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Bipolar Psychopharmacotherapy

Bipolar Psychopharmacotherapy: Caring for the Patient Edited by Hagop S. Akiskal and Mauricio Tohen
# 2006 John Wiley & Sons, Ltd ISBN: 0-470-85607-6
c19.fm Page 367 Wednesday, October 19, 2005 9:59 AM
ffirs.fm Page iii Wednesday, October 19, 2005 9:13 AM

Bipolar
Psychopharmacotherapy
Caring for the Patient

Editors

Hagop S. Akiskal
International Mood Center,
University of California at San Diego, La Jolla, CA, USA

and

Mauricio Tohen
Lilly Research Laboratories, Indianapolis, IN and McLean Hospital,
Harvard Medical School, Belmont, MA, USA
ffirs.fm Page iv Wednesday, October 19, 2005 9:13 AM

Copyright © 2006 John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester,
West Sussex PO19 8SQ, England
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Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available
in electronic books.
Library of Congress Cataloging in Publication Data
Bipolar psychopharmacotherapy : caring for the patient / editors, Hagop S. Akiskal and Mauricio Tohen.
p. cm.
Includes bibliographical references and index.
ISBN-13 978-0-470-85607-9 (cloth : alk. paper)
ISBN-10 0-470-85607-6 (cloth : alk. paper)
1. Manic-depressive illness—Chemotherapy. 2. Lithium—Therapeutic use. 3. Antipsychotic drugs.
4. Psychopharmacology. [DNLM: 1. Bipolar Disorder—drug therapy. 2. Anticonvulsants—therapeutic use.
3. Antimanic Agents—therapeutic use. 4. Antipsychotic Agents—therapeutic use. 5. Bipolar
Disorder—prevention & control. WM 207 B6176 2006] I. Akiskal, Hagop S. II. Tohen, Mauricio.
RC516.B529 2006
616.89′5061—dc22
2005013978
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
ISBN-13 978-0-470-85607-9 (HB)
ISBN-10 0-470-85607-6 (HB)
Typeset in 11/13pt Times by Integra Software Services Pvt. Ltd, Pondicherry, India
Printed and bound in Great Britain by Antony Rowe Ltd, Chippenham, Wiltshire
This book is printed on acid-free paper responsibly manufactured from sustainable forestry in which
at least two trees are planted for each one used for paper production.
ffirs.fm Page v Wednesday, October 19, 2005 9:13 AM

Dedication

This book is dedicated to bipolar patients and their families, for the privilege of
caring for them.
c19.fm Page 367 Wednesday, October 19, 2005 9:59 AM
ftoc.fm Page vii Wednesday, October 19, 2005 9:13 AM

Contents

List of Contributors ix

Preface xiii

Chapter 1 The Scope of Bipolar Disorders 1

Hagop S. Akiskal

Chapter 2 Lithium Treatment: Focus on Long-Term

Prophylaxis 9
Mogens Schou and Paul Grof

Chapter 3 Valproate: Clinical Pharmacological Profile 27

Charles L. Bowden and Vivek Singh

Chapter 4 Pharmacological Profile and Clinical Utility of

Lamotrigine in Bipolar Disorders 43
David J. Muzina, Joseph R. Calabrese

Chapter 5 Carbamazepine, Other Anticonvulsants and

Augmenting Agents 63
Heinz Grunze

Chapter 6 Olanzapine in Treatment for Bipolar Disorder 85

Mauricio Tohen, Giedra Campbell, and Daniel Lin

Chapter 7 Haloperidol and Risperidone in Mania 105

John Cookson

Chapter 8 A Comparison of “Second Generation Antipsychotics”

in the Treatment for Bipolar Disorder: Focus
on Clozapine, Quetiapine, Ziprasidone
and Aripiprazole 125
Paul E. Keck, Jr. and Susan L. McElroy
ftoc.fm Page viii Wednesday, October 19, 2005 9:13 AM

viii Contents

Chapter 9 Complex Combination Therapy: The Evolution

Toward Rational Polypharmacy in Lithium-Resistant
Bipolar Illness 135
Robert M. Post, Andrew M. Speer and Gabriele S. Leverich

Chapter 10 The Primacy of Mania 169

Athanasios Koukopoulos

Chapter 11 Diagnostic and Clinical Management Approaches

to Bipolar Depression, Bipolar II and Their Comorbidities 193
Giulio Perugi, S. Nassir Ghaemi and Hagop S. Akiskal

Chapter 12 Bipolarity in Women: Therapeutic Issues 235

Susan L. McElroy, Lesley M. Arnold and Lori L. Altshuler

Chapter 13 Pediatric Bipolar Disorder: The Promise of

Psychopharmacotherapy 279
Joseph Biederman

Chapter 14 Treatment for Bipolar Disorder in Older Adults 301

Kenneth I. Shulman

Chapter 15 Psychosocial Interventions in Bipolar Disorders:

Rationale and Effectiveness 313
David J. Miklowitz

Chapter 16 The Pivotal Role of Psychoeducation in the

Long-Term Treatment of Bipolar Disorder 333
Francesc Colom and Eduard Vieta

Chapter 17 The Role of Treatment Setting in the

Pharmacotherapy of Bipolar Disorder 347
Jean-Michel Azorin

Chapter 18 Suicide Prevention 353

Zoltán Rihmer

Chapter 19 Principles of Caring for Bipolar Patients 367

Hagop S. Akiskal and Kareen K. Akiskal

Index 389
fbetw.fm Page ix Wednesday, October 19, 2005 9:13 AM

List of Contributors

Hagop S. Akiskal, International Mood Center, Department of Psychiatry at the

University of San Diego and Veterans Administration Medical Center, 3350 La Jolla
Village Dr. (116-A), San Diego, CA 92161, USA

Kareen K. Akiskal, International Mood Center, University of California at San

Diego, 9500 Gilman Drive, La Jolla, CA 92093-0603, USA

Lori L. Altshuler, UCLA Mood Disorders Research Program, UCLA, USA

Lesley M. Arnold, Women’s Health Research Program, University of Cincinnati

College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267, USA

Jean-Michel Azorin, Department of Psychiatry, Ste Marguerite Hospital, 13274

Marseille Cedex 9, France

Joseph Biederman, Pediatric Psychopharmacology Unit (ACC 725), Massachusetts

General Hospital, 15 Parkman Street, Boston, MA 02114-3139, USA

Charles L. Bowden, Department of Psychiatry, Mail Code 7792, University

of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio TX
78229-3900, USA

Joseph R. Calabrese, Case Western Reserve University, School of Medicine,

Cleveland, Ohio 44106, USA

Giedra Campbell Lilly, Research Laboratories, Eli Lilly & Co, 525 S. Meridian
Street, Indianapolis, IN 46225, USA

Francesc Colom, Bipolar Disorders Program, Stanley Research Center, IDIBAPS,

Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain

John Cookson, Royal London Hospital, St Clement’s, 2A Bow Road, London E3

4LL, UK
fbetw.fm Page x Wednesday, October 19, 2005 9:13 AM

x List of Contributors

S. Nassir Ghaemi, Bipolar Disorder Research Program, Cambridge Hospital,

Department of Psychiatry and Harvard University, Cambridge, MA 02139, USA

Paul Grof, Deparmtent of Psychiatry, University of Ottawa, Royal Ottawa Hospital,

1145 Carling Avenue, Ottawa, Ontario K2E 7L2, Canada

Heinz Grunze, Psychiatrische Klinik und Poliklinik LMU München, Ludwig

Maximilians Universität München, Nussbaumstrasse 7, D-80336 Munich,
Germany

Paul E. Keck, University of Cincinnati College of Medicine, Department of

Psychiatry, 231 Albert Sabin Way, ML 559, Cincinnati, OH 45267-0559, USA

Athanasios Koukopoulos, Centro Lucio Bini, Via Crescenzio 42, 00193 Rome, Italy

Gabriele S. Leverich, Biological Psychiatry Branch, National Institute of Mental

Health, Bldg. 10, 10 Center Drive MSC 1272, Bethesda, MD 20892-1272, USA

Daniel Lin Lilly, Research Laboratories, Eli Lilly & Co, 525 S. Meridian Street,
Indianapolis, IN 46225, USA

Susan L. McElroy, Psychopharmacology Research Program, Department of

Psychiatry, University of Cincinnati College of Medicine, 231 Albert Sabin Way,
Cincinnati, OH 45267, USA

David J. Miklowitz, Department of Psychology, Davie Hall CB#3270, University

of North Carolina, Chapel Hill, NC 27599-3270, USA

David Muzina, Department of Psychiatry and Psychology, Desk P-57, 9500

Euclid Avenue, Cleveland, Ohio 44195, USA

Giulio Perugi, Institute of Psychiatry, Via Roma 67, 56100 Pisa, Italy

Robert M. Post, Biological Psychiatry Branch, National Institute of Mental

Health, Bldg. 10, Rm. 3s239, 10 Center Drive MSC 1272, Bethesda, MD
20892-1272, USA

