In late 1918, Private JK, a 19-year old single private in the British army, was admitted to the Richmond War Hospital, a 32-bed establishment on the grounds of the Richmond District Asylum (later St Brendan’s Hospital) in Dublin. It was dedicated to the treatment of soldiers with mental troubles as a result of the first World War.

Private JK had been in the army for a year and a half, and archival clinical records describe him as “stout and strong” with “alopecia areata” (patchy hair loss), “tongue tremulous” and “tremor of right hand”.

Mentally, Private JK was “depressed” and “complains of pain in his head and states he sleeps badly and is disturbed by dreams when he does sleep”.

Private JK had joined the army in 1917 and went to the Western Front in 1918. He was there for five months but “was blown up and buried for 36 hours” near Kemmel, a village six miles south-west of Ypres in Belgium, the scene of intense, sustained battles. Unsurprisingly, Private JK got shell shock as a result of his experiences.

The case of Private JK is typical of many who were treated at the Richmond War Hospital between June 1916 and December 1919. Over this period, the War Hospital attended to the needs of 362 soldiers with various nervous and mental troubles as a result of the first World War.

According to the clinical records, Private JK recovered quickly. One week after admission, he had “improved considerably. He is fairly bright and cheerful. He complains of pain and dizziness in his head occasionally. Sleeps and eat well”.

Rapid recovery

This apparent rapid recovery was by no means unique. More than half of the soldiers admitted to the Richmond War Hospital reportedly recovered following their time there, although a minority moved on to different locations for further treatment (eg Belfast War Hospital, which opened in 1917), and a small number were transferred to general asylums.

Many of the cases admitted to the Richmond War Hospital were characterised not only by characteristic symptoms of shell shock, but also features of depression, which was a relatively common feature within shell shock but could also attain considerable severity in its own right.

Corporal IJ, for example, was a 26-year old, single Wesleyan admitted to the Richmond War Hospital in late 1918. Corporal IJ was described as “stout”, complained of a cough; and seemed mentally “somewhat depressed, and hypochondriacal”.

He complained “of pain and clattering noises in his head. He states his head jumps now and then, and that he sleeps badly and dreams much. He states he has nothing to live for”.

Corporal IJ had joined the army in 1914 and spent time in India, only to return in 1915 when “he used to suffer with his head and ears”.

He then came back to Ireland and had been in several hospital since he came home” suffering with “influenza and pneumonia”. On his first night at the Richmond War Hospital, Corporal IJ “remained quiet and slept well”.

War Neuroses: Netley Hospital

One week after admission, Corporal IJ remained “dull and depressed and inclined to be hypochondriacal. He is very nervous. He took a peculiar cold shiver while I was speaking to him recently but when put to bed his temperature did not rise. He denies he ever had malaria. Sleeps and eats well.”

Two weeks after admission, Corporal IJ was transferred to Belfast War Hospital for further treatment.

Melancholia

Melancholia or depression was a common problem in other war hospitals too and was the most common diagnosis (18 per cent) among soldiers from the expeditionary force in France admitted to the Lord Derby War Hospital, Warrington, Lancashire, between June 1916 and June 1917.

As the diagnosis of shell shock became increasingly common throughout the network of war hospitals in Ireland and England, a broad range of treatments were proposed.

The nature of these treatments reflected diverse views about the origins of shell shock as well as differing opinions about the best way to resolve its debilitating symptoms.

Some of the initial treatments for shell shock were notably 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 even electric shocks to alter soldiers’ behaviour (as shown vividly in Pat Barker’s novel, Regeneration, and the subsequent movie).

Other treatments were more psychological in nature, 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 the traumatic experiences, (ie thinking about them differently) 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, focussing on altering patterns of thought and behaviour so as to reduce symptoms.

There were, however, other approaches to the management of shell shock which certain first World War 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. Against this background, treatment at the Richmond War Hospital focused on the provision of rest and quietude for soldiers, hot and cold baths, and a certain amount of medication (eg pain-relieving medication), as well as care for physical illnesses such as epilepsy and malaria. There was also a strong emphasis on activities such as trips out of the hospital, drama groups and choirs.

Caffeine and antipyrin treatment

Many of these treatments were long-established in the Richmond District Asylum and elsewhere, well prior to the arrival of the War Hospital. The provision of hot and cold baths, for example, was a continuation of the long-standing practice of hydrotherapy (regular shower-baths) in asylums, and was later specifically recommended for shell shock in the 1922 Report of the War Office Committee of Enquiry into Shell Shock.

Antipyrin, also known as phenazone, was one of the medications used at the Richmond War Hospital. This was a useful medication for reducing pain and body temperature, first discovered in 1883 by Ludwig Knorr (1859-1921), a German chemist. Its actions in alleviating pain, reducing inflammation and restoring body temperature would have been very useful for soldiers suffering the after-effects of battle or a difficult journey back to Ireland.

Caffeine, too, was used as a treatment at the Richmond War Hospital and was well-established as a medication during this period, having been the subject of particularly approving mention in Dr William H Burt’s 1896 edition of his remarkable Physiological Materia Medica (Containing All that is Known of the Physiological Action of Our Remedies Together with their Characteristic Indications and Pharmacology).

The addictive potential of caffeine was clearly recognised at the Richmond as medical staff noted that when it was discontinued, the soldiers begged for its reinstatement.

Bromides were another form of medication used at the War Hospital. Bromides have 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.

Fletcher’s hydrobromate syrup, which was prescribed at the War Hospital, was a curious concoction, listed in the British Medical Journal on April 1st 1882 and described as a palatable treatment for, among other matters, “exhaustion of the brain”.

Ground-breaking mental health service

Overall, the treatments provided at the Richmond War Hospital tended firmly towards the benign of the spectrum, and the hospital represented a unique and ground-breaking initiative in Irish mental health services during an era when the Irish asylums were constantly expanding, and there were deep concerns about conditions and treatments in many of them, including the main Richmond Asylum itself.

The Richmond War Hospital differed significantly from the main asylum because it was aimed at a specific population (soldiers), did not require that patients be formally certified as insane and assumed a more progressive approach to treatment and recovery.

While many of these changes were apparently short-lived, and did not immediately generalise to Ireland’s broader asylum system after the War Hospital closed in 1919, they were nonetheless provocative changes which would echo through later reforms of Ireland’s psychiatric hospitals throughout the 1900s.

Professor Brendan Kelly is Associate Clinical Professor of Psychiatry at UCD School of Medicine and Medical Science, and author of “He Lost Himself Completely”: Shell Shock and Its Treatment at Dublin’s Richmond War Hospital, 1916-1919 (theliffeypress.com)