The First World War and the Legacy of Shellshock

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HISTORY OF PSYCHIATRY

2014 marks the centenary of the beginning of World War I. This year, in many parts of the world, commemorative events will be held, marking the 100th anniversary of the start of what was referred to at the time as the Great War.

The scale of that war was unprecedented at the time. Sixteen nations mobilized over 65 million soldiers. Of these, 8.5 million were killed, another 21.2 million were wounded, and 7.75 million captured or missing.¹

Beyond these numbers, however, World War I also ushered in a change in how war in the western world was conducted. While prewar international agreements had banned the use of certain weapons of mass destruction (eg, chemical weapons) and differentiated between the treatment of soldiers and civilians, these distinctions were quickly erased once fighting began. The German military developed and regularly used poison gas against enemy combatants, waged unrestricted submarine attacks against commercial vessels, and shot civilians and practiced mass rape in Belgium. At the same time, Britain and its allies carried out a blockade of central Europe, hoping to starve their enemies into submission. And the Ottoman Empire undertook the first genocide of its kind against its indigenous Armenian population. For good reason, then, historians have referred to the Great War as the first example of “total war.”

In the history of psychiatry, the First World War is often identified with the rise of the disorder of “shellshock.” Referred to at the time most often as “war neurosis,” the malady was characterized by a common core of possible symptoms: tics, convulsions, muscle spasms, paralyses, shakes, and problems in memory were among the most prominent.

The scale of the problem matched the scale of the war itself. In Germany, over 600,000 servicemen were treated in military hospitals for “nervous” diseases during the four years of war. In the UK, 80,000 cases of war neurosis were diagnosed between 1914 and 1918, and around 200,000 veterans ended up receiving pensions for war-related nervous disorders following the war.² Yet while World War I has been widely seen as having given birth to shellshock -and by extension, to present-day PTSD-as well as to its clinical recognition, the  history of the phenomenon actually dates back several decades earlier.

As historian Martin Lengwiler³ notes, the notion of war neurosis required a peculiar etiological connection to be drawn in order for it to emerge as a viable diagnosis. Psychiatrists and neurologists needed to be convinced that a causal link could exist between military service and war on the one hand and a set of nervous symptoms on the other. This was by no means obvious to observers in the 19th century (and it often remains a matter of debate today as well in pension cases involving veterans).

In German-speaking Europe at least, it was psychiatrist Werner Nasse (1822-1889) who first tied combat to symptomatology. Reporting on the cases of several veterans of the German wars of unification (1864-1866)-who had afterward exhibited symptoms of emotional withdrawal, memory lapses, apathy, listlessness, shakes, and convulsions-Nasse argued that their symptoms were best explained by the circumstances of soldiers in the field. “War psychosis,” as he referred to it, arose from the physical stresses, the cold and unhealthy living conditions, and the poor diet under which soldiers suffered during active duty.³

Many in both the medical community and the military establishment, however, remained dubious of the claim that war could produce psychiatric symptoms. For one, the late-19th century was the heyday of the idea of degeneration, ie, the notion that hereditary pathologies could cumulatively corrupt and overwhelm entire families, communities, and even nations.⁴ The increasing prevalence of neurasthenia and hysteria toward the end of the century was taken by some as an indication not of the effects of environmental factors on mental health, but rather of how pathological predispositions transmitted to offspring could lead to increasing numbers of mental “defectives,” ill-equipped for the vagaries of modern life (including combat). For many observers, biology in this instance was destiny.

In addition, a great number of authorities believed that a third possibility existed that might account for the apparent explosion in the rate of war neurosis-namely, that the men were not sick at all, but were merely simulating. Feigning illness in order to either avoid some kind of social responsibility or gain some benefit was a topic discussed among physicians dating back to ancient times. But “malingering” or “simulation,” as the phenomenon was generally called, only first drew concerted scholarly interest over the course of the 19th century, becoming an especially prominent topic at the end of the century in public deliberations about and criticisms of social insurance compensation to workers.^5(pp124-148) In this instance, shellshock symptoms were dismissed as little more than a sham, a ruse on the part of the weak and cowardly.

While debate about the nature of war neurosis continued on after the war, it was World War II that eventually cemented recognition of warfare as an etiological factor in mental disorders. Shellshock and World War I, however, ended up playing a pivotal role in the broader history of mental health care. With the enlistment of psychiatrists and neurologists into military service, notions that had been circulating within psychiatry for decades-trauma, degeneration, malingering, functional illness, for example-came face-to-face with the realities of modern war. In the process, their encounter altered how clinicians and the public came to look at mental illness.

On the one hand, the lesson of the meteoric rise of war neurosis appeared to support the idea that traumatic mental experiences could cause nervous disorders and, thus, reinforced the growth of psychotherapy. On the other hand, shellshock convinced many observers that mental illness was an urgent public problem, one requiring decisive, effective, and efficient action. In a postwar climate where societies faced economic hardships and divisive ideological conflicts, this appraisal encouraged both policymakers and psychiatrist to entertain the use of more radically adventurous and cheaper techniques, such as eugenics, to promote public mental health.

Disclosures:

Dr Eghigian is Associate Professor of Modern History and former Director of the Science, Technology, and Society Program at Penn State University, University Park, Pa. He writes and teaches on the history of madness, mental illness, and mental health in the Western world. He is the editor and author of numerous books, most recently From Madness to Mental Health: Psychiatric Disorder and its Treatment in Western Civilization (Rutgers University Press; 2010). He is also co-editor of the scholarly blog, h-madness. Dr Eghigian is the History Section Editor for Psychiatric Times.

References:

1. WWI Casualty and Death Tables. PBS. http://www.pbs.org/greatwar/resources/casdeath_pop.html. Accessed February 28, 2014.
2. Lerner P. Hysterical Men: War, Psychiatry, and the Politics of Trauma in Germany, 1890-1930. Ithaca, NY: Cornell University Press; 2003.
3. Lengwiler M. Zwischen Klinik und Kaserne: Die Geschichte der Militärpsychiatrie in Deutschland and der Schweiz 1870-1914. Zurich: Chronos; 2000.
4. Pick D. Faces of Degeneration: A European Disorder, c. 1848-1918. Cambridge and New York: Cambridge University Press; 1989.
5. Cooter R. Malingering in modernity. In: Cooter R, Harrison M, Sturdy S, eds. War, Medicine, and Modernity. Phoenix Mill, Gloucestershire, UK: Sutton Publishing; 1998.