Zoltán Rihmer, National Institute for Psychiatry and Neurology, Budapest 27,
POB 1, 1281 Hungary

Mogens Schou, The Psychiatric Hospital, Skovagervej 2, DK-8240 Risskov,

Denmark
fbetw.fm Page xi Wednesday, October 19, 2005 9:13 AM

List of Contributors xi

Kenneth I. Shulman, Department of Psychiatry, Sunnybrook & Women’s College

Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto,
ON M4N 3M5, Canada

Vivek Singh, Department of Psychiatry, University of Texas Health Science Center,

7703 Floyd Curl Drive, San Antonio TX 78229-3900, USA

Andrew Speer, Biological Psychiatry Branch, National Institute of Mental

Health, Bldg. 10, 10 Center Drive MSC 1272, Bethesda, MD 20892-1272, USA

Mauricio Tohen, McLean Hospital, Harvard Medical School, Belmont, MA and

Lilly Research Laboratories, Eli Lilly & Co, 525 S. Meridian Street, Indianapolis,
IN 46225, USA

Eduardo Vieta, Clinical Institute of Psychiatry and Psychology, Hospital Clinic,

University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
c19.fm Page 367 Wednesday, October 19, 2005 9:59 AM
fpref.fm Page xiii Wednesday, October 19, 2005 9:13 AM

Preface

Bipolar disorder has emerged as a major public health problem. Its prevalence,
phenomenology, subtypes, treatment and outcome are all under reevaluation.
A burgeoning research-based literature has appeared and continues to grow.
New therapeutic modalities, both psychopharmacologic and psychosocial, have
been introduced. The clinical and scientific challenges presented by this condition
have created the psychiatric subspecialty for bipolar disorders. One of the major chal-
lenges for this subspecialty is to integrate the emerging clinical science of bipolar
treatments.
The idea for this book was born in October 1998 at the ECNP Congress in Paris.
One of the topics discussed at that meeting was the fact that clinicians in both
Europe and the United States used antipsychotics in bipolar disorder, yet US
guidelines gave priority to lithium or anticonvulsants. The two editors decided to
hold an international conference in Paris, France, on bipolar disorder at the 50th
anniversary of the introduction of chlorpromazine in the same city in 1952. It
would be recalled that the first patients treated with this agent suffered from
bipolar mania.
For a variety of logistic reasons, the conference was held in Monte Carlo
instead of Paris in February 2002. Presided by the present editors and supported
by an unrestricted educational grant from Eli Lilly, the conference covered the
clinical psychopharmacology and related topics dealing with all agents available
at that time for the treatment of bipolar disorder. With a roster of 24 of the top
experts in the field and over 500 opinion leaders and researchers from all over the
world in attendance, to the best of our knowledge, it was the largest freestanding
conference on bipolar disorder.
As we were editing the book on the material presented at the Monte Carlo con-
ference, the field of bipolar psychopharmacology virtually exploded into a revolu-
tion. With so many new agents approved for bipolar disorder between 2002 and
2005, we had to revise the plans for this book in a radical way. The 19 chapters of
the present book now overlap no more than 20% with the original conference in
Monte Carlo. All chapters have been independently peer reviewed and updated
through April 2005. We have endeavored – and we believe we have succeeded –
in recruiting contributors who are the pioneers in bipolar psychopharmacotherapy
and its clinical applications in children, the elderly and women. Special attention
fpref.fm Page xiv Wednesday, October 19, 2005 9:13 AM

xiv Preface

is also given to bipolar depression, which has emerged as a major clinical and
therapeutic challenge.
The book goes beyond pharmacotherapy to cover innovative psychoeducational
and psychosocial interventions, managing the patients in the hospital and subse-
quent long-term care in the community. Questions about the health care climate,
advocacy organizations for bipolar disorder and social parameters impacting it are
also addressed. Finally, suicide prevention is given special consideration. This
book, then, provides a broad integrative philosophy of caring for bipolar patients
and their families.
Hagop S. Akiskal and Mauricio Tohen
c01.fm Page 1 Wednesday, October 19, 2005 9:13 AM

CHAPTER

1
The Scope of Bipolar Disorders
Hagop S. Akiskal
International Mood Center
University of California at San Diego, USA

DIAGNOSTIC AND PUBLIC HEALTH ASPECTS

Recent advances in the epidemiology, psychopathology and pharmacotherapy of
bipolar disorders have led to a greater recognition of this illness in all of its varieties
(Akiskal et al., 2000). The lifetime risk for bipolar conditions is about 1% for the
core (bipolar I) phenotype, making it at least equal in prevalence to schizophrenia.
A higher percentage of acute psychiatric hospital admissions is now being
assigned to the category of mania, and the recognition of clinically attenuated
outpatient forms of the illness (soft bipolar spectrum) is increasing. The latter
(bipolar II and beyond) is now estimated to be at least 4–5 times more prevalent
than bipolar I (Angst et al., 2003; Hirschfeld et al., 2003; Judd and Akiskal, 2003).
Reasons for the current focus on the entire diagnosable range of bipolar conditions
are several. Predominant among these is the tendency of diagnostic practice to
follow the availability of effective treatment modalities (Lehmann, 1969). After
the discovery of chlorpromazine, North American psychiatrists were tacitly
encouraged to elicit subtle degrees of formal thought disorder from their patients
so as to bring them the benefits of this new class of drugs. By the early 1970s,
schizophrenia had become more or less synonymous with psychosis. With the
advent of lithium carbonate treatment and its well-documented efficacy for bipolar
disorders, this trend became reversed in favor of bipolar disorders. Beginning with
DSM-III (American Psychiatric Association, 1980), the concept of schizophrenia
has been largely restricted to a core group of deteriorating psychotic disorders, while
mood disorders have been broadened to include even those with mood-incongruent
psychotic features that may or may not coincide with affective episodes. This
diagnostic approach reflects more than just therapeutic fashion; it is supported
by familial aggregation, course and outcome (Akiskal, 2002). Available evidence
indicates that mood disorders are often recurrent and, especially in bipolar conditions,

Bipolar Psychopharmacotherapy: Caring for the Patient Edited by Hagop S. Akiskal and Mauricio Tohen
# 2006 John Wiley & Sons, Ltd ISBN: 0-470-85607-6
c01.fm Page 2 Wednesday, October 19, 2005 9:13 AM

2 Bipolar Psychopharmacotherapy

can lead to considerable impairment in developmental, conjugal and social spheres.

The public health significance of bipolar disorder is summarized in Table 1.1. The
most important of these is suicide, seen in as many as 20% of those who receive
inadequate or no treatment, and must be considered a preventable complication
(Khuri and Akiskal, 1983). It now appears that bipolar II may account for a
disproportionately large portion of suicidal morbidity and mortality among all the
affectively ill (Rihmer and Pestality, 1999), emphasizing the importance of early
and accurate diagnosis.
At the “softest” end of the spectrum, milder degrees of bipolar disorder – subsumed
under the rubrics of cyclothymic disorder (Akiskal etal., 1977) and bipolar disorder
not otherwise specified (bipolar NOS) – are now categorized as mood disorders
rather than being grouped with neurotic or personality disorders. Although these
seemingly attenuated and “atypical” variants may not be easily distinguishable
from nonaffective personality disorders, the clinician is advised to err on the side
of affective diagnosis because of treatment implications.
External validating strategies – such as family history, course and inter-episodic
temperamental features – are often necessary to confirm the diagnosis of the
bipolar spectrum (Akiskal, 2003). The most established of bipolarity beyond classic
mania and bipolar I is the bipolar II type, so-named originally by Dunner, Gershon
and Goodwin (1976). Like diabetes type II, its onset is often insidious, but its
ravages no less devastating than that of the psychotic forms of the illness. This is
particularly true for cyclothymic depression, a variant of bipolar II we have termed
“bipolar II-½” (Akiskal and Pinto, 1999). Arising from a cyclothymic temperament,
it pursues an unstable course and is likely to be misdiagnosed as axis II cluster B.
These patients represent the “dark side” of bipolarity (Akiskal, Hantouche and
Allilaire, 2003; Hantouche, Angst and Akiskal, 2003).
The American Psychiatric Association (2000) Diagnostic Manual of Mental
Disorders, even in its last edition (DSM-IV), does not recognize hypomanic or

Table 1.1: Public health aspects of bipolar disorder

• Lifelong cyclical illness
• 1–5% of population
• Peak onset 15–30 years
• 5–10-year delay in correct diagnosis
• Frequent hospitalization
• Repeated hospitalization
• Repeated conjugal disruption: promiscuity
• Repeated job change/loss
• Financial disasters
• Alcohol/substance abuse
• 50% nonadherence to medication
• Increased cardiovascular mortality
• Suicide (highest within 10 years of illness onset)
c01.fm Page 3 Wednesday, October 19, 2005 9:13 AM

