WAR NEUROSES.NEUROSES IN WORLD WAR I
FROM TRAUMATIC NEUROSIS TO HYSTERIA: GERMANY
SHELL SHOCK AND THE CULTURAL HISTORY OF WAR: BRITAIN
TREATMENT SYSTEMS WITHIN
THE EUROPEAN CONTEXT
WORLD WAR I AND PSYCHIATRY: CHANGES IN HISTORICAL INTERPRETATION
WORLD WAR II
WAR AND TRAUMA IN THE 1980S AND 1990S
War neuroses is a collective term used to denote the complex of nervous and mental disorders of soldiers in modern wartime societies. The term itself is inaccurate and has been the subject of debate since its first use in the psychiatric milieus during World War I; the term has competed with other psychiatric labels, but was used through World War II in military psychiatry. Thus, a history of war neuroses is in many ways a story of controversial medical discourses and practices relating to psychological trauma in wartime. From the perspective of medical history, questions like how physicians came to understand the impact of war on the psyche, how diagnostic categories were shaped, and how therapeutic responses came into action have become the focus of attention. Cultural history studies also offer important contributions to the understanding of war neuroses. Based on a wide range of sources, such as letters from the front and patients' records as well as films, novels, and popular literature, a cultural history of war neuroses emphasizes human experiences, the symbolizing and narrating of soldiers' suffering, and the understanding of body and gender.
Against this background, our understanding of the history of war neuroses and their place within the two "total wars" has expanded greatly. Its study has increasingly focused on comparative perspectives. The psychological suffering of soldiers was a mass phenomenon that affected all wartime societies, but reactions differed according to differing national traditions and different medical ways of understanding, representing, and acting. For example, the British World War I concept of "shell shock" cannot simply be equated with German "traumatic neurosis" or French "war hysteria." This is also true for the range of treatment systems. Although hypnosis could be viewed as unscientific and ineffective in the French neurological profession, German doctors, such as Hamburg psychiatrist Max Nonne (1861–1959), succeeded in advancing "hypnosis therapy" as medicine's most effective response to war neuroses.
The medical discourse largely neglects the mental suffering of soldiers before World War I. This is not to say that soldiers did not suffer from mental problems. There is no doubt that psychiatric casualties occurred in the wars of the nineteenth century, such as in the Franco-Prussian War of 1870–1871, when doctors noticed symptoms of distress among soldiers but were at a loss as to how to explain them. However, doctors rarely discussed these experiences on a broader scale. Thus, the military and the medical profession paid little attention to mental breakdowns. World War I fundamentally changed the discussion. Shortly after war broke out in the summer of 1914, soldiers, military authorities, and doctors of all the warring societies found themselves confronted with disturbing symptoms they had never seen before. Soldiers were repeatedly observed in a state of agitation and exhaustion, complaining of irritation, headaches, and insomnia. As the war raged on, doctors began seeing increasingly severe cases. These men were trembling from head to foot, weeping uncontrollably, or falling into a state of apathy from one minute to the next, staring into space, remaining in a state of confusion. Others were stricken with speech disorders, visual and hearing impairment, and memory loss. On the face of it, these men seemed to have fully lost control over their bodies. Like no other war, World War I produced vast numbers of mentally distressed soldiers, thus eliciting a massive response on the part of the military and psychiatrists. More-over, this war led to the rapid decline of somatic interpretations, thus accelerating the expansion of knowledge in psychiatry and influencing psychiatric theorizing and decision making on war neuroses for decades, in particular during World War II.
