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The First World War and the Legacy of Shellshock

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

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