The Scope of Bipolar Disorders 3

manic switches occurring during pharmacotherapy, electroconvulsive therapy,

phototherapy and sleep deprivation as indicators of bipolar disorder. These patients
are obviously not unipolar major depressive disorder (MDD), nor are they classified
under bipolar not-otherwise specified (NOS). Therefore, this common clinical
phenomenon is voted by the DSM Committee out of existence! Since at least 1983,
there has been good evidence that such switching on antidepressants requires bipolar
family history (Akiskal et al., 1983, 2000, 2003). They are best regarded as less
penetrant forms of bipolar disorder (bipolar III). Diagnostic status of depressive
states with mood swings in the setting of multiple drug abuse, particularly that of
stimulants, is controversial, but we contend that many of these individuals belong
to a provisional bipolar type III-½ (Akiskal and Pinto, 1999; Maremmani et al.,
2003; Camacho and Akiskal, 2005). This is relevant in a book on advances in bipolar
disorder, because many of these patients respond favorably to anticonvulsant mood
stabilizers. Finally, I would like to mention bipolar type IV, which refers to
individuals who develop depression later in life from a lifelong background of
hyperthymic temperament (hypomanic traits without clear-cut episodes); their
bipolar status might be inferred from familial bipolarity (Cassano et al., 1992).
In a French national study (Table 1.2), 65% of all major depressions belonged to
the bipolar spectrum, of which the most prevalent were the bipolar II and II-½
phenotypes (Akiskal et al., 2005b). These considerations are important because
nearly all pharmacologic treatments covered in this book – certainly those
approved by regulatory bodies – pertain to bipolar I. Thus, there is a wide gap
between the psychopharmacology of bipolar disorder and the public health
significance of the phenotypes observed in the community and the clinic.
Lithium was the first specific agent for bipolar disorder approved for clinical use.
This was 35 years ago. Many other agents have been approved since then, almost all
of them in the last decade. They are all covered in this book. Lithium medicalized
psychiatry in bringing significant attention to the course of bipolar disorder. Its
importance should not be overshadowed by these new developments. Many patients,

Table 1.2: Bipolar spectrum subtypes (n=316)

in the French EPIDEP study of major depression
(n=493): validation by bipolar family history*
N %
Bipolar I 41 8.4
Bipolar II 61 12.4
Bipolar II-½ 164 33.5
Bipolar III 28 5.7
Bipolar IV 22 4.5
Total 316 64.5
* Akiskal et al. (2005b)
c01.fm Page 4 Wednesday, October 19, 2005 9:13 AM

4 Bipolar Psychopharmacotherapy

especially those in the “core” classic form of the illness, do respond to lithium. Its
judicious use, often in combination with other agents in rational polypharmacy,
requires intimate knowledge of its physiological and medical characteristics.
Regrettably, young psychiatrists are not having adequate experience with this
agent. A summary of the medical workup of patients in preparation of lithium use
(Akiskal, 1999) is given in this chapter’s appendix.

PSYCHOLOGICAL AND SOCIAL ASPECTS

The long-term, essentially life-long, nature of bipolar disorder and its vicissitudes
dictate continuity of treatment and long-term caring. To solve practical problems in
the patients’ lives requires caring that goes beyond medications and psychotherapy, to
include the family, significant others and the community.
Bipolar disorder continues to be poorly understood by both the public and
doctors. More often than not, a bipolar child is classified as having conduct disorder
or Attention Deficit Hyperactivity Disorder (ADHD) (Dilsaver, Henderson-Fuller
and Akiskal, 2003). A teenager’s suicide attempt is misattributed to problems of
the heart, adolescent crisis or substance abuse; promiscuous behavior is blamed on
childhood “sexual abuse.” Bipolar patients from time to time describe their parents as
“monsters” or “emotionally abusive,” which some psychotherapists accept on blind
faith without ever talking to the parents. Bipolar II patients are often diagnosed as
unipolar and/or borderline personality (Akiskal, 2004), treated with antidepressants
without mood stabilizers, resulting in tragic aggravation of the course of the
illness (Akiskal and Mallya, 1987; Akiskal et al., 2005a). Excessive spending,
squandering, of one’s economic resources and pathological generosity may lead
to financial ruin before bipolarity is considered.
Polls of members of the Depressive and Manic-Depressive Association in the
U.S. have shown a latency of 10 years from the onset of symptoms until the
correct diagnosis of bipolar disorder (Hirschfeld et al., 2003). Early diagnosis is
critical because suicide in bipolar patients often occurs within this early period.
The comfort, support, destigmatization, information and advocacy provided by
such a conglomeration of patients, families and community leaders (many of
whom are themselves bipolar) represents a novel approach in the rehabilitation of
the bipolar patient into society. This is a humane and just cause.
Given that about 10% of patients with bipolar illness have creative and leadership
achievements (Akiskal and Akiskal, 1988), sophisticated clinical management of
bipolar illness can potentially safeguard the adaptive capacity and contributions that
gifted bipolar people provide to society. Although psychotically ill (bipolar) patients
are represented in the media as being creative, this is a destigmatization campaign
at best and glamorizing madness at worst. Achievement and creativity are largely
attributes of the softer spectrum represented in the attenuated temperamental
expressions of bipolarity involving bipolar II (Akiskal and Akiskal, 1988, 2005).
c01.fm Page 5 Wednesday, October 19, 2005 9:13 AM

The Scope of Bipolar Disorders 5

Spanning from temperament to psychosis, bipolarity is a fascinating yet tragic

human condition. Mental health professionals who treat these individuals must use
pharmacotherapy and psychosocial interventions compassionately, judiciously
and rigorously – only rarely “aggressively.” Severe bipolar illness is not just an
ordinary illness to be medicated to “mediocrity.” The temperament of these
individuals deserves all our consideration and respect. While most psychotic bipolar
patients are neither leaders nor creators, they are the reservoir of the genes, which
in dilute form, might serve as the seeds of genius (Akiskal, 2000).

APPENDIX: LABORATORY CONSIDERATIONS IN THE

CLINICAL USE OF LITHIUM
More than any other development, the introduction of lithium has emphasized the
role of physicianship in psychiatry. The scientific literature and clinical wisdom
on the therapeutic aspects of this salt have been well summarized in a monograph
by Jefferson et al. (1983). The success of lithium treatment is dependent on the
thoroughness of the initial workup, on dosage titration procedures and on appropriate
monitoring throughout therapy.
The type of workup depends on the age of the patient and concurrent medical
conditions (Table 1.3). In young (less than 40 years), physically healthy subjects,
preparation for lithium therapy should include medical history (especially focused
on neurologic, renal, cardiac, gastrointestinal, endocrine and cutaneous systems),
physical examination and laboratory evaluation focusing on electrolytes and
thyroid. In older patients or those with a history of cardiac disease, a baseline
electrocardiogram (EKG) should be obtained, and an electroencephalogram
(EEG) performed if epilepsy is suspected; if there is a history of renal disease,
thorough evaluation of baseline kidney function is mandatory. Given rigor-
ous indications for lithium, major medical illness and abnormalities in laboratory
indices do not necessarily contraindicate its use; they do dictate, however, greater
medical vigilance, including frequent determination of blood levels and use of
lower doses.