The intellectual history of war neuroses can be traced back to three medical concepts: neurasthenia, hysteria, and traumatic neurosis. All three emerged at the end of the nineteenth century, reflecting the increasing ability of psychiatrists to describe industrial and urban modernity. Neurasthenia, literally "nerve weakness," originally was viewed as a disorder of overworked businessmen who could no longer bear the strain of modern life. When Europe went to war, officers often were diagnosed with neurasthenia, receiving lengthy treatments in popular spas and health resorts. Besides neurasthenia, the concept of traumatic neurosis, coined by Berlin neurologist Hermann Oppenheim (1858–1919), dealt with industrial modernity, referring to posttraumatic symptoms in working-class men who had been suffering as a result of accidents in factories or workshops. In the context of growing state welfare systems and workers compensation legislation, traumatic neurosis became a hotly debated subject. As the war proceeded, the debate on the nature of traumatic neuroses developed in the German psychiatric community, splitting it up into two groups. On the one hand, Oppenheim and his followers had taken the view that the impact of a traumatic experience, such as an exploding shell, could be found in microscopic changes in the brain or central nervous system. On the other hand, a group led by Nonne advocated a psychological position. For these doctors, the modern concept of hysteria, as formulated primarily by the French neurologist Jean-Martin Charcot (1825–1893), was at the heart of war neuroses. As Nonne and his fellow proponents of the psychological position showed, there was no direct relationship between traumatic war experience and the outbreak of neurotic symptoms. Soldiers who had never been in the combat zone could suffer from this disease. Meanwhile, thousands of those who had fought at the front seemed able to resist the horrible psychological impacts of mechanized warfare. In many cases it was not the immediate effect of war that caused the symptoms of distress. Men who had never come under fire were put in psychiatric hospitals. Hence, Nonne argued, there could be a variety of reasons for war neuroses, such as a pathogenic predisposition, a lack of will power, "pension neurosis" or a soldier's overwhelming desire to get away from the front lines. As diverse as these explanations were, the fact that strong forces of the psyche were responsible for the disorders was common to all of them. The clash of these two approaches ended in favor of the proponents of the psychological position, who also claimed to have the better therapeutic competence. In fact, the well-organized and successful treatment demonstrations at a large conference held in Munich in 1916 were decisive for the debate.
As in Germany, British war medicine produced varied and often contradictory definitions of the mental suffering of soldiers. In this context, the emergence of the concept of "shell shock" is of utmost interest. Perhaps no other psychiatric term has become as influential in the history of war neuroses and in calling to mind the destructive powers of war in men's bodies. In February 1915, psychologist Charles S. Myers (1873–1946) introduced the term in an article for The Lancet. Shell shock linked mental suffering explicitly to the horrors of trench warfare, thus expressing a direct and causal connection between artillery fire and shock symptoms. Consequently, afflicted officers and soldiers were quick to adopt this term, and psychiatrists were able to make clear that professional and scientifically substantiated medical treatment was badly needed. When shell shock reached epidemic proportions that same year, military authorities feared a loss of troop morale and began raising questions about it. Was shell shock really a legitimate disease of soldiers with shattered nerves, or simply an artifact supporting the aims of homesick men, malingerers, or even deserters? By 1916, psychiatric categories were increasingly described in vague language. Patients would inaccurately be described as being "sick" or "nervous." Though military medical policy was to remove shell shock from the list of diagnostic categories, the term had already gained public attention, and forged its way into political discussions and cultural notions about war. Shell shock is the only medical concept originating from wartime experience that has moved on to become a powerful metaphorical key to the historical understanding of war and modernity. Highly intertwined with British culture's understanding and memorializing of the Great War, shell shock has become a symbol of the dreadful experiences soldiers underwent in trench warfare. In the 1990s, English author Pat Barker gave a fascinating narrative of the shell shock phenomenon in her prize-winning novel trilogy, Regeneration.
Psychiatry in World War I brought a wide variety of treatment methods, including electrical faradization, hypnosis, isolation, forced diets, and deception. None of these methods was new. Rather, psychiatrists combined fragments of several established therapies. From a comparative perspective, the treatment systems of World War I show considerable differences, reflecting different styles of scientific thought and different traditions of treatment practices. However, there are at least two features common to European wartime psychiatry. First, specific treatment systems had a strong tendency to class bias. For example, in Britain, some shell shock hospitals, like Craiglockhart in Edinburgh, were for officers and provided "soft" analytical therapy, whereas at Queen Square in London, soldiers were confronted with a harsh electrical faradization therapy. Second, most treatment methods operated through suggestion. The ultimate way of achieving therapeutic success in war neuroses was seen as a charismatic doctor who worked on recovering a soldier's will and self-control through suggestive power. A pathological will, based on nervous exhaustion, driven by misguided ideas, or paralyzed by shock experience should be converted into a healthy one again. It was asserted that previously "normal" men could be cured through these treatments, whereas psychologically "abnormal" men had carried their pathological constitution into war and could not be cured. In other words, wartime experiences were not directly responsible for causing the disturbing symptoms but were an extension of what had existed before.
