being treated for shell shock were subject to stigma from the civilian population. It is a very stigmatised and heavily criticised ailment. 

Lieutenant James Butlin who was treated at Craiglockhart in May 1917 wrote in a letter that the local inhabitants, and I quote, 'have two theories concerning us. The first theory is that we are lunatics under careful surveillance, but nonetheless dangerous. The second is that we are victims of venereal disease and confined here as punishment. From the looks of the population I gather that the second theory is most strongly held.'

The Army did little to actually convince the civilian population of the legitimacy of shellshock in this period and whilst the officers were receiving undoubtedly better treatment they still were labelled with the same amount of stigma. Moreover, like the other ranks, they were being treated with the expectation that they would be returned to duty at the front and this caused a lot of issues and problems for the practitioners at Craiglockhart. 

WHR Rivers, for example, really struggled with the concept of what he was trying to do, whether he was trying to cure men or whether he was simply trying to stabilise them enough to carry out their duties and more. 

Whilst the form the treatment took for both officers and men varied and was dependent on social class, the desired outcome always remained the same and that transcended the artificial barriers of social class.

But, undoubtedly, it can be seen that ideas surrounding shell shock progressed throughout the war and this was motivated by the undeniable fact that it was not a condition only affecting the lower classes of men. 

According to one survey published in 1917, for example, while the ratio of officers to men at the front was around 1 to 30, with patients in hospitals specialised in war neuroses, the ratio of officers to men was actually about 1 to 6. 

In addition, the reality of the British military situation in the latter years of the war forced these ideas to change. The original social elite who composed the officer corps before 1916 had been progressively whittled away through casualties. Men from far more humble origins were taking their places and even senior NCOs were being promoted from the ranks into officer positions. 

The old social distinctions were being removed the longer the war went on and this made it harder and harder to sustain the belief that social class was at the root of the shell shock issue.

So, what lessons are learned?

As I mentioned earlier the Southborough Committee of Enquiry, which was the official enquiry launched by the War Office, reported in 1922. You can actually buy a copy of the report if you are interested. It has been published and it is really fascinating reading for the sheer amount of evidence that has been collected. 

In this report the enquiry made several recommendations on how to deal with psychological casualties in future based on the experience of practitioners, soldiers and the Army hierarchy in the First World War. These included how to deal with casualties in forward areas, in specialist psychological centres and base hospitals as well as suggestions on the form that treatment should actually take. 

However, while there is undoubtedly a change in attitude towards psychological breakdown, old assumptions refused to go away. It was still seen as a form of weakness and an opportunity for some men to escape their duty. 

If anything, the official report of the Southborough Enquiry confirmed many of the class assumptions that had been expressed in 1914. The official view remained that well trained troops properly led would not suffer from shell shock. 

The many servicemen who had succumbed to this order were either member of Kitchener's hastily assembled Pals battalions, which were predominantly drawn from the working class anyway, or unwilling conscripts who followed, who were themselves a lower class of Englishmen or led by a lower class of officer.

Indeed, even some physiatrists following the report commented that... this is a lengthy quote so I do apologise but it bears listening to. 

'There should be no excuse given for the establishment of a belief that a functional nervous disability constitutes a right to compensation. This is hard saying. It may seem cruel that those whose sufferings are real, whose illness has been brought on by enemy action and very likely in the course of patriotic service should be treated with such apparent callousness. But there can be no doubt that in an overwhelming proportion of cases these patients succumb to shock because they get something out of it. To give them this reward is not ultimately a benefit to them because it encourages the weaker tendencies in their character. The nation cannot call on its citizens for courage and sacrifice and, at the same time, state by implication that an unconscious cowardice or an unconscious dishonesty will somehow be rewarded.'

Just a summary of the lessons learned there.

So, in conclusion, while this paper has been regrettably brief, I do hope that I have demonstrated to you the ways in which the British Army's treatment of shell shock, both on a cultural, practical and a functional level was regulated by the prism of social class. 

Initially, the Army regarded psychological casualties from the other ranks as either insane or as shirkers and malingerers, faking their symptoms in order to shirk their duty and simply get out of being at the front. Yet no such assumptions were ever applied to officers, who were actually treated far more sympathetically throughout the war.

As the war progressed such assumptions slowly eroded as the Army attempted to find solutions and more practical experimentation was done and lessons and the knowledge base grew, but they never entirely disappeared. Indeed, it could be argued that it was only the suffering of so many officers that even forced the change in these beliefs at all. 

However, a post-war reassertion of masculinity, as seen in the results declared by the Southborough Committee report, saw the same charges levelled once again. 

Sadly, it should also be noted that many of the lessons learnt during the First World War on how to deal with shell shock and psychological casualties were forgotten during peacetime. These had to be hurriedly learnt when war broke out in 1939 when once again the Army put millions of civilians into uniform and many of the same battles over diagnosis and treatment were re-fought.

Thank you very much.

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