Table 1.3: Recommended laboratory workup of patients

considered for lithium therapy
Healthy <40 years All others: consider
Weight EKG
CBC EEG
T4/TSH TRH test
FBS/serum electrolytes 24-hour urine volume
Urinalysis Urine concentration test
BUN/creatinine Creatinine clearance
Exploring the Variety of Random
Documents with Different Content
a good deal queerer to be living in one of the big famous French forts which
the Germans were trying to pound to bits with their enormous siege guns.
But we soon settled down and got fairly well used to the sound of the fort’s
guns and the row of the German artillery and the crashing of the shells
around us.
We were told off into parties in the fort, each party being commanded by
a non-commissioned officer, who used to light the way for us with an
electric lamp that he carried in front of him, hung round his neck.
We ate and drank and slept with the French gunners, and taken
altogether we were very comfortable, and were spared something of the
awful noise of the firing, for when the guns of the forts were fired the noise
was worse than thunderbolts, and everything about was shaken in the most
extraordinary manner.
The Germans were mad to get at us and they shot tons and tons of shells
at us, and time after time made efforts to storm the forts and Lille itself. In
these attempts they lost immense numbers of men, and when we got outside
of the fort we saw the dead bodies of the Germans lying about in thousands
—so thick on the ground were they that we had to clamber over them as
best we could.
Our own fort was pretty lucky, but the next one to us was very badly
damaged, huge holes being made where the monster shells got home, and
most of the defenders of the fort being wiped out. The German big guns
certainly did a vast amount of mischief against forts—so the Germans will
know what to expect when our own big guns get to work on forts in
Germany.
It was soon clear that it would not be possible to hold on at Lille for
long, because we were so hopelessly outnumbered. The fight went on, day
and night, for a full week, and the Germans bombarded everything.
On Sunday, October 4th, there was some desperate fighting in the streets
of the town and the outskirts. German troops were rushed up in armoured
trains and motors, but when it came to hand-to-hand fighting they were not
much good, and on the Monday they were driven away with heavy loss.
We had a few goes at them with the bayonet, and that charging was very
hard work. It had to be done in short rushes of about a hundred yards, but
we could not get near enough to them to give the bayonet a fair chance. In
that respect it was the same old story—the Germans would not face the
steel. In anything like equal numbers they can’t stand up against a charge.
They would mostly run for it, firing at us over their shoulders as they
bolted, but not doing a great deal of mischief that way. When they could run
no more and saw that the game was up, they would throw away their rifles
and surrender, and we then brought them in.
Before the fighting began, and while it was going on, a good many of the
inhabitants got into a panic and fled to Boulogne and Calais; but the French
troops held out gamely, and on the Tuesday a fearful lot of execution was
done amongst the masses of Germans by the French artillery fire. Neither
the German guns nor the infantry could make a stand against this onslaught,
and at this time the German losses were particularly heavy, hundreds of
men falling together. At the end of that part of the battle the Germans for
the time being were completely routed, and they were driven back a good
dozen miles.
The Durhams suffered greatly in the fighting, and the good old West
Yorkshires, who had seen a lot of hard work with us, had been badly cut up
too. Some splendid help was given by the little Gurkhas, who had joined the
British; but unfortunately I was not able to see much of what they did,
because soon after they appeared with their famous knives I got my wound.
Some of the most exciting and dangerous work was done at night, when
we tried to get at the Germans with the bayonet and rout them out of their
trenches and positions. We had to do everything so quietly—creep out of
the forts, creep along the ground, and creep up to the enemy as near as we
could get, and sometimes that was not very close, because of such things as
barbed wire entanglements.
These entanglements were particularly horrible, because they were so
hard to overcome and tore the flesh and clothing. At first we had a pretty
good way of destroying them, and that was by putting the muzzles of our
rifles on the wire and blowing it away; but there were two serious
drawbacks to that trick—one was that it was a waste of ammunition, and
the other was that the noise of the firing gave us away, and let the Germans
loose on us with guns and rifles.
We soon got too canny to go on with that practice, and just before I was
wounded and sent home a very ingenious arrangement had been fixed to the
muzzle of the rifle for wire-cutting—a pair of shears which you could work
with a swivel from near the trigger, so that instead of putting the muzzle of
the rifle against the wire, you could cut it by using the pliers.
It was in one of these night affairs that I was nearly finished as a soldier.
I was ordered to join a reconnoitring party. We got clear of the fort, and
made our way over the country for about a mile. We were then in a field
which had been harvested and harrowed, so that it was pretty hard ground
to go over. In spite of it all we were getting on very nicely when the
Germans got wind of our movements and opened a terrible fire with rifles
and maxims.
We lost a lot of men, and where a man fell there he had to lie, dead or
living.
Suddenly I fell plump on the ground, and found that I could not get up
again, though I did my best to keep up with my chums. Then I felt an awful
pain in my thigh and knew that I was hurt, but I must have been struck five
minutes before I fell, by a bullet from a German rifle. It had gone clean
through my right thigh. They told me afterwards that I had had a very
narrow shave indeed; but a miss is as good as a mile.
I knew there was nothing for it but pluck and patience, so I made the
best of things, and waited till the day broke and brought the battalion
stretcher-bearers,
 [To face p. 80.
“WE FOUND A FAIR LOT OF GERMANS IN HOUSES AND FARMS” (p. 72).

who always came out just about dawn to collect the wounded.
I was lying on the ground, in a sort of ditch, for six hours before I was
picked up by the stretcher-bearers and carried to a stable which was being
used as a temporary hospital.
The Germans fired on the wounded as they were being carried off in the
grey light, but they didn’t hit me again.
I lay in the stable for about eight hours, waiting for the ambulance,
which took me to the rail-head, and then I was put in a train and taken to
Rouen—and that travelling was simply awful, because the French trains jolt
like traction-engines.
 All the same, I had a pleasant voyage to Southampton, and hoped that I
might be sent to a hospital near home, but I was too ill to go a long journey
to the north, so I was taken to Woolwich, and afterwards sent here, to the
Royal Hospital at Richmond, where everybody is kindness itself, and can’t
do enough for you, it seems.
I’ve had a month in bed, so far, but I’m hoping to be out of it soon and
hobbling about.
 CHAPTER VII

GERMAN TREACHERY AND HATRED

[“Die hard, my men, die hard!” shouted the heroic Colonel Inglis, when, at
Albuhera, in the Peninsular War, his regiment, the 57th Foot, were furiously
engaged with the enemy. And the regiment obeyed, for when the bloody fight was
ended twenty-two out of twenty-five officers had been killed or wounded, 425 of
570 rank and file had fallen and thirty bullets had riddled the King’s Colour. The
57th is now the 1st Battalion Middlesex Regiment, but the regiment is still best
known by its gallant nickname of the “Die-Hards.” It has suffered exceptional
losses in this war, and the story of some of its doings is told by Corporal W.
Bratby, who relates a tale which he has described as a brother’s revenge.]