Unlike in Britain, French war psychiatry continued to use the established term of hysteria, providing psychiatrists with a unified and established treatment protocol to cure hysterical soldiers. Electrical treatment, called torpillage, was considered an effective method of restoring a soldier's will and virility. In contrast, a patient's experience was dominated by feelings of helplessness and pain.
As the war continued, resistance against the "active therapies" increased. One such case occurred in the heated atmosphere of postwar Austria. A former lieutenant, supported by the social democratic press, accused the leading Viennese psychiatrist, Julius Wagner-Jauregg (1857–1940), of treating him and other soldiers brutally. In fact, Wagner-Jauregg and other Austro-Hungarian psychiatrists, who already had come into conflict with soldiers in wartime, believed that electrical treatment worked best in the therapy of war neuroses. In 1920, the Parliament set up an investigating committee and Sigmund Freud (1856–1939) was appointed as scientific expert. Freud made use of this opportunity of Wagner-Jauregg's hearing to present psychoanalytical approaches to their best advantage. However, in the end he spoke in Wagner-Jauregg's favor. Freud himself did not treat any patients diagnosed with war neuroses, but he developed a strong interest in this subject, communicating with nerve specialists in German and Austro-Hungarian war hospitals.
Advocating an efficient and "softer" treatment of war neuroses, psychoanalysts presented their ideas in Budapest in 1918 at the Fifth Psychoanalytic Congress. Since the war ended shortly afterward, no practical steps were taken. However, psychoanalysts' guiding ideas in explaining war neuroses as being the result of unresolved mental conflicts and overwhelming internal forces to escape the danger zone of war had an impact on the military psychiatry of World War II.
In the 1970s and 1980s, German historians tended to characterize World War I psychiatrists as sadistic doctors, torturing suffering soldiers until they were ready for the front again. Significantly, this interpretation arose under the influence of early historical studies on Nazi medicine. Although these studies suggested that German psychiatry of World War I foreshadowed the medical brutalities in the Nazi regime, in the late twentieth and early twenty-first centuries approaches have left this one-sided continuity model behind. For example, historian Paul Lerner proposes an explanation of war psychiatry's actions in terms of rationalization processes. Lerner argues that, against the background of national mobilization for total war, the principles and priorities of modern societies such as economization, efficiency, and standardization became ultimate medical values. Moreover, Lerner points out the specific interactions of medicine and the state in modern times, drawing attention to the responsibility of psychiatrists in the domain of pension funds as well as social and disability insurance. Having experienced how difficult it had been to treat soldiers with nervous disorders and facing the spiraling costs for war pensions, the doctors' aim was to protect the state from a flood of "war neurotics." This had important repercussions on therapy. A rationalized and patriotic approach to war psychiatry mobilized all intellectual, institutional, and therapeutic resources, both in terms of efficient manpower economy and the financial situation of the state, thus obtaining the best results when making mentally suffering soldiers fit for work and military services again.
In this sense, the history of war neuroses demonstrates the close relationship between war, medicine, and modernity, "the medicalization of war and the militarization of medicine." However, this relationship cannot be characterized from just one vantage point. It would be too short-sighted to portray the connection of war and psychiatry in one way—that is, merely as a science spearheaded by military obedience. Psychiatrists were not simply cogs in a war machine. It is worth shedding light on competing aspects, and on the rivalry between military authorities and psychiatric experts. For example, what about a mentally confused soldier who was staggering back to the communication zone after an artillery attack? Military code could define such behavior as cowardice in the face of the enemy, committing the soldier to a drumhead court-martial. In contrast, many psychiatrists would assume that the soldier had a pathological reaction and would do everything in their power to transfer and treat the soldier in a special psychiatric hospital. Thus, psychiatric diagnoses such as "hysteria" or "psychopathic personality," while they might stigmatize soldiers, could also save their lives.
