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Section I Introduction

Table of Contents




Before the United States entered the World War, the attention of both the American medical profession and the public had been attracted by the prevalence of some apparently new types of mental reactions under the stress of actual campaign. From the earliest days of the fighting at Mons, stories had come to the United States of strange new diseases apparently having their origin in the stress and special horrors of modern warfare and presenting problems in treatment and prevention that baffled the medical organizations of the armies that later were to become our allies. After making all possible allowances for exaggeration and highly colored lay reports of technical and medical matters, it was apparent that some new medical problems had arisen in connection with the reactions of the central nervous system to the new conditions of warfare. It was also apparent that a new type of casualty which might threaten most seriously the manpower of armies existed in the inability of human beings to stand more than a certain amount of exposure to the effects of high explosives, even though they escaped bodily injury. For these reasons the first published reports on the neurological and psychiatric aspects of the war were eagerly read by neurologists and psychiatrists in the United States who realized, even then, that the time might very soon come when they would be dealing with the same problems in troops serving under their own flag.

The first impression to receive confirmation by reports from the scene of conflict was that relating to the increased incidence of mental disorders occasioned by war. It had been observed that not only in actual war but even in peaceful mobilization, such as that of our own Army along the Mexican border in 1916, there was a higher rate of mental disease among soldiers than in civil life. The discharge rate for mental diseases in the United States Army in 1916 was three times the admission rate for these disorders in the adult male population of the State of New York, one-tenth of all discharges for disability being for mental diseases, mental deficiency, epilepsy, and the neuroses.1 Out of a group of 1,069 enlisted men discharged from the United States Army in 1912 on account of disability from all causes, more than 200, or practically 20 per cent, were found to be mentally diseased or defective during the year.2

Among the reasons adduced for the excessive prevalence of insanity among soldiers, the peculiar kind of stress which military life imposes upon psychopathic individuals was considered the most important. Many people are able to make satisfactory adjustments to life only with the greatest difficulty and under exceptionally favorable circumstances. On account of certain inadequacies of character or personality, life presents to them complexities of which their fellow men are unaware. By means of fortunate changes in their en-


vironment, opportune withdrawals from difficult situations, and many other expedients not required by most people, individuals with serious defects in adaptation manage to get along in civil life with fair success. Others, who are able to make adjustments that are only partially successful, escape serious mishaps through a lot of charitable allowances on the part of persons with whom they come in contact and the support of these persons in critical situations. In military life such aid is lacking. The individual who, with much assistance, only barely succeeds in making satisfactory adjustments, is here thrown upon his own meager resources. All kinds of personalities, some of them just able to adapt themselves to life under the best of conditions, must fit into the one iron mold which experience has shown to be best for the stern business of war. The result is a heavy incidence of those varieties of mental shipwreck that we call psychoses and neuroses, and the merciless disclosure of a large number of constitutionally inferior individuals.1

While it was assumed that with actual fighting the rate for mental disease rose sharply, what impressed American neurologists and psychiatrists most was the extraordinary prevalence of the neuroses,-functional nervous conditions that came to be known chiefly as "shell-shock," from the apparent association of these conditions with the high explosives used in battle. Accounts reached this country of the queer aura of symptoms that characterized these cases, and many and varied were the interpretations advanced in the early reports in explanation of the phenomena of "shell-shock," so little understood at the time. There were descriptions of cases with staring eyes, violent tremors, a look of terror, and blue, cold extremities. Some were deaf and some were dumb; others were blind or paralyzed. In general, these conditions were associated with the central nervous system and the shock of exposure to the strain of battle under new conditions of warfare.

There was much difference of opinion as to whether the causes of "shell-shock" were mainly physical or mental. Some were inclined to look for injuries to the central nervous system as the chief explanation for the production of this condition, others claimed that the disorder was mostly psychological. It was recognized that the appearance of neurological symptoms in certain cases could be accounted for by the physical effects of shell explosion, even without external injury. But there was considerable controversy about that group of "shell-shock" cases among patients exposed to shell fire in whom there may or may not have been damage to the central nervous system but whose symptoms were those of neuroses familiar in civil practice, colored in a distinctive way by the precipitating cause.1 Mott included them in his group of "injuries of the central nervous system without visible injury," holding that some unknown physical or chemical change must underlie such striking disabilities.3 Wiltshire gave less weight to the factor of physical damage, though still recognizing its existence, and put the emphasis upon psychologic factors in his explanation of the phenomenon.4

There was common agreement upon one point, however, and that was the importance of the constitutional make-up of the individual exposed to shell fire as a contributing factor in shell-shock.


Numerous observers at the front and in home hospitals noted the absence of "shell-shock" among the wounded. "Among scores of Canadian soldiers returned with severe head injuries," according to Farrar, "most of them shrapnel and gunshot wounds with loss of portions of the skull, symptoms of psychosis or traumatic neurosis have practically never been observed * * * trench neuroses occur usually in unwounded soldiers."5

The frequency of mental and nervous affections was remarked by medical writers in every combatant nation, and all agreed that the terrible conditions of modern warfare, with its new methods of fighting-high explosives, liquid fire, tanks, poison gas, bombing planes, the "warfare of attrition" in the trenches-contributed to the creation of a novel disease entity. At first called "shell-shock," this disease came gradually to be recognized as "war neurosis," a condition very similar to the neuroses of civil life, but highly colored by the terrifying influences of new conditions of combat. An American observer wrote that "the present war is the first in which * * * the functional nervous diseases ('shell-shock') have constituted a major medico-military problem. As every nation and race engaged is suffering from the symptoms, it is apparent that new conditions of warfare are chiefly responsible for their prevalence."1

The Russians, in their war with the Japanese, developed the first army medical service in which mental cases were treated by specialists, both at the front and upon return to home territory;6 but this service was primarily for insane soldiers, the functional neuroses not being especially significant. It is possible that the neuroses may not have been distinguished from the pyschoses in previous wars. However, Read, who made a very careful study of the problem, had this to say: "* * * war neurotic states have an intimate relationship with the conditions under which this great war was fought-the enormously high explosives, special trench warfare, poison gases, and horrors that were not present to any extent in previous wars. It is stated that no war neuroses were observed in the Boer War, where the methods were so different, but some traces were seen in the Russo-Japanese War."7 Though none of the symptomatic expressions of war neurosis were considered new, all having been noted by the military surgeons in previous wars, still the great frequency of their occurrence in the World War was a decided novelty to war-time medical experience.


(1) Salmon, Thomas W.: War Neuroses ("Shell-Shock"). Monograph, Mental Hygiene War Work Committee of the National Committee for Mental Hygiene (Inc.), New York.

(2) Annual Report of the Surgeon General, U. S. Army, 1913, 238.

(3) Mott, Frederick W.: Effects of High Explosives upon the Central Nervous System. (Lettsomian Lectures Nos. 1, 2, and 3). The Lancet, London, February 12, 1916, 331-38; February 26, 1916, 441-51; March 11, 1916, 545-53.

(4) Whiltshire, H.: Contribution to the Etiology of Shell-Shock. The Lancet, London, June 17, 1916, 1207-12.

(5) Farrar, Clarence B.: War and Neurosis. American Journal of Insanity, Baltimore, lxxiii, No. 4, April, 1917, 12.

(6) Richards, Robert L.: Mental and Nervous Disorders in the Russo-Japanese War. The Military Surgeon, Washington, 1910, xxvi, No. 2, 177.

(7) Read, C. S.: Military Psychiatry in Peace and War. Lewis, London, 1920, 143.