The old “Die-Hards” went into action at Mons nearly a thousand strong; but
when, after Mons had been left behind, a roaring furnace, the roll was
called, not more than 270 of us were left. D Company came out a shattered
remnant—only thirty-six men, and no officers. When what was left of us
marched away, other regiments were shouting, “Three cheers for the Die-
Hards!” And three rousing cheers they gave; but I had no heart for them,
because I had left my younger brother Jack, a “Die-Hard” like myself. They
told me that he had been killed by a bursting shell while doing his duty with
the machine-gun section.
I did not say much. I asked the adjutant if any of the machine-gun
section had returned, and he answered sadly, “No, they’ve all gone.”
Jack and I were brothers and had been good old chums all our lives—I
had taught him a bit of boxing and he was most promising with the gloves,
and we had a widowed mother to keep; so I really felt as if something had
gone snap in my head and that all I cared for was to get my revenge from
the Germans. The last words I heard him say were, “Well, Bill, I’m going
right into the firing line,” and I remember laughing and saying, “Yes, Jack,
but you’re not the only one who’s going to do that.”
Jack laughed too and said, “All right, Bill, I’ll see you in the firing line,”
and with that he went and I saw no more of him.
 I had been in the regiment five years and nine months when the war
broke out and Jack had served more than two years. I had become a
corporal and he was a lance-corporal.
The days in the beginning were swelteringly hot; but the “Die-Hards,”
being typical Cockneys, made the best of them. Our Brigade consisted of
ourselves (the 4th Middlesex), the 2nd Royal Scots, the 1st Gordon
Highlanders and the 2nd Royal Irish Rifles. We began operations with
trench digging, one particular trench, the machine-gun trench, being allotted
to B Company. I helped to superintend the construction of the trenches, and
I was proud of the work when I saw what was done from them when the
Germans showed themselves.
Our machine-gun caused enormous havoc amongst the German ranks,
and I am sure that my brother did his part in settling a lot of them, for he
was keen on his work and full of go. The Royal Irish at this stage were
doing splendidly—they were not more than 350 yards from the enemy,
separated from them by a railway—and they were lucky enough to fetch
one gun out of action again, but the enormously superior numbers of the
Germans told and the famous retreat began. The machine-gunners had
suffered very heavily and it was hard to learn anything definite about the
position in the trenches.
Officers and men were falling everywhere on both sides, and I saw a
reconnoitring patrol of Uhlans bowled over in trying to avoid some of the
4th Royal Fusiliers. An officer and seven men of the Uhlans were killed in
that little affair without getting in a shot in return. It was not much, but it
was something cheering after what we had gone through at Mons. We
looked upon it as a bit of sport, and after that we went into châteaux, cafés
and other places, and discussed affairs in a proper Tommy-like spirit. It is
very strange, but if it had not been for the language I could have thought at
times that I was back in Kilburn or in London, on strike duty again, as I was
at the time of the railway trouble three years ago.
We were fighting a rearguard action for three days right off the reel, and
doing that wonderful march to which “Kitchener’s test” or anything like it
was a mere nothing. Owing to the heat, we discarded overcoats, kits and in
some cases rifles and equipment. Our transport was blown to pieces three
days after Mons, which to the 8th Brigade is known as the Wednesday.
 But lost kit and shattered transport mattered little to most of us, and
certainly had slight significance for me, because the only thing I had in
mind was this determination to get revenge. I am not exaggerating in the
least, I am merely putting down on record the state of my feelings and
wishing to make you understand how remarkable a change had come over
me, an alteration such as is brought about, I take it, by war, and war alone.
Perhaps, too, the excessive stress and strain of those early days of the war
had something to do with my condition; but whatever the cause, there it
was. Danger itself meant nothing, and I, like the rest of us, took the
ordinary fighting and the incessant and truly horrible shell fire as a matter
of course, a part of the day’s work. I bided my time, and it came.
We had crossed the Aisne, a dangerous unit still, in spite of our losses,
for we had received reinforcements from the base; but just before crossing
the river we sat down on the road, waiting for a favourable opportunity to
cross by a pontoon bridge which the Engineers were building. That pontoon
replaced a bridge which had been blown up.
On the word “Rise” we fell in, and in doing so a man had the misfortune
to shoot himself through the hand.
The colonel came up at once and ordered the injured man to go back to
the hospital in a village about a mile and a half up the road, in rear of the
bridge. I was told off to take him, and we went to a house that had been
turned into a hospital, the people in it being typically French. There were
some sad cases there, amongst them one of our own fellows who had been
severely wounded and a trooper of the 4th Hussars who was the only
survivor of a reconnoitring party. He had been shot while going through the
village that morning. Just at that time we had had many losses of small
bodies—in one case a sergeant and five men had been blown to pieces.
After I had got the wounded man into the hospital I asked the
“monsieur” in charge of the house for some tea, which he very willingly
produced—it had no milk in it, of course, but by that time I had almost
forgotten that milk existed.
At this time the village was being shelled, but that did not affect the
enjoyment of my tea-drinking, and after that refreshing draught and a chunk
of “bully” and some biscuit crumbs which I found in the corner of a none-
too-clean haversack, I “packed down” for the night.
 At about four o’clock next morning I awoke and went back to the bridge,
which my battalion had crossed on the previous day, the “Die-hards” being
the first to have the honour to cross. By this time we had got past the
sweltering stage of things and had become accustomed to soaking weather,
and on this particular morning I was thoroughly cold and wet and generally
“fed up” with things; but I still glowed with the longing to get level with the
Germans.
You must bear in mind that regiments had been broken up and scattered
in the most astonishing manner and had become mixed up with other
regiments, and I had lost my own and had to set to work to find it.
I got over the bridge and reached some artillery.
“Have you seen anything of the Middlesex?” I asked.
“Yes,” the gunners answered, “they’ve just gone into action on the brow
of the hill.”
I made my way towards the top of a neighbouring hill and found that my
battalion had taken up a position there, but I had to wander about aimlessly,
and I did so till I came across one or two men who were separated from the
battalion. They directed me to the actual position, which was on the ridge of
the hill, and to the ridge I went and found that it was lined with remnants of
the brigade.
I tried to find my own company, but could not do so, as it had been
surprised in the night; so I attached myself to another and lay down with the
corporal on the sodden ground.
Wet through, cold, hungry and physically miserable, but still tough in
spirit, we lay there, wishing that all sorts of impossible things would
happen.
The corporal showed me where he had hit a German scout. We watched
the poor devil rolling about—then we finished him off.
In addition to the wet there was a fog, and under cover of this the
Germans crept up and were on us almost before we knew of their presence.
The alarm was first given by a man near us who was suffering from ague
or some such ailment and had been moaning and groaning a good deal.
Suddenly he cried, “Here they are, corporal! Fire at ’em!”
My loaded rifle was lying just in front of me. I snatched it up, and as I
did so the Germans jumped out of the mist on to us, with loud shouts. I
brought the first German down and my chum dropped one; and we
managed to fetch the officer down. He was carrying a revolver and a stick,
like most German officers, so that you had no difficulty in distinguishing
them.
When the alarm was given I gave a quick look over a small hump in the
ground and then we were rushed; but I hated the idea of retiring, and kept
on shouting, “Crawl back! Crawl back!”
Machine-guns and rifles were rattling and men were shouting and
cursing. In the midst of it all I was sane enough to hang on to my fire till I
got a good chance—and I did not wait for nothing.
Up came two Germans with a stretcher. They advanced till they were not
more than twenty-five yards away, for I could see their faces quite clearly;
then I took aim, and down went one of the pair and “bang” off the stretcher
fell a maxim. The second German seemed to hesitate, but before he could
pull himself together he had gone down too. I began to feel satisfied.
By this time the order to retire had been given and I kept on shouting,
“Keep down! Crawl back!” and the lads crawled and jumped with curious
laughs and curses.
In that excited retirement the man who was with me was shot in the
chest. I halted for a little while to see what had really happened to him, and
finding that he was killed I took his waterproof sheet and left him. I hurried
on until I was in a valley, well away from the ridge; then an officer
managed to get us together and lead us into a wood.
As we got into the wood I spotted a quarry. I said to the officer, “Is it
best to go down here, sir?”
“I’ll have a look—yes,” he answered.
We went into the quarry, where there were Royal Scots, Middlesex,
Gordons and Royal Irish.
The officer was afraid that we might be rushed, in which case we should
be cut up, so he put a man out on scout. We were not rushed, however, and
when the firing ceased we filed out and lined the ridge again, and there we
lay, expecting the Germans to come back, but for the time being we saw no
more of them.
By some means one of the Irishmen had got drunk and wanted to fight
the Germans “on his own.” He was shouting for them to come on and was
wandering about. Soon afterwards he was found lying on the top of the hill,
having been shot in the thigh. He was carried out of action and I have never
heard of him since.
After that affair of the hill-crest we had a lot of trench work, and very
harassing it was. For five days we stayed in trenches, so near to the enemy
that it was death to show your head.
Trench fighting is one of the most terrible features of the war, for not
only is there the constant peril of instant death, which, of course, every
soldier gets accustomed to, but there is also the extreme discomfort and
danger of illness arising from insanitary surroundings. Often enough, too,
when a new trench was being dug we would find that we were working on
ground that had been previously occupied, and the spades brought up many
a ghastly reminder of an earlier fight.
Sometimes in this wonderful warfare we were so very close to the
Germans that when we sang hymns—and many a hymn that a soldier has
sung at his mother’s knee has gone up from the trenches from many a brave
lad who has given his life for his country—the Germans would harmonise
with them. It was strange to hear these men singing like that and to bear in
mind that they were the soldiers who had done such monstrous things as we
saw during the retreat, when they thought that certain victory was theirs.
Time after time, with my own eyes, I saw evidence of the brutal outrages of
the German troops, especially on women and children, yet it seems hard to
convince some of the people at home that these things have been done.
At one time in the trenches, for a whole week, we were so situated that
we dare not even speak for fear of revealing our position—we were
subjected to an enfilade fire and did not dare to speak or light a fire, which
meant that we had no hot food for a week, and we could not even smoke,
which was the biggest hardship of all for a lot of the lads. We were thankful
when we were relieved; but were sorry indeed to find how dearly the
newcomers paid for their experience. We had been cramped and
uncomfortable, but pretty safe, and the Germans had not been able to get at
us to do us any real mischief, but our reliefs walked about as unconcernedly
as if they were on furlough, with the result that on the very first night they
went into action they lost a hundred men.
The system of trenches grew into a sort of enormous gridiron, and if you
walked about—which you could only attempt to do at night—you were
almost certain to drop into a trench or a hole of some sort. This made
getting about a very exciting job, and it added enormously to the intense
strain of fighting in the trenches, a strain which was hardest to bear in the
night-time, when we were constantly expecting attacks and when the
Germans adopted all kinds of devices to get at us.
The Germans are what we call dirty fighters, and they will take
advantage of anything to try and score over you. They have no respect for
anything and made a particular point in many of the places they overran of
desecrating the churches. They never hesitated to turn a place of worship
into a scene for an orgy, and I remember going into one church after the
Germans had occupied it and being shocked at their conduct. In this
particular place they had been able to lay hands on a good deal of
champagne and they had drunk to excess, turning the church into a
drinking-place, so that when we reached it there was an indescribable scene
—filthy straw on the floor, empty champagne bottles littered everywhere,
and the whole building degraded and desecrated.
The Germans had got a French uniform and stuffed it with straw and
propped it up to resemble a man, and on the uniform they had stuck a piece
of paper with some writing on it in German. I do not know what the writing
was, but I took it to be some insult to the brave men who were defending
their country and preventing the Germans from getting anywhere near Paris.
I could tell you much more and many things of the Germans’ dirty fighting,
and of things that were far worse than such an incident as turning a church
into a drinking-place; but perhaps enough has been said on that point of
late.
But that dirty fighting does not mean that the Germans do not fight
bravely—far from it; they are hard cases, especially when they are in
overwhelming numbers, which is the form of fighting that they like best of
all. They are great believers in weight and hurling masses of men at a given
point, and they are absolutely mad at times when their opponents are the
English.
I will tell you of a case which illustrates this particular hatred. One night
we were attacked by the Germans, though there was but little hope of them
doing anything serious, in view of the fact that we were in trenches and that
there were the barbed wire entanglements everywhere. There had been no
sign of an attack, but in the middle of the night a furious assault was made
upon us and a young German by some extraordinary means managed to get
through the entanglements. An officer of the Buffs was near us, and in some
way which I cannot explain the German managed to reach him. With a
fierce cry he sprang directly at the officer, put an arm round his neck, and
with the revolver which he held in the other hand shot him.
It was the work of a moment; but it succeeded—so did our bayonet
attack on the German, for almost as soon as his shot had rung out in the
night a dozen bayonets had pierced him. He died very quickly, but not
before he had managed to show how intensely he hated all the English. He
was a fine young fellow, not more than seventeen or eighteen years old, and
it was impossible not to admire the courage and cleverness he had shown in
getting through the awful barbed wire entanglements and hurling himself
upon us in the trenches in the middle of the night. The point that puzzles me
even now, when I recall the incident, is how the young German managed to
make such a clean jump for the officer. I daresay there was something more
than luck in it.
At this time we were with the Buffs, who told us that they were being
badly troubled by snipers. I was in a trench with Lieutenant Cole, who was
afterwards killed, and he said to me, “Corporal, the snipers are worrying our
people, but it’s very difficult to locate them. Try and see what you can make
out of it.”
It was very difficult, but I set to work to try and make something out.
Before long, with the help of the glasses, I concluded that the sniping came
from a wood not far away, and I told the officer that I thought they were in a
tree there. The consequence was that a platoon loaded up, went round,
concentrated their fire on this particular spot and brought down two German
roosters from a tree. We were glad to be rid of the pests, and they ought to
have been satisfied, for they had had a very good innings.
I have been telling about the determination I had to be revenged for my
brother’s death. That was my great object, and I kept it in mind before
anything else—and I think I carried it out. Apart from any motive, it is the
British soldier’s duty to do everything he can to settle the enemy, especially
the Germans, and I am glad that I did my bit in this respect.
Now listen to what has really happened. After all that fighting and
suffering with the grand old “Die-Hards” I got my own turn, after many
wonderful escapes. A shell burst near me and the fragments peppered me on
the right hand here and about this side of the body, and bowled me out for
the time being. I was sent home, and here I am in London again, getting
well and expecting the call to come at any time to go back to the front.
When it comes I shall be ready to obey.
Look at this postcard. It is written, as you see, by a British soldier who is
a prisoner of war in Germany, and it tells the glad news that my brother,
who, I was told, was killed months ago by a bursting shell, is not dead, but
is alive and well, although he is a prisoner of war.
 CHAPTER VIII

