Shell shock in Ireland: The Richmond War Hospital,Dublin (1916–19)

Establishing the Richmond War Hospital

In January 1916, RMS Donelan reported to the committee of the Richmond District Asylum, a large public asylum which opened in 1814, that the British military authorities sought accommodation to use as an observation hospital for soldiers with nervous and mental troubles (Reynolds, 1992: 217). The need for such a facility had become apparent over the previous two years: while soldiers’ physical injuries from the war were increasingly managed through a network of dedicated clinics and hospitals, there was much greater uncertainty regarding their psychological problems.

The most puzzling aspect of this emergent issue was the lack of any consistent association between identifiable physical injuries and psychological symptoms such as loss of memory, dizziness, tremor, headache, poor concentration, tinnitus and hypersensitivity to noise (Jones, Fear and Wessely, 2007: 1641–2). The term ‘shell shock’ evolved to describe such cases which developed following exposure to shell fire but were not associated with identifiable physical injury (Myers, 1915). Over time, a series of psychiatric facilities throughout Great Britain and Ireland was made available to assess and treat such soldiers when they were sent back from the Front (Shepherd, 2002). One of these was the RWH.

While the RWH was located on the grounds of the main Richmond District Asylum and was an administrative element within the larger institution, the War Hospital was, in many important respects, separate from the main establishment. In the first instance, a new and separate block was put at the disposal of the army for the War Hospital, and its patients did not appear on the main asylum’s record books (Collins, 2013). Moreover, the army agreed to pay 21 shillings a week per occupied bed – a rate that was distinctly advantageous for the asylum managers: the weekly cost per patient was under 14 shillings, and the army provided clothing for its own patients, making the arrangement an especially lucrative one (Reynolds, 1992: 217).

The RWH was staffed by Richmond Asylum personnel, and while making this arrangement was not without complexity (Reynolds, 1992: 217–18), there was little time for hesitation because immediately following its opening, soldiers began to arrive at the RWH with all the signs and symptoms of shell shock and various other mental and physical disorders. The case of Private VW is a good example. ¹ He was a 23-year-old Presbyterian private admitted from King George V Hospital (a war hospital dealing with physical injuries, in Dublin). On admission to the RWH, Private VW’s ‘tongue [was] tremulous. Speech stammering and hesitating’. Mentally, he ‘has headache every now and again and suffers from noises in his head at times’, and had also complained of ‘visions’ and ‘insomnia’. Private VW had joined the army in 1911 and ‘was out in India at the outbreak of the war. He states he was blown out of a trench at Arras [a city in Northern France, associated with the Battle of Arras, 1917] and since then his speech has been affected’.

On his first night at the RWH, Private VW ‘remained quiet and slept well during the night’. One week after admission, he was ‘quiet and well-conducted and gives no trouble. He states he had no voices in his head since he came here and that he is feeling much better’. Two weeks after admission, Private VW was ‘bright and cheerful and is looking much stronger. He states he is now feeling very much better’. This improvement was sustained, and one month after admission Private VW continued ‘to improve. He states he is now feeling all right in every way except that he is not physically strong. Sleeps and eats well’. Two months after admission, Private VW was ‘discharged and sent to his home’.

Private VW clearly demonstrated many of the symptoms commonly associated with shell shock: tremulousness, speech problems, headache, ‘visions’ and ‘insomnia’, all following exposure to shell fire in France. Many of these features are also apparent in the case of Lieutenant ST, a single, 19-year-old Church of England lieutenant admitted also from King George V Hospital in late 1918, after almost four years army service. On admission, Lieutenant ST had a cough and his ‘tongue and limbs are tremulous’. He had ‘some scratches on his hands as if he had recently broken glass’.