Compared with the extensive research on World War I, World War II has not been studied in great detail and book-length studies on the psychiatric responses to war neuroses are still rare. At first glance, World War II produced hardly any new findings in the psychiatric literature about the effects of war on the psyche. Generally, in addition to psychological and psychoanalytical conceptual approaches to war neuroses, emerging psychosomatic and psychopharmacological knowledge provided new explanatory models.
In Britain, where in 1939 some forty thousand veterans were still receiving pensions for nervous or mental disorders, the medical policy was to have a very restrictive definition of war neuroses. Taking up the very arguments of the War Office Committee of Enquiry into Shell-Shock of 1922, which had recommended avoiding the term shell shock and exhibiting a defensive attitude toward the procedures of war pensions, the authorities agreed that the "mistakes" that had been made in the medical management of war neuroses should not happen again. Of course, World War II saw new methods of warfare; for the majority of the British troops, trench warfare and the shell shock syndrome were a thing of the past. A key element in British military efforts to fight the Nazis was the strategy of bombing German cities. The bombing missions placed an enormous burden of strain on military pilots. Each flying operation incurred high risks due to counterattacks by German flak and fighter pilots. However, aircrews could expect to meet with little sympathy when they were emotionally troubled. British historian Ben Shephard has shown that the British Bomber Command did nearly everything it could to keep the pilots flying, establishing a draconian system of military discipline, in which moral arguments overruled medical explanations. "Lack of Moral Fiber" (LMF) was one of the most common diagnoses. In contrast, military psychiatrists were more tolerant toward the land forces. In the theaters of war in North Africa, Italy, and France, British psychiatrists tended to recognize several fatigue symptoms, seeing "combat exhaustion" as being the result of great physical exertion and lack of sleep. Furthermore, psychosomatic approaches brought about new diagnoses, such as gastritis or peptic ulcer.
Meanwhile, in Germany, the psychiatric debate on "pension neurosis" had continued in the 1920s and 1930s. Working-class veterans, supported by Social Democratic representatives, insisted on their status as war victims and their right to a war pension. In contrast, the psychiatric establishment, allied with conservatives and the emerging extreme Right, continued in rejecting this position, arguing that war neurotics were malingerers and work-shy hysterical men who would undermine Germany's efforts for recovering national strength. In this sense, for many psychiatrists the Great War became an integral part of analyzing a lesson on what must be avoided in the future. In the mid- and late 1930s, this strategy also meshed with that of the Nazi regime, promoting an efficient preparation of the next war. At the beginning of the war, when the German concept of blitzkrieg was successful and soldiers were constantly on the move, psychiatric cases seemed to be rare. From the end of 1941, though, when the German army came unstuck before Moscow, the situation changed. During defensive and nerve-racking warfare with intense fighting periods, psychoneurotic symptoms increased. The German treatment system closely followed that of World War I. Electrical faradization, chiefly promoted by Cologne psychiatrist Friedrich Panse (1899–1973), came into use again. Generally speaking, and quite in contrast to World War I, German military authorities of World War II treated mentally suffering soldiers with unrelenting severity. In the last months of the war, the military's disciplinary system became arbitrary; scattered soldiers would be accused of malingering and desertion (Nazi and SS commanders spoke of undermining the military strength, Wehrkraftzersetzung) and were executed without legal proceedings.
Since the early 1980s, under the influence of post–Vietnam-War American psychiatry, the medical discourse has focused on psychological trauma (post-traumatic stress disorder or PTSD) and on mysterious fatigue syndromes (chronic fatigue syndrome or CFS). For a while it seemed that those diseases spared Europe. However, the Balkan wars in the 1990s saw the rise of the "Balkan syndrome." Like the "Gulf War syndrome"—another type of categorizing soldiers' emotional and mental suffering that is widely recognized in Great Britain—these syndromes are, on the one hand, attributed to certain toxic effects of environmental hazards such as pesticides or depleted uranium from armor piercing ammunition. On the other hand, psychological causes like "friendly fire" (troops being shot by their own side) are taken into consideration. In fact, the medical community debates the extent to which soldiers are affected and even the existence of those psychiatric syndromes. In 1999, the British Ministry of Defence funded a large-scale study on the health problems experienced by thousands of British Gulf War soldiers and their families. This study, carried out by a research team at King's College London, focused on the mentally and emotionally disturbing effects of war.