LIFE IN THE TRENCHES

[The winter of the war was marked by an abnormal rainfall and storms of
uncommon severity: also by the extraordinary development of trench warfare.
The rain and storms, the frost and snow, made it impossible to carry out the
greater operations of campaigning, with the result that both sides dug themselves
in and fought from rival trenches which in many cases were separated by only a
few yards. This story deals with life in the trenches, at La Bassée, and it gives a
wonderful understanding of the privations that have been uncomplainingly borne
by British soldiers. The teller is Private G. Townsend, 2nd Battalion East
Lancashire Regiment, who has had more than six years’ service with the colours.
These long-service men have compelled the attention of even the Germans who
despised the “contemptible little army,” for they have admitted that the seasoned
British private soldier is the equal of a German non-commissioned officer.]

When the rebellion broke out in South Africa we—the old “Lily Whites”—
were the only imperial regiment kept in that country. We were sitting still
and stiff for twenty days, till General Botha got his own troops ready.
During that time we were guarding Cape Town, and it took us all we knew
to hold in, because the big war was on, and we were about seven thousand
miles away from the seat of it. We had to wait till General Botha was ready,
and that was not for more than a month after the British and the Germans
met in Belgium.
We were eager to get away from South Africa, and at last we sailed—but
what a slow voyage it was! Almost a record, I should think. We were thirty-
two days getting to Southampton; but that was because we had halts on the
way and were convoyed by some of the British warships which have
worked such marvels in this war. We had with us a noble cruiser which on a
later day, though we thought her slow, knocked more speed out of herself
than the builders ever dreamed of, and that was when she helped to sink the
German warships off the Falkland Islands.
By the time we reached the south of England some big things had
happened, and we were keener than ever to get to the front. We had not long
to wait. We landed, and in less than a week we left England and crossed
over to France, where we went into billets for four days, to settle down.
From the billets we marched nearly seven miles and went into trenches. For
three full months, in the worst time of a very bad year, I ate and drank, and
slept and fought, in trenches, with intervals in billets, sometimes up to the
hips in water and often enough sleeping on a thick couch of mud. I cannot
go into too much detail, but I can say that our officers always tried to go
one better than the Germans, for the sake of the men—and for the most part
they succeeded. We have picked up a lot from the Germans in this trench
game. They have a main trench and about four trenches behind that, the first
of the four being about twenty yards away; so that if you knock them out of
one you knock them into another.
That march to the trenches was a thing that can never be forgotten. It
was very dark and raining heavily, so that we were thoroughly soaked; but
we had no time to think of that, for we were bound for the firing line, we
were going to fight for the first time, and we wondered who amongst us
would be absent when the next roll was called. The trench to which we
were bound was in its little way famous. It had been the scene of some
terrible fighting. The Indian troops were holding it, but they had been
driven out by the Germans, who took possession and thought they were
going to hold it; but the Connaught Rangers made a desperate charge,
routed the Germans with the bayonet and retook the trenches. The
Connaughts won, but at a very heavy cost, and about 150 of the brave
fellows fell and were buried near the little bit of sodden, muddy ground on
which they had fought. It was to relieve the Connaughts that we went into
the trenches on La Bassée Road that stormy night.
It was not a very cheerful beginning, and as much unlike going into
action as anything you can imagine. But we felt queer, this being our first
taste of fighting, as we slipped into the trenches with our rifles loaded and
prepared to fire in the wild night at an enemy we could not see. As soon as
we went into the trenches we were ankle-deep in mud, and we were in mud,
day and night, for seventy-two hours without a break. That was the
beginning of three solid months of a sort of animal life in trenches and dug-
outs, with occasional breaks for the change and rest in billets without which
it would not be possible to live.
In a storm-swept trench—a barricade trench we called it—pointing my
rifle at an enemy I could not see, I fired my first shot in battle. My section
of thirteen men was in the trench which was nearest to the Germans, and
that meant that we were separated from them by only a very few dozen
yards. An officer of the Connaughts had given a descriptive object to fire at,
and this was a small white outhouse which could be dimly made out in the
darkness. The outhouse had the German trenches just in front of it, and we
made a target of the building in the hope of potting the men in the trenches.
The order came, one man up and one man down, which meant that a
man who was firing was standing for two hours and the man who was down
was sitting or otherwise resting, or observing, as we call it.
Throughout that long night we kept up fire from the trenches, all anxious
for the day to break, so that we could see what sort of a place we were in
and what we were doing; but when the melancholy morning broke there
was nothing to see in front of us except the portholes of the German
trenches.
We had got through the first night of battle safely and had given the
Germans good-morning with what we came to call the “awaking fire,”
though it sent many a man to sleep for the last time—and we were settling
down to make some tea. That was shortly after midday of our first day in
the trenches. I was working “partners” with my left-hand man, Private
Smith, who said, “I’ll just have a look to see what’s going on.”
He popped his head over the top of the trench and almost instantly he
fell into my arms, for he had been shot—there must have been a sniper
waiting for him—and had received what proved to be a most extraordinary
wound. A bullet had struck him on the side of the head, just below the ear,
and gone clean through and out at the other side, leaving a hole on each
side.
“I’m hit!” said Smith, as he fell—that was all.
I was badly upset, as this was the first man I had seen shot, and being my
special chum it came home to me; but I didn’t let that prevent me from
doing my best for him. Smith was quite conscious, and a plucky chap, and
he knew that there was nothing for it but to see it through till night came.
We bandaged him up as best we could and he had to lie there, in the mud
and water and misery, till it was dark, then he was able to walk away from
the trench to the nearest first-aid station, where the doctor complimented
him on his courage and told him what an extraordinary case it was and what
a miraculous escape he had had. Later on Smith was invalided home.
 During the whole of that first spell in trenches we had no water to drink
except what we fetched from a natural trench half-a-mile away. Men
volunteered for this duty, which was very dangerous, as it meant hurrying
over open ground, and the man who was fetching the water was under fire
all the time, both going and coming, if the Germans saw him. This job was
usually carried out a little before daybreak, when there was just light
enough for the man to see, and not enough for the Germans to spot him; and
a chap was always thankful when he was safely back in the trench and
under cover.
At the end of the seventy-two hours we left the trenches. We came out at
ten o’clock at night, expecting to be out for three days. We marched to an
old barn which had been pretty well blown to pieces by shells, and into it
we went; but it was no better than the trenches. The rain poured on to us
through the shattered roof and it was bitterly cold, so that I could not sleep.
We had everything on, so as to be ready for a call instantly, and without so
much as a blanket I was thoroughly miserable. Instead of having three days
off we were ordered to go into a fresh lot of trenches, and next afternoon we
marched into them and there we stayed for six weeks, coming out seven or
eight times. In these trenches we were in dug-outs, so that we got a change
from standing sometimes hip-deep in mud and water by getting into the
dug-out and resting there. A dug-out was simply a hole made in the side of
the trench, high enough to be fairly dry and comfortable.
During the whole of these six weeks it meant practically death to show
yourself, and so merciless was the fire that for the whole of the time a dead
German soldier was lying on the ground about a hundred yards away from
us. He was there when we went and was still there when we left. We could
not send out a party to bury him and the Germans themselves never
troubled about the poor beggar. One day a chum of mine, named Tobin, was
on the look-out when his rifle suddenly cracked, and he turned round and
said, “I’ve hit one.” And so he had, for he had knocked a German over not
far away and no doubt killed him.
What with the weather and the mud and the constant firing we had a
very bad time. Each night we had four hours’ digging, which was
excessively hard work, and if we were not digging we were fetching rations
in for the company. These rations had to be fetched at night from carts
three-quarters of a mile away, which was the nearest the drivers dare bring
them. These expeditions were always interesting, because we never knew
what we were going to get—sometimes it would be a fifty-pound tin of
biscuits and sometimes a bag of letters or a lot of cigarettes, but whatever it
was we took it to our dug-outs, just as animals take food to their holes, and
the things were issued next morning.
One way and another we had between fifty and sixty men wounded in
our own particular trenches, mostly by rifle fire, though occasionally a shell
would burst near us and do a lot of mischief; and what was happening in
our own trenches was taking place all around La Bassée. We should have
suffered much more heavily if we had not been provided with periscopes,
which have saved many a precious life and limb.
We paid very little attention to the German shell fire, and as for the “Jack
Johnsons” we took them as much as a matter of course as we took our
breakfast. Some of the German artillery fire actually amused us, and this
was when they got their mortars to work. We could see the shot coming and
often enough could dodge it, though frequently the great fat thing would
drive into the ground and smother us with mud. For some of the German
artillery fire we were really very thankful, because in their rage they were
smashing up some farm buildings not far away from us. The cause of our
gratitude was that this shelling saved us the trouble of cutting down and
chopping firewood for warmth and cooking in the trenches. When night
came we simply went to the farmhouse, and the firewood, in the shape of
shattered doors and beams and furniture, was waiting for us. The farm
people had left, so we were able to help ourselves to chickens, which we
did, and a glorious change they were on the everlasting bully beef. A
chicken doesn’t go very far with hungry soldiers, and on one occasion we
had a chicken apiece, and remarkably good they were too, roasted in the
trenches. Another great time was when we caught a little pig at the farm and
killed it and took it to the trenches, where we cooked it.
When we had finished with the second lot of trenches we went into a
third set, and I was there till I was wounded and sent home. These trenches
were only about a hundred and twenty yards from the second lot, so that the
whole of the three months I spent in trenches was passed in a very little area
of ground, an experience which is so totally different from that of so many
of our soldiers who were out at the war at the very beginning, and covered
such great distances in marching from place to place and battle to battle.
These chaps were lucky, because they got the change of scene and the
excitement of big fighting, but the only change we had was in going out of
one trench into another.
It was now the middle of December and bitter weather, but we were
cheered up by the thought of Christmas, and found that things were getting
much more lively than they had been. One night a splendid act was
performed by Lieutenant Seckham, one of our platoon officers, and two of
our privates, Cunningham and Harris.
An officer of the Royal Engineers had gone out to fix up some barbed
wire entanglements in front of our trenches. The Germans were firing
heavily at the time, and they must have either seen or heard the officer at
work. They went for him and struck him down and there he lay in the open.
To leave the trenches was a most perilous thing to do, but Mr. Seckham and
the two men got out and on to the open ground, and bit by bit they made
their way to the Engineer officer, got hold of him, and under a furious fire
brought him right along and into our trench, and we gave a cheer which
rang out in the night above the firing and told the Germans that their frantic
efforts had failed. Mr. Seckham was a splendid officer in every way and we
were greatly grieved when, not long afterwards, he was killed. Another of
our fine young platoon officers, Lieutenant Townsend, has been killed since
I came home.
We were so near the Germans at times that we could throw things at
them and they could hurl things at us, and we both did, the things being
little bombs, after the style of the old hand-grenade. We got up a bomb-
throwing class and hurled our bombs; but it was not possible to throw them
very far—only twenty-five yards or so. The West Yorkshires, who were
near us, got a great many of these missiles thrown at them, but they did not
all explode. One day a sergeant of ours—Jarvis—was out getting wood
when he saw one of them lying on the ground. He picked it up and looked
at it, then threw it down and instantly it exploded, and he had no fewer than
forty-three wounds, mostly cuts, caused by the flying fragments, so that the
bomb made a proper mess of him.
Our own bombs were made of ordinary pound jam tins, filled with
explosive and so on, like a little shell, which, as the case of the sergeant
showed, was not anything like as sweet a thing to get as jam. The
 [To face p. 102.
“WE WERE SO NEAR THE GERMANS THAT THEY COULD HURL BOMBS AT
US.”