Mentally, Lieutenant ST was ‘dull and depressed and his memory is confused. He complains of pains and noises in his head and insomnia. He is unable to give a collected account of himself. He cannot give many particulars of his service. He, however, states that he served at Salonica [i.e. Thessaloniki, in Greece] and in France and came home in May last suffering from shell shock’. He was admitted to war hospitals in Halifax and Nottingham, before coming to Ireland. On his first night at the RWH, Lieutenant ST ‘remained quiet and slept well during the night’. One week after admission, Lieutenant ST was ‘somewhat brighter and more cheerful but his memory is still confused. He states his head does not now trouble him much. He states he is subject to “fits” if annoyed but does not lose consciousness’. Two weeks after admission, Lieutenant ST was still ‘improving gradually. The attendant informs me he is usually quiet and well-conducted but is inclined to be irritable and easily annoyed. He states he is feeling much better and that his head is much less troublesome’. One week later, Lieutenant ST was ‘transferred to Belfast War Hospital’ for further treatment. Belfast War Hospital operated from 15 May 1917 to 17 November 1919, during which time it treated 1215 soldiers for mental and psychological problems, including 74 transferred from the RWH (Dawson, 1925: 220–1).

Overall, the soldiers admitted to the RWH presented with a wide variety of symptoms, many of which accorded with contemporary clinical descriptions of shell shock, commonly combined with substantial levels of depression. This diversity of clinical presentations was not unique to the Richmond. In 1917, at the spring meeting of the Irish Division of the Medico-Psychological Association (MPA), which discussed the RWH in some detail (Anon., 1917), Major W.R. Dawson, ‘Specialist in Nerve Diseases to the Troops in Ireland’ (Dawson, 1925: 219), emphasized the variety of clinical presentations of shell shock:

Major WR Dawson gave a most interesting account of cases of shell shock and cases resulting from war stress. These varied from cases of slight nervous disturbance, where men were easily startled by sudden sounds or noises, to the most serious breakdowns.

Cases in which excessive tremor was a cardinal symptom in patients suffering from traumatic neurasthenia [a clinical syndrome characterized by of anxiety, fatigue, neuralgia, headache and depressed mood], loss of speech, and hearing, and sight. Loss of sight appeared to be regained quicker than the loss of hearing or speech. It is often most difficult to restore the powers of speech. Some had got good results from treatment by hypnotism, but this had been found of little use in other hands. Major Dawson spoke of the great kindness and attention of Dr Forde and Dr Dwyer [at the RWH] with regard to the wounded soldiers, which was beyond all praise. (Anon., 1917: 299)

Treating shell shock

As the diagnosis of shell shock became increasingly common, a broad range of treatments were proposed across Ireland, Great Britain and elsewhere. Some of the initial treatments were essentially disciplinary in nature, highlighting an apparent conflict between private intentions of the soldier and a sense of public duty, leading to the use of isolation, restricted diet and electric shocks to alter soldiers’ behaviour (Howorth, 2000). Other treatments were more psychological in tone, regarding war neurosis as attributable, at least in part, to unconscious psychological conflict in the soldier’s mind. This idea led to treatments such as hypnosis and abreaction, which involved soldiers re-experiencing or re-living traumatic memories in an effort to purge them of their emotional impact.

In all cases there was a strong emphasis on prompt treatment, cognitive re-structuring of traumatic experiences (i.e. thinking differently about the past) (Rivers, 1918), and collaboration with the therapist in the search for a cure. Many of these therapies have certain similarities with current cognitive and behavioural approaches to post-traumatic stress disorder (PTSD), focusing on altering patterns of thought and behaviour in order to reduce symptoms (Bisson and Andrew, 2007).

There were, however, other approaches to the management of shell shock which certain authorities viewed as equally if not more effective than approaches based on discipline, hypnosis, re-experiencing or abreaction. These included, most notably, approaches based primarily on rest and less intrusive forms of therapy.

After World War I had ended, the War Office Committee of Enquiry into ‘Shell-Shock’ addressed the issue of treatment in its comprehensive Report (1922), which drew attention to the importance of rest in preventing shell shock in the first instance:

Captain Gee, V.C., expressed himself emphatically that frequent leave home did much to prevent nervous breakdown, and attributed the comparative absence of ‘shell-shock’ in his brigade to this. He also advocated rest in cases showing initial symptoms of nervous breakdown.

Colonel Fuller considered that if organisation, training and administration were based on a psychological foundation, ‘shell-shock’ and nervous strain could be combated, and considered that in training insufficient regard was given to the psychology of the individual. A high morale undoubtedly tended to lessen ‘shell-shock’. Morale depended chiefly on a sense of security and comfort. Officers should be assiduous in their concern for their men. Removal from the front and visits home lessen the incidence of ‘shell-shock’.