American literary scholar Elaine Showalter has suggested a provocative interpretation of the "new" war-related mental syndromes. Showalter stresses the needs of suffering people for medical legitimacy and public attention along with the multiplying and infectious effects of mass media, calling these syndromes hystories—hysterical narratives that represent and, above all, produce obscure psychosomatic effects for an ever-increasing segment of population. From a historical perspective, the introduction of the new psychiatric categories of the 1980s and 1990s has made perfectly clear that there is no universal and no singular element in the history of war neuroses. It seems that every war produces its own signature nervous and mental diseases. Consequently, it would be naive to argue that medicine in the twentieth century constantly improved diagnostic and therapeutic progress in managing the shattering effects of war. Rather, it would be worthwhile to deepen the historical investigations of histories of mental suffering with regard to different European wartime and postwar societies. This could highlight the multiple and often contradictory accounts and contexts of the "war neuroses," with respect to political narratives, military conditions, and cultural and social meanings.
Barker, Pat. Regeneration. London, 1991. First in prizewinning novel trilogy on shell shock and British culture in and after the Great War. Regeneration was made into a film in 1997 starring Jonathan Pryce and James Wilby.
——. The Eye in the Door. New York, 1994.
——. The Ghost Road. London, 1995.
Binneveld, Hans. From Shell Shock to Combat Stress: A Comparative History of Military Psychiatry. Translated by John O'Kane. Amsterdam, 1997. A good introduction into the history of military psychiatry with a strong focus on the twentieth century.
Bourke, Joanna. Dismembering the Male: Men's Bodies, Britain, and the Great War. London, 1996. Excellent discussion of the impact of World War I on the male body, mainly in Britain.
Cooter, Roger, Mark Harrison, and Steve Sturdy, eds. War, Medicine, and Modernity. Stroud, U.K., 1998. Excellent collection of articles, examines processes of rationalization as a key feature in understanding the relationship of medicine and modern warfare.
Eissler, Kurt Robert. Freud as an Expert Witness: The Discussion of War Neuroses between Freud and Wagner-Jauregg. Translated by Christine Trollope. New York, 1986. Provides a psychoanalytical approach to war neuroses in World War I.
Hofer, Hans-Georg. Nervenschwäche und Krieg. Modernitätskritik und Krisenbewältigung in der österreichischen Psychiatrie (1880–1920). Vienna, 2004. Discusses the history of war neuroses in Austro-Hungary against the background of the fin-de-siècle discourses on nervousness and modernity.
Journal of Contemporary History 35, no. 1 (2000). Special Issue: Shell-Shock. Most helpful collection of articles with an emphasis on comparative perspectives; includes articles on war neuroses in France, Germany, Great Britain, Ireland, Italy, and Russia.
Leed, Eric . No Man's Land: Combat and Identity in World War I. New York, 1979. Still one of the best books on the history of World War I, with an influential chapter on war neuroses.
Leese, Peter. Shell Shock: Traumatic Neurosis and the British Soldiers of the First World War. Basingstoke, U.K., 2002. Traces the complex career of shell shock in World War I–Britain, clearly organized, integrates the patients records into historical analysis.
Lerner, Paul. Hysterical Men: War, Psychiatry, and the Politics of Trauma in Germany, 1890–1930. Ithaca, N.Y., 2003. Very well-written study on German psychiatry and on the debates on "pension neurosis" and male hysteria in the era of World War I.
Micale, Mark S., and Paul Lerner, eds. Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870–1930. Cambridge, U.K., 2001. Standard work of the historical trauma studies with a fine, clearly written introduction, includes papers on different European countries, lots of references.
Shephard, Ben. A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century. Cambridge, Mass., 2001. Offers a wide-ranging survey of psychiatric responses to war trauma in the twentieth century, also a good starting point for a historical account of war neuroses in World War II.
Showalter, Elaine. Hystories: Hysterical Epidemics and Modern Media. New York, 1997. Provocative and inspiring book on hysterical epidemics and the role of modern mass media at the end of twentieth century.