Germans were very fond of flinging these hand-bombs and seemed to

have a great idea of their value in attacks and defence.
Christmas Eve was with us, Christmas Day was soon to dawn—and
what a strange and terrible Christmas it was to be!
On Christmas Eve itself we plainly heard the Germans shouting.
“A merry Christmas to you!” they said, and there was no mistaking the
German voices that came to us in our trenches out of the darkness.
“A merry Christmas to you!”
Again the Germans greeted us, though we could not see them, and there
was something pathetic in the words, which were shouted in a lull in the
fighting. Some of our men answered the wish, but I did not—I had no heart
to do so, when I knew that the message meant so little.
It may have been a matter of sentiment, because this was the time of
peace on earth and goodwill towards men, or it may not; but at any rate the
order came that if the Germans did not fire we were not to fire. But
Christmas or no Christmas, and in spite of their greetings, the Germans
went on firing, and we were forced to do the same, so throughout the night
of Christmas Eve we had our rifles going and did not stop till it was
daylight.
But the rifle fire was not the only sound of warfare that was heard—
there was the sharp booming of artillery. The field batteries were hard at it
and we knew they must be doing fearful mischief amongst the Germans.
The night became truly awful; but how dreadful we did not know till
Christmas Day itself, then, the firing having ceased, we saw that the ground
in front of us, not very far away, was littered with the German dead.
A Merry Christmas!
The very men who had sent the greeting to us were lying dead within our
sight, for the Germans had started to change their position and the British
shells had shattered them. Something like two hundred and fifty of the
Germans were lying dead upon the field, and sorry indeed must the dawn of
Christmas Day have been to those who were left.
Peace on earth! There was peace of a sort, for as we looked on the
German dead from our trenches we saw two Germans appear in full view,
holding up their hands, to show us that they were unarmed.
You can imagine what a solemn spectacle that was—what a Christmas
Day it was which dawned upon us in the trenches. We knew instinctively
what was wanted—the ground was littered with the German dead and the
Germans wanted an armistice so that they could bury them.
One of our officers went out and talked with the two Germans who were
holding up their hands—covered by British rifles. He soon learned what
they wanted, and the armistice was granted.
It was about three o’clock in the afternoon of Christmas Day when the
Germans set to work to bury their dead, and as they did so we left our
trenches and stood on the open ground and watched them. We saw them
perfectly clearly, because the main German trench was not more than 120
yards away, and the burial took place a few yards behind this.
 I have seen a photograph of British and German soldiers fraternising on
Christmas Day; but there was nothing of this sort with us. The only incident
I witnessed was a British officer shaking hands with a German officer. That
was all. I did not shake hands with them—and I had not the least wish to do
so, though I bore them no ill-will on that sad Christmas Day.
I was thankful when Christmas was over and we had settled down to
ordinary routine work, killing and being killed, for it is astonishing how
soon you get accustomed to the business of firing on and being fired at.
The trenches had got from bad to worse. When I first went into them
there was eighteen inches of water and five inches of mud; but now it was a
matter of standing almost up to the waist in water. They became so bad that
instead of using the communication trenches, which you might almost call
tunnels, it was decided that we should cross the open country to get to our
fighting-place, the main trench—indeed, we had no option, because the
communication trench was almost impassable.
On a mid-January night, and very bad at that, we began the journey to
the trenches. If there had been just ordinary honest darkness we should have
been all right and quite satisfied; but though there was darkness enough
there was plenty of light—the uncanny brightness which came from the
star-shells.
Star-shells were going up all along the line and bursting. They are a sort
of firework, giving a brilliant light, and as they exploded they showed us up
almost as clearly as if we had been in daylight.
We had only a very short distance to go, but the star-lights made the
journey to the trenches a desperate undertaking.
In single file, a little bunch of ten of us, crouching down, holding our
loaded rifles and carrying all we possessed—we went along, losing no time.
From the stealthy way in which we started on our little trip you might
have thought that we were burglars or villains bent on some fearsome job,
instead of ordinary British soldiers getting back to their trenches.
We went with caution, and had not covered more than ten yards when
what I take to be machine-gun fire was opened on us.
All at once, without the slightest warning, a real hail of bullets struck us,
and of the ten men of us who were advancing in single file three were killed
and four were wounded. The three who were shot down in the ghastly glare
of the star-shells were ahead of me.
 When that happened we were ordered to keep well apart and open out,
but there was not much chance for those of us who were left; at any rate, no
sooner had we obeyed and were making a little headway than I was struck
myself on the head.
For half-an-hour or so I was unconscious; then I recovered and picked
myself up and found that I was all alone. I crawled a few yards to a trench
and got into it; but finding it full of water I thought I might as well be killed
as drowned, so I got out, and not caring in the least for the German bullets
or the star-shells, I made my way as best I could to the nearest dressing-
station, and received attention. After that I found myself in a motor-car, and
later at a clearing-station and on the boat for home.
You can see the scar of the wound here; but I don’t bother about that. I
suffer terribly from sleeplessness—and too often I see again the German
soldiers who had wished us a merry Christmas—and were buried at the
back of their trenches on the gloomy afternoon of Christmas Day.
 CHAPTER IX

