The Scope of Suffering and Traumatization During World War I

Mealtime in the Trenches by Otto Dix

Maarten Van Son et al.

The years of World War I, 1914–1918, were a time of immense suffering, not only among warring soldiers, but also among civilians in the various countries at war and in surrounding countries to which displaced people fled. In addition to the suffering of the countless refugees from the war zones, there was increasing hunger and shortage of all kinds of essential commodities throughout many countries (Van Bergen, 1999; Whalen, 1984), along with extensive environmental damage and the total destruction of civil infrastructures. In all involved countries there was immeasurable mourning and grief for the myriad dead. 

For combat soldiers themselves, especially those in the trenches, suffering did not consist only of physical or mental wounding. There was also constant misery produced by the intrinsically horrific conditions in the trenches, as illustrated in a 1918 issue of the French trench journal Le Filon (quoted by Van Bergen, 1999, p. 10): 

Fighting a modern war means to entrench yourself in a hole filled with water and to sit in it for ten days without moving, it means looking and listening and keeping a grenade in your hand, it means eating cold food and sinking in the mud and carrying your food through the dark night and wandering hour after hour around the same point without ever finding it, it means being hit by grenades which come from God knows where–in short: it means privation. 

This picture easily extended to include torment due to the constant presence of vermin, and the need to function despite chronic lack of sleep, exhaustion, cold, thirst, hunger, poor rations, complete lack of sanitation facilities, inadequate medical care, and high rates of disease (e.g., dysentery, trench foot and other severe skin disorders, malaria, tuberculosis, pneumonia, and the deadly Spanish influenza pandemic of 1918). There was the constant stress of seeing fellow soldiers being killed or wounded, of the stench and sight of unburied decomposing bodies, of hearing unheeded screams for help from the wounded trapped in no-man’s land, and of helplessly watching the wounded drown in mud without the possibility of being rescued. Soldiers lived in trenches for weeks or months at a time, and more often than not, furloughs were extraordinarily brief or entirely absent; thus, there was no relief from the dreadful existence in the trenches. Finally, fear was an ever-present experience. In this war especially, with its unprecedented reliance on massive bombardments and static trench warfare, confrontation with death was inescapable. 

Gilbert (1995) reports that the defeated Central Powers lost 3,500,000 soldiers on the battlefield. The victorious Allied Powers lost 5,100,000 men. Gilbert also reported that, on average, this was more than 5,600 soldiers killed each day of the war. The fact that 20,000 British soldiers were killed on the first day of the Battle of the Somme is often recalled with horror. On average, a similar number of soldiers were killed in every four-day period of the First World War (p. 541). 

American Soldier Suffering Shell Shock

How about the mental casualties, also referred to as soldiers with shell shock, neurasthenia, war neurosis, or the German term, Kriegsneurosen? After the war, a witness stated, ‘‘under conditions such as existed in France it is inevitable for the man to break down at one time or another’’ (War Office Committee, 1922, p. 5). During the initial stages of the war this insight did not exist among the upper army echelons. In fact, many military authorities were so prejudiced or ignorant about mental casualties that, for example, the official British military position was that shell shock and malingering were impossible to separate, therefore, both should be dealt with in army prisons (Stone, 1985, p. 250). Some ‘‘shell shocked’’ soldiers even received court-martialed death sentences for ‘‘desertion’’ (Babington, 1983, 1997). 

However, it became increasingly difficult to ignore the scope of mental breakdown following the mass devastation of the Battle of the Somme, in particular among the British forces (Bogacz, 1989; Feudtner, 1993; War Office Committee, 1922). Such breakdowns could be caused not only by acute trauma but also by accumulating stresses and strains of life in the war zone. Rivers (War Office Committee, 1922) remarked on these latter cases: 

‘‘These were the men who, especially in the early stages of the war, after some shell explosion or something else had knocked them down badly, went on struggling to do their duty until they finally collapsed entirely’’ (p. 55).  

It was believed, even by Freud (1919), that with the end of the war ‘‘most of the neurotic diseases that had been brought about by the war disappeared’’ (p. 1). Reality was quite different, with long-term psychiatric disability for  thousands of soldiers on all sides of the Great War. In 1917, the German  psychiatrist Robert Gaupp concluded that Kriegsneurosen (war neuroses)  constituted the largest category of wounded soldiers in the German army: more than 613,000 men. Entire German companies suffered from constant vomiting or unceasing fits of crying (Van Bergen, 1999, p. 211). The numbers within the British ranks are less clear, but one thing is certain: the official number of 80,000 is a vast underestimation (Van Bergen, 1999). 

Although, at least in Britain, many shell shocked soldiers were gradually able to work, they still experienced significant emotional difficulties: ‘‘The position in 1925 was that 60% were still affected with varying degrees of nervous anxiety, but the number who were unemployable had fallen to 20%’’ (Babington, 1997, p. 122). In 1929, British mental hospitals still housed 65,000 cases of  ‘‘shell shock’’ (Winter, 1979). In 1932, 36% of veterans receiving disability pensions from the British government were listed as psychiatric casualties of the war (Leed, 1979, p. 185). In 1939, 120,000 British veterans were receiving pensions or had been paid a final award for war-related ‘‘primary psychiatric disability’’ (Babington, 1997). Finally, in 1942, Thom reported that 58% (68,000 men) of all the patients being cared for in veterans’ hospitals in the United States