SECTION I
IN THE UNITED STATES
INTRODUCTION
Before the United States entered the World War, the attentionof both the American medical profession and the public had been attracted by theprevalence of some apparently new types of mental reactions under the stress ofactual campaign. From the earliest days of the fighting at Mons, stories hadcome to the United States of strange new diseases apparently having their originin the stress and special horrors of modern warfare and presenting problems intreatment and prevention that baffled the medical organizations of the armiesthat later were to become our allies. After making all possible allowances forexaggeration and highly colored lay reports of technical and medical matters, itwas apparent that some new medical problems had arisen in connection with thereactions of the central nervous system to the new conditions of warfare. It wasalso apparent that a new type of casualty which might threaten most seriouslythe manpower of armies existed in the inability of human beings to stand morethan a certain amount of exposure to the effects of high explosives, even thoughthey escaped bodily injury. For these reasons the first published reports on theneurological and psychiatric aspects of the war were eagerly read byneurologists and psychiatrists in the United States who realized, even then,that the time might very soon come when they would be dealing with the sameproblems in troops serving under their own flag.
The first impression to receive confirmation by reports fromthe scene of conflict was that relating to the increased incidence of mentaldisorders occasioned by war. It had been observed that not only in actual warbut even in peaceful mobilization, such as that of our own Army along theMexican border in 1916, there was a higher rate of mental disease among soldiersthan in civil life. The discharge rate for mental diseases in the United StatesArmy in 1916 was three times the admission rate for these disorders in the adultmale population of the State of New York, one-tenth of all discharges fordisability being for mental diseases, mental deficiency, epilepsy, and theneuroses.1 Out of a group of 1,069 enlisted mendischarged from the United States Army in 1912 on account of disability from allcauses, more than 200, or practically 20 per cent, were found to be mentallydiseased or defective during the year.2
Among the reasons adduced for the excessive prevalence ofinsanity among soldiers, the peculiar kind of stress which military life imposesupon psychopathic individuals was considered the most important. Many people areable to make satisfactory adjustments to life only with the greatest difficultyand under exceptionally favorable circumstances. On account of certaininadequacies of character or personality, life presents to them complexities ofwhich their fellow men are unaware. By means of fortunate changes in their en-
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vironment, opportune withdrawals from difficult situations,and many other expedients not required by most people, individuals with seriousdefects 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 ofpersons with whom they come in contact and the support of these persons incritical 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, someof them just able to adapt themselves to life under the best of conditions, mustfit into the one iron mold which experience has shown to be best for the sternbusiness of war. The result is a heavy incidence of those varieties of mentalshipwreck that we call psychoses and neuroses, and the merciless disclosure of alarge number of constitutionally inferior individuals.1
While it was assumed that with actual fighting the rate formental disease rose sharply, what impressed American neurologists andpsychiatrists most was the extraordinary prevalence of the neuroses,-functionalnervous conditions that came to be known chiefly as "shell-shock,"from the apparent association of these conditions with the high explosives usedin battle. Accounts reached this country of the queer aura of symptoms thatcharacterized these cases, and many and varied were the interpretations advancedin the early reports in explanation of the phenomena of "shell-shock,"so little understood at the time. There were descriptions of cases with staringeyes, violent tremors, a look of terror, and blue, cold extremities. Some weredeaf and some were dumb; others were blind or paralyzed. In general, theseconditions were associated with the central nervous system and the shock ofexposure to the strain of battle under new conditions of warfare.
There was much difference of opinion as to whether the causesof "shell-shock" were mainly physical or mental. Some were inclined tolook for injuries to the central nervous system as the chief explanation for theproduction of this condition, others claimed that the disorder was mostlypsychological. It was recognized that the appearance of neurological symptoms incertain cases could be accounted for by the physical effects of shell explosion,even without external injury. But there was considerable controversy about thatgroup of "shell-shock" cases among patients exposed to shell fire inwhom there may or may not have been damage to the central nervous system butwhose symptoms were those of neuroses familiar in civil practice, colored in adistinctive way by the precipitating cause.1Mott included them in his group of "injuries of the central nervous systemwithout visible injury," holding that some unknown physical or chemicalchange must underlie such striking disabilities.3Wiltshire gave less weight to the factor of physical damage, though stillrecognizing its existence, and put the emphasis upon psychologic factors in hisexplanation of the phenomenon.4
There was common agreement upon one point, however, and thatwas the importance of the constitutional make-up of the individual exposed toshell fire as a contributing factor in shell-shock.
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Numerous observers at the front and in home hospitals notedthe absence of "shell-shock" among the wounded. "Among scores ofCanadian soldiers returned with severe head injuries," according to Farrar,"most of them shrapnel and gunshot wounds with loss of portions of theskull, symptoms of psychosis or traumatic neurosis have practically never beenobserved * * * trench neuroses occur usually in unwounded soldiers."5
The frequency of mental and nervous affections was remarked by medicalwriters in every combatant nation, and all agreed that the terrible conditionsof modern warfare, with its new methods of fighting-high explosives, liquidfire, tanks, poison gas, bombing planes, the "warfare of attrition" inthe trenches-contributed to the creation of a novel disease entity. At firstcalled "shell-shock," this disease came gradually to be recognized as"war neurosis," a condition very similar to the neuroses of civillife, but highly colored by the terrifying influences of new conditions ofcombat. An American observer wrote that "the present war is the first inwhich * * * the functional nervous diseases ('shell-shock') haveconstituted a major medico-military problem. As every nation and race engaged issuffering from the symptoms, it is apparent that new conditions of warfare arechiefly responsible for their prevalence."1
The Russians, in their war with the Japanese, developed the first armymedical service in which mental cases were treated by specialists, both at thefront and upon return to home territory;6 butthis service was primarily for insane soldiers, the functional neuroses notbeing especially significant. It is possible that the neuroses may not have beendistinguished from the pyschoses in previous wars. However, Read, who made avery careful study of the problem, had this to say: "* * * war neuroticstates have an intimate relationship with the conditions under which this greatwar was fought-the enormously high explosives, special trench warfare, poisongases, and horrors that were not present to any extent in previous wars. It isstated that no war neuroses were observed in the Boer War, where the methodswere so different, but some traces were seen in the Russo-Japanese War."7Though none of the symptomatic expressions of war neurosis were considered new,all having been noted by the military surgeons in previous wars, still the greatfrequency of their occurrence in the World War was a decided novelty to war-timemedical experience.
REFERENCES
(1) Salmon, Thomas W.: War Neuroses ("Shell-Shock").Monograph, Mental Hygiene War Work Committee of the National Committee forMental 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 theCentral 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 ofShell-Shock. The Lancet, London, June 17, 1916, 1207-12.
(5) Farrar, Clarence B.: War and Neurosis. American Journalof Insanity, Baltimore, lxxiii, No. 4, April, 1917, 12.
(6) Richards, Robert L.: Mental and Nervous Disorders in theRusso-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.