SAPPING AND MINING: THE “LUCKY COMPANY”

[In blowing up bridges, repairing the ravages of the enemy, in throwing

pontoons over rivers, and in countless other ways, the Royal Engineers have
contributed largely to the success of the British operations in the war. These
splendid men, known a century ago as the Royal Sappers and Miners, have not
only worked with the greatest energy since the war began, but they have also seen
some hard fighting. This story of Sapper William Bell, 23rd Field Company,
Royal Engineers, gives a picture of the many-sided operations of the magnificent
corps whose mottoes are “Everywhere” and “Where right and glory lead.”]

Sheer hard work was the order of the day for our chaps from the time I
landed in France from an old Irish cattle-boat till the day when I was
packed off back to England suffering from rheumatic fever.
We worked excessively hard, and so did everybody else. Wherever there
was an obstacle it had to go, and the infantry themselves time after time
slaved away at digging and clearing, all of which was over and above the
strain of the fighting and tremendous marching. It was a rare sight to see the
Guards sweeping down the corn with their bayonets—sickles that reaped
many a grim harvest then and later.
It was during the early stage of the war that bridges were blown up in
wholesale fashion to check the German advance, and the work being
particularly dangerous we had some very narrow escapes. A very near thing
happened at Soissons.
We had been ordered to blow up a bridge, and during the day we charged
it with gun-cotton, and were waiting to set the fuse until the last of our
troops had crossed over. That was a long business, and exciting enough for
anybody, because for hours the men of a whole division were passing, and
all the time that great passing body of men, horses, guns, waggons and so
on, was under a heavy artillery fire from the Germans.
At last the bridge was clear—it had served its purpose; the division was
on the other side of the river, and all that remained to be done was to blow
up the bridge. Three sections of our company retired, and the remaining
section was left behind to attend to the fuse.
Very soon we heard a terrific report, and the same awful thought
occurred to many of us—that there had been a premature explosion and that
the section was lost. One of my chums, judging by the time of the fuse, said
it was certain that the section was blown up, and indeed it was actually
reported that an officer and a dozen men had been killed.
But, to our intense relief, we learned that the report was wrong; but we
heard also how narrowly our fellows had escaped, and how much they
owed to the presence of mind and coolness of the officer. It seems that as
soon as the fuse was fired the lieutenant instinctively suspected that
something was wrong, and instantly ordered the men to lie flat, with the
result that they were uninjured by the tremendous upheaval of masonry,
though they were a bit shaken when they caught us up on the road later.
This incident gives a good idea of the sort of work and the danger that the
Royal Engineers were constantly experiencing in the earlier stages of the
war, so that one can easily understand what is happening now in the bitter
winter-time.
An Engineer, like the referee in a football match, sees a lot of the game,
and it was near a French village that we had a fine view of a famous affair.
We had been sent to the spot on special duty, and were resting on the
crest of a hill, watching the effects of the enemy’s field-guns.
Suddenly in the distance we saw figures moving. At first we could not
clearly make them out, but presently we saw that they were Algerian troops,
and that there seemed to be hosts of them. They swarmed on swiftly, and
took up a position in some trenches near us.
The Algerians, like our Indian troops, hate trench fighting, and long to
come to grips with the enemy. We knew this well enough, but we realised
the peril of leaving cover and advancing towards an enemy who was very
close, and who was sweeping the ground with an uncommonly deadly fire.
Putting all fear aside, remembering only their intense desire to come to
grips, giving no thought to what must happen to them, the Algerians with
enthusiastic shouts sprang from the trenches and bounded, like the sons of
the desert they are, across the shell-swept zone that separated them from the
annihilating gunfire of the enemy.
 What happened was truly terrible. The Algerians were literally mowed
down, as they charged across the deadly zone, and for a piece of sheer
recklessness I consider that this attack was as good—or as bad—as the
charge of the Light Brigade.
The Algerians were cut to pieces in the mad attempt to reach the German
batteries, and the handful of survivors were forced to retire. To their
everlasting credit be it said that, in withdrawing under that terrible fire, they
did their best to bring their wounded men away. They picked up as many of
the fallen as they could and slung them across the shoulder, as the best way
of carrying them out of danger.
I shall never forget the scene that met my eyes when we returned to the
village. Women were weeping and wringing their hands as the survivors
carried their wounded through the streets—for the French are deeply
attached to their Colonial troops—and the men of the place were nearly as
bad; even some of our chaps, who are not too easily moved, were upset.
While in this locality we had a very warm time of it, for we were
continuously under artillery fire. We were in a remarkably good position for
seeing the battle, some of our batteries being on our right, some on our left,
and the German guns in front. It was really hot work, and when we were not
hard at it carrying out our own duties, we took cover on the other side of a
hill near the road; but some of our men got rather tired of cover, and found
the position irksome; but if you so much as showed yourself you were
practically done for. One day our trumpeter exposed himself, just for a
moment; but it was enough. He was instantly struck and badly wounded.
At another time we were in our sleeping-quarters in a school-house, and
had an escape that was truly miraculous. We had settled down and were
feeling pretty comfortable, when the Germans suddenly started shelling us;
suddenly, too, with a terrific crash, a shell dropped and burst in the very
midst of us.
Theoretically, the lot of us in that school-house ought to have been
wiped out by this particular shell, but the extraordinary fact is that though
every one was badly shaken up, only one of our men was wounded—all the
rest of us escaped. Luckily we had the hospital men at hand, and the poor
chap who had been knocked over was taken away at once to the doctors.
We had had a very hard, hot time, and were glad when the French came
and relieved us, and gave our division a bit of rest and change. The
Germans in that particular part were thoroughly beaten, and a batch of 500
who were covering the retreat were captured by the French.
They had started for Paris, and were very near it when they were bagged.
I dare say they got to Paris all right. So did we, for we entrained for the city,
but stayed there less than an hour. I had a chance of seeing something of the
thorough way in which Paris had been prepared for defence, and on my way
to Ypres I noticed how extensively the bridges that were likely to be of any
use to the Germans had been destroyed. The loss in bridges alone in this
great war has been stupendous.
When we entered Ypres it was a beautiful old cathedral city; now it is a
shapeless mass of ruins, a melancholy centre of the longest and deadliest
battle that has ever been fought in the history of the world. We had a
rousing reception from the British troops who were already in the city, and
a specially warm greeting from our own R.E. men, who gave me a huge
quantity of pipes, tobacco and cigarettes from home, to divide amongst our
company.
We were soon in the thick of the fiercest and most eventful part of the
fighting. We were put to work digging trenches for the infantry and fixing
up wire entanglements. The wire was in coils half a mile
 [To face p. 112.
“WE HAD A VERY WARM TIME OF IT” (p. 111).

long, and what with that and the barbs and the weight, the carrying and
dragging and fixing was a truly fearsome job.
And not only that, but it was extremely dangerous, because we were
constantly under fire—sometimes we were fixing up wire within a few
hundred yards of the German lines. Before getting to Ypres we had covering
parties of infantry to protect us from snipers and sudden attacks; but at
Ypres this protection was rarely given, because of the very heavy pressure
on the firing line. We were ceaselessly sniped; but on the whole our
casualties were remarkably few—but we were always known as the “Lucky
Company.”
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