Dr Mapother thought every anxiety neurosis case in its very early stage could have been cured if taken out of the line and sent to a rest camp. (War Office Committee, 1922: 158)

In its final recommendations, the Committee warned against the indiscriminate use of therapies based on discipline, hypnosis, re-experiencing or abreaction:

The committee are of opinion that the production of hypnoidal state and deep hypnotic sleep, while beneficial as a means of conveying suggestions or eliciting forgotten experiences are useful in selected cases, but in the majority they are unnecessary and may even aggravate the symptoms for a time. They do not recommend psycho-analysis in the Freudian sense. (p. 192)

Instead, the Committee placed strong emphasis on the curative properties of simple ‘rest of mind and body’:

The establishment of an atmosphere of cure is the basis of all successful treatment, the personality of the physician is, therefore, of the greatest importance. While recognising that each individual case of war neurosis must be treated on its merits, the Committee are of opinion that good results will be obtained in the majority by the simplest forms of psycho-therapy, i.e., explanation, persuasion and suggestion, aided by such physical methods as baths, electricity and massage. Rest of mind and body is essential in all cases. (p. 192)

Treatment at the Richmond War Hospital

An approach to treatment that accorded substantial importance to rest and recuperation was in plentiful evidence at the RWH, in combination with other forms of support for the soldiers:

The Irish Automobile Club took patients out for drives. In his annual report for 1916, Donelan [RMS] thanked the Irish Automobile Club, the Irish Red Cross Society, Colonel WR Dawson, the Royal Artillery Medical Corps and others for their generous assistance towards the recreation and comfort of the patients. Although singers and dramatic groups had visited the asylum in the past and had entertained the patients, the involvement of the voluntary groups with the war hospital was more regular and sustained. (Reynolds, 1992: 218–19)

In addition to these measures, however, staff at the RWH also used various medicinal treatments, as outlined at the 1917 spring meeting of the Irish Division of the MPA:

Dr Forde, who had had many opportunities of treating these cases, gave the meeting the benefit of his experiences. He regarded these cases of shell shock as due to a dislocation of the brain-cells. Hot and cold baths given alternately had produced good results in some cases of loss of the power of speech. Many cases are borderland cases of insanity. There was marked tremulousness of the musculature and shakings of the body, with profuse perspiration of the skin of the head. He had found a mixture of the bromides, together with antipyrin, and citrate of caffeine, gave great relief where headaches existed, and when the mixture was discontinued the men begged for its repetition. Fletcher’s syrup of the hydrobromates was useful, and hastened recovery in some of the cases he had treated. (Anon., 1917: 298)

The ‘hot and cold baths’ to which Forde referred were a continuation of the long-standing practice of hydrotherapy (regular shower-baths, etc.) in asylums (Braslow, 1994) and they would later be explicitly recommended for shell shock in the 1922 Report (War Office Committee,1922: 192).

Antipyrin, also known as phenazone, is an analgesic, non-steroidal anti-inflammatory and antipyretic medication (i.e. reduces pain and body temperature) discovered in 1883 by Ludwig Knorr (1859–1921), a German chemist (Brune, 1997). Its actions in alleviating pain, reducing inflammation and restoring body temperature would have been very useful for soldiers suffering the immediate after-effects of battle.

Caffeine, too, was the subject of approving mention in Dr William H. Burt’s 1896 edition of Physiological Materia Medica:

Caffeine is a marked diuretic, from its great power to increase the renal arterial blood-pressure … Citrate of Caffeine has been found to possess great value as a diuretic and cardiac stimulant … Caffeine checks and lessens the elimination of nitrogen by diminishing the amount of urea excreted, and, in this way, is of great service to man in preventing the tissue metamorphosis, or actual wear and tear, of daily life. (Burt, 1896: 321)

The addictive potential of caffeine was clearly recognized at the Richmond as Forde noted that ‘when the mixture was discontinued the men begged for its repetition’. Bromides, also used by Forde at the RWH, had a chequered history in psychiatry, having been used to induce ‘bromide sleep’ towards the end of the 1800s, but then abandoned, possibly owing to toxicity (Shorter, 1997: 201–2). Fletcher’s hydrobromate syrup, specifically recommended by Forde, was a curious concoction, listed in the British Medical Journal in 1882 in its ‘Reports and analyses and descriptions of new inventions in medicine, surgery, dietetics and the allied sciences’:

Fletcher and Fletcher’s Syrup of Hydrobromate of Iron and Quinine. This is by no means an unpalatable preparation, and affords a convenient mode of administering a useful remedy. Each fluid drachm contains two grains of hydrobromate of iron, one grain of hydrobromate of quinine, with thirty minims of dilute hydrobromic acid. The dose is a teaspoonful or more in water. (Anon., 1882: 464)

Soon after its appearance, Fletcher’s hydrobromate syrup was a widely-used remedy for, among other ailments, ‘exhaustion of the brain’ (Walker, 1988: 132), and it clearly formed an important part of the complex mixture of medicines administered by Forde and colleagues at the RWH in 1917.

The treatments described by Forde were not, however, the only possible treatment options at the time. Other approaches included ‘treatment in country houses’, as was practised in England, based primarily on rest and recuperation (Anon., 1918: 4), and Phosferine, which claimed to be a ‘proven remedy for influenza, indigestion, sleeplessness’ and more than 17 other ailments, including ‘mental exhaustion’ and ‘nerve shock’ (Anon., 1919: 6). Notwithstanding these apparently miraculous powers, there is no record that Phosferine was used at the RWH.

In any case, after outlining the treatments provided at the hospital, Forde went on to provide the 1917 MPA meeting with an overview of cases seen at the RWH up to that point, during the first 10 months of its operations:

Hallucinations of sight and hearing were sometimes present, but many of the cases were quite conscious of the hallucinations, and realised that they were abnormal, and were, therefore, not to be regarded as ordinarily insane patients suffering from hallucinatory states. Altogether it appeared that 56 patients out of the original 104 had been dealt with at the Richmond Asylum War Hospital. Of these 26 had been sent to other asylums, 12 had been sent home, and the balance had been able to resume their occupations. The patients were segregated from the other asylum inmates, and not certified insane. (Anon., 1917: 299)

Notwithstanding the apparent therapeutic successes at the RWH, however, few patients returned to active army duty. Dawson pointed out that, of the 362 patients treated at the RWH, ‘about two-thirds were discharged to their friends or to ordinary military hospitals, two returned to duty [0.6%], and only 31 were sent directly to civil asylums’ (Dawson, 1925: 219–20). This is very similar to outcomes recorded at Belfast War Hospital where, of the 1,215 admissions over 2½ years, just 18 (1.5%) returned to military duty. Statistics were similar at other war hospitals including, for example, the Red Cross Military Hospital at Maghull in England:

It is evident that the outcome in the war neuroses is good from a medical point of view and poor from a military point of view. It is the opinion of all those consulted that, with the end of the war, most cases, even the most severe, will speedily recover, those who do not being the constitutionally neurotic and patients who have been so badly managed that very unfavourable habit-reactions have developed. This cheering fact brings little consolation, however, to those who are chiefly concerned with the wastage of fighting men. (Salmon, 1917: 41–2)

At the 1917 MPA meeting in Ireland, following Forde’s account of the RWH, Dr Leeper, honorary secretary of the Irish Division, who would later go on to become president of the MPA in 1931 (Kelly, 2005), ‘pointed out that so far as he understood the causation of shell shock was due to the sudden effect upon the blood vascular system by shell explosion, driving the blood of the body towards the nerve centres, and thereby disorganising or injuring them with sudden violence, or interfering with their functions’ (Anon., 1917: 299). Shell shock and mental troubles were not, however, the only ailments among soldiers returning from war; many had physical illnesses too, and these presented significant challenges to the RWH.

Physical illnesses at the Richmond War Hospital

All the Irish asylums experienced significant difficulties with physical illnesses among inpatients in the decades leading up to World War I. In the main Richmond District Asylum there was a particular problem with infectious diseases such as dysentery which, according to the Inspector of Lunatics, in 1892 had become ‘almost endemic in this institution – 73 cases with 14 deaths occurred last year, and it may be mentioned that in no less than three of these cases secondary abscesses were found in the liver’ (Inspector of Lunatics (Ireland), 1893: 9). The death rate at the Richmond was, as a result, quite high, at 12.5% per year, although similar rates were reported in asylums elsewhere, e.g. South Carolina Lunatic Asylum which reported a death rate of 14%, between 1890 and 1915 (McCandless, 2003).

There was also a significant problem with tuberculosis (TB) (Kelly, 2011) and TB had become the single most common cause of death among inpatients in the Irish psychiatric hospitals towards the end of the 1800s (Inspector of Lunatics (Ireland), 1893: 7). By the early 1900s, TB accounted for over 25% of deaths in Irish mental hospitals (Finnane, 1981: 137) and almost 16% of all deaths in the Irish population (Jones, 1999). Similar problems were reported in asylums in other countries (McCandless, 2003). At the main Richmond Asylum in 1907, the RMS, Dr John Conolly Norman (Kelly, 2007; Reynolds, 1992), drew the urgent attention of Richmond Asylum Joint Committee to the problem and recommended physical isolation of TB patients:

I believe the desirability of isolation as far as possible in cases of pulmonary consumption will now be generally recognised … The present, therefore, seems to be a particularly suitable time to again draw attention to the great prevalence among our patients of tuberculosis consumption and the need that exists for some special provision for isolating sufferers from this disease. No large scheme of new construction or re-arrangement ought to be considered without a special view to this topic. (Norman, 1907: 540)

Eight years later, the arrival of the RWH was to bring even further challenges to the medical staff, as soldiers with other physical illnesses, in addition to their mental troubles, started to arrive. Private CD, for example, was a Roman Catholic private admitted in late 1918, having come directly from another war hospital in England. On admission to the RWH, Private CD’s ‘tongue and limbs were fairly steady’ but he was mentally ‘dull and mildly depressed and seems more-or-less despondent. He complains of some pain in his head and loss of memory. He states he used to hear some noise but this is now less troublesome and that at one time he thought he heard voices but these have also disappeared’. Private CD had been in the army for four years and served in the Dardanelles, Serbia, Macedonia, Egypt and Salonica.

One week after admission, medical records note that Private CD had ‘a slight attack of malaria [from which he had suffered in the past] a couple of days ago and complained of some headache. He has been on quinine since’. Quinine was a standard treatment for malaria, which was a substantial problem among Irish soldiers in the war (Dungan, 1997; Richardson, 2010: 154, 203, 243, 316). Happily, two weeks after admission, Private CD was ‘much improved. His headache has disappeared. He is, however, not quite as bright as one would wish’.

One month after admission, clinical notes record that Private CD was ‘quiet but rather distant in his manner. He is very ‘feeble-minded’… he tried to step-dance [and] sing … on invitation from his comrades. He has not the slightest idea of either’. He was, nonetheless, ‘much improved’. Three months after admission, Private CD ‘went out on pass’, ‘took some drink’, and ‘kicked up a row’ at another Dublin hospital; he was ‘brought back under escort’. The final opinion expressed about Private CD in the clinical records is that he was ‘very feeble-minded and has little intelligence’. He was ‘discharged to care of friends’ just over four months after admission.

For soldiers like Private CD, there were many factors relevant to their hospitalization, including psychological symptoms probably stemming from the war (‘pain in his head and loss of memory’; hearing ‘noises’ and ‘voices’), physical illness (malaria) and possible pre-existing mental disorder or intellectual disability (‘very feeble-minded and has little intelligence’).

In addition to malaria, other infectious and non-infectious disorders were also in clear evidence both in the battlefield and, in due course, in the war hospitals. Clinical records at the RWH contain especially compelling clinical descriptions of epilepsy, such as that provided in the clinical records of Sergeant EF, a 33-year-old Presbyterian sergeant, admitted to the RWH from another Irish military hospital in 1918. He had a documented history of epilepsy having ‘had a fit while in France. States he has been gradually losing the power of his left arm. This arm was injured in the African (Boer) War’.

On admission, Sergeant EF was ‘fairly well nourished …Tongue tremulous. Left arm weak in grasp. Scars above elbow … States the loss of power has been gradual’. Mentally, Sergeant EF was ‘fairly bright and cheerful’ but ‘complains of pain in his head. States he feels nervous and suffers from insomnia. He denies hallucinations’. One week after admission, Sergeant EF had ‘improved in his appearance and is bright and cheerful. He admits he is feeling better’. Three days later, clinical notes provide further details about his medical history: Sergeant EF ‘has been very quiet and well-conducted and has been allowed out on pass accompanied by other companion patients. He seems rational in his conversation. He states the first fit he had was in 1904 in India; that he had two in 1905; had one in 1911; and one in 1915; and one last April. He describes a kind of sensory aura. States he knows when the fits are coming on as he gets a sensation of tightness about the chest for about four or five days prior to the fits. He states he began to lose power of the arm about three months ago’. Just sixteen days after admission to the RWH, Sergeant EF was ‘transferred to Belfast’ War Hospital for further treatment.

Sergeant EF’s clinical record provides a very clear description of epilepsy, with a prolonged, characteristic prodrome (Clarke, 1994: 912–13), although it is not clear from the records whether or not his epilepsy was due to an injury sustained while serving with the army at an earlier point. The observation that Sergeant EF was ‘gradually losing the power of his left arm’ (italics added) is interesting, especially as he may have also fulfilled criteria for shell shock, a possibility further supported by his other complaints, including tremor, ‘pain in his head’, nervousness and insomnia.

Clearly, Sergeant EF presented to the RWH with a complex combination of physical and mental symptoms, all of which required care, medical attention and quietude. A similar combination of physical and mental health need was apparent in several other cases including, for example, that of Gunner TU, a single, Roman Catholic gunner admitted in early 1919 from King George V Hospital. On admission, his ‘tongue [was] coated, breath foul’ and he had ‘ronchi over chest’; clearly, he showed signs of an upper respiratory tract (or chest) infection, possibly compounded by poor oral hygiene. Mentally, Gunner TU appeared ‘dull and depressed’ and ‘rather feeble-minded. He presents a worried appearance. He states at times he feels inclined [to] attack people in his vicinity. He complains of an almost constant headache. When in bed he states someone talks to him. This has been so since he was in France and he admits he is “low-spirited”.’

Gunner TU had joined the army in 1915 and went to Alexandria later that year. He ‘was discharged for a bad chest’ but re-joined and went to France in 1916. On his return in 1917 he was admitted to various war hospitals in England and diagnosed with influenza. On his first night following admission to the RWH, Gunner TU ‘remained quiet and slept well during the night’. One week after admission, he was ‘quiet and well-conducted. He states he is feeling better and that his headache is much less. He seems a rather weak-minded individual’.

Two weeks after admission, clinical notes record that Gunner TU ‘was allowed out on pass’ but ‘took some drink’ and had to be escorted back to the RWH. The medical officer recorded that since that incident Gunner TU ‘has been almost constantly worrying me for passes [i.e. permission to leave] … and is rather inclined to be insolent when refused. He assumes an air of injured innocence and states he did nothing of any harm. He is very feeble-minded and has little appreciation of right conduct’. Two months after admission, however, Gunner TU had ‘recently improved very much and has become more docile and respectful in his manner. He has improved in every way. He states he is now feeling stronger and better. He expressed no delusion and denies hallucinations. He is however rather feeble-minded. Sleeps and eats well. He is now allowed out on pass every day and returns all right’. One month later, he was ‘discharged to care of mother’.

Similar cases combining physical and mental health problems, including cases of epilepsy and infectious diseases, were reported in other war hospitals, including, for example, Lord Derby Hospital in Warrington, England, which also recorded significant rates of discharge and recovery (Eager, 1918: 294). The overall treatment paradigm in Warrington appears to have been similar to that at the RWH, with a particular emphasis on massage, leave from the hospital during convalescence, and employment in the farm and garden.

Prisoners of war at the Richmond War Hospital

The psychological effects of being a prisoner of war (POW) were widely debated over the course of the twentieth century. By the end of the century, a considerable body of literature had accumulated to support the idea that being a POW, at least during World War II (1939–45) and the Korean War (1950–53), could have enduring negative effects on mental health (Page, 1992). At the time of World War I, however, when the RWH was in operation, this idea was far from accepted; indeed, it was widely believed that spending time in captivity protected against mental illness. A psychiatric conference in Munich in September 1916, for example, examined the mental health of POWs and concluded that they were immune from ‘war neuroses’ such as shell shock (Jones and Wessely, 2010: 164).

This position was apparently backed up by evidence from elsewhere: one study of 12,000 French and British POWs in World War I did not find a single case of neurosis, while another POW study reported just five cases among 80,000 POWs (Lerner, 2001). These conclusions are, however, significantly undermined by other sources of historical evidence, including evidence from British pension files which indicate that, after the war, large numbers of British POWs received financial compensation and suffered from psychological symptoms, such as neurasthenia or ‘disordered action of the heart’ (DAH, also known as ‘cardiac neurosis’) (Jones et al., 2002; Jones and Wessely, 2005) as a result of their experiences (Jones and Wessely, 2010).

The complexity of elucidating the precise effects of the POW experience is demonstrated by the case of Private WY, a 26-year old Church of England private admitted to RWH from King George V Hospital in mid-1919, having served in the army for almost five years. On admission Private WY was ‘thin and delicate-looking’. His heart was ‘weak’ and he had ‘some slight scars on legs, one of bullet wound’. Mentally, Private WY seemed ‘rather dull and depressed and complains of pain and ringing noises in his head. Insomnia. Pains in his stomach. He complains much of the treatment he received in Germany as a prisoner. He is feeble-minded’.

Private WY had joined the army in 1914. He ‘went to the Front in June 1915 and was there for three years and was wounded near Albert [in northern France] in 1916. Came home and volunteered to go out again after about seven weeks and was taken prisoner’ in early 1918. On his first night following admission to the RWH, Private WY ‘remained quiet and slept well during the night’. One week after admission he was ‘quiet and well-conducted but rather feeble-minded. He tells me he has no trouble with his head at present and that he is feeling well. The depression is passing off’. Two weeks after admission, Private WY was ‘much brighter and more cheerful and tells me all his head trouble has passed off … He possesses no delusion and denies hallucinations’. One week later, Private WY was ‘transferred to Belfast War Hospital’ for further treatment.

While no further record of Private WY’s clinical progress is available, his story indicates that at least some POWs were admitted to the RWH, although it is substantially less clear to what extent Private WY’s symptoms were due to his POW experience, to what extent they stemmed from other experiences of war (e.g. exposure to shell fire), and to what extent they were attributable to pre-existing mental disorder or possible intellectual disability (‘feeble-minded’). Efforts to elucidate these issues from the clinical records is complicated by the fact that the negative psychological effects of being a POW were not widely accepted at the time (Jones and Wessely, 2010) and, as a result, medical officers may have pro-actively sought other explanations for psychological symptoms such as those experienced by Private WY.

The generally benign view of the psychological effects of the POW experience around the time of World War I was to change later in the twentieth century, when, after World War II, the negative effects of being a POW became significantly clearer. One of the clearest accounts of this was written by Dr Aidan McCarthy, who was born and grew up in Castletownbere, County Cork, and graduated as a medical doctor from University College Cork in 1938 (McCarthy, 2005). McCarthy joined the Royal Air Force (RAF) in 1939 and ended up as a POW in Japan. After the war, he was awarded an OBE for his POW work.

McCarthy’s personal account of the POW experience in World War II is stark and disturbing: the food in the Japanese camps was ‘appalling’; the accommodation ‘badly overcrowded and soon bacillary dysentery cases appeared’; ‘diabolical punishment’ was performed on certain prisoners; and the forced labour was ‘reminiscent of a Tractarian picture of Hell’ (McCarthy, 2005: 104). Following his release, McCarthy was clearly in a state of ‘shock’:

It is very difficult to describe my feelings at this time. I found it hard to believe that the brutality, beatings and starvation were over. I found it impossible to believe that the recent holocaust was real, not just a nightmare. Home seemed even less real. It was like being in a void. We lived for the day, neither able to look back into the past – nor look forward into the future. Later I realised that we must have been in a state of shock. (McCarthy, 2005: 139)

Following the release of POWs after World War II, ‘the Medical Branch of the RAF had a busy time rehabilitating minds and body to normality. The neuro-psychiatrists soon realised that their experiences with German POWs had not prepared them for the Far East POWs at all’ (p. 158). Clearly, the POW experience in World War II had substantial potential to produce adverse psychological effects, and the prisoner of war cases described at the RWH, combined with other historical evidence from World War I pension files (Jones and Wessely, 2010), suggests psychological trauma of a similar nature among at least some POWs from World War I too, although its precise parameters are difficult to define.

Legacy of the Richmond War Hospital

The history of mental disorders occasioned by World War I, and the history of shell shock in particular, are complex and important histories, indelibly linked with social, political and cultural circumstances, issues of class and gender, and the history of war itself (Reid, 2010). In this context, the legacy of the RWH is multi-layered and complex to unravel. Nonetheless, its legacy can be usefully considered in terms of three key components:

In terms of the RWH’s legacy to the Irish asylum system, the establishment clearly provided a significant contrast to the general asylum system owing to its relatively brief inpatient stays and generally positive treatment outcomes: by the time the RWH closed on 23 December 1919, 362 patients had been treated, and RMS Donelan reported that more than half ‘were successfully treated and enabled to return to their homes’ (Reynolds, 1992: 219). The RWH was innovative in terms of treatments too, owing, at least in part, to the level of ‘cooperation and involvement of voluntary organisations in the care of the patients’ (p. 218). Thus, while ‘singers and dramatic groups had visited the asylum in the past and had entertained the patients, the involvement of the voluntary groups with the war hospital was more regular and sustained. Later such cooperation was to be developed for the asylum at large, helping in some way to make life less claustrophobic for the patients’ (pp. 218–19). Finally, the RWH facilitated voluntary admission status for its patients, thus avoiding the stigma of involuntary detention; this was a reform that was to gain a strong foothold in the Irish asylum system more widely only with the rather belated introduction of the Mental Treatment Act 1945 (Kelly, 2008).

Regarding the legacy of the war hospitals to psychiatry more generally, the very diagnosis of ‘shell shock’ forced doctors and others to realize that even ‘normal’ people could break down in situations of sufficient trauma and stress (Howorth, 2000), in stark contrast to the theory of degeneration, i.e. the idea that mental illness was largely biological and genetic in origin, and worsened with each generational cycle (Shorter, 1997: 93–4). As a result, the experiences of World War I contributed significantly to the emergence of hybrid models of bio-psycho-social psychiatry later in the twentieth century (Gabbard and Kay, 2001). In addition, the experience of shell shock, and the treatments that evolved to manage it, also generated new scope for the practice of psychotherapy, much of which, in retrospect, appears more aligned with later movements into cognitive therapy rather than the Freudian approaches which had been so evident until then (Howorth, 2000). Moreover, World War I, and the psychological symptoms its soldiers experienced, provided further evidence that there was not always an identifiable physical cause for psychological symptoms, but rather a unity between psychological and physical symptoms (Anon., 1917).

Finally, the RWH still plays a significant role in Ireland’s memory and commemoration of World War I and, in particular, historical recognition of the contribution made by the Irish to the war effort. While the psychological problems associated with the war were recognized at the time (e.g. through the establishment of the RWH in the first instance) and, to a certain extent, in the early aftermath of the war (e.g. in Liam O’Flaherty’s novel, Return of the Brute, 1929), there was limited further remembrance of the psychological suffering of soldiers until the approach of the centenary of the war, in 2014. The silence of many soldiers in the decades following the war may be attributable to a desire to forget, the cognitive effects of war trauma on memory, or a belief that the true horror of what these soldiers had seen was impossible to convey to anyone who had not been there (Howorth, 2000; Richardson, 2010: 14–18).

From 2011 onwards, however, the Irish who died in World War I formed an important element of diplomacy between Ireland and Great Britain (Higgins, 2014) and in 2014 there was considerable media coverage of specific cases of war-time trauma (Byrne, 2014; McGreevy, 2014). One hundred years earlier, at the time of the war itself, the treatments designed to assist such soldiers were provided at the RWH and, later, Belfast War Hospital, among other locations (including Leopardstown Hospital, Dublin, and the Hermitage Hospital, Lucan). Despite the limitations of these establishments, they were generally forward-looking institutions that reported high recovery rates, pointed the way for future reform of Ireland’s asylum system and brought positive changes to the practice of psychiatry throughout Ireland and Great Britain.

Today, their legacies can help deepen Ireland’s memory of the psychological effects of World War I on the Irish. For all these reasons, few could disagree with Dawson’s overall conclusion about the RWH and its Belfast counterpart:

At all events, I think it has been shown that neither institution could easily have been dispensed with, and that both in their varying degrees have deserved well of the country, and of the brave men who sacrificed so much in defending it. (Dawson, 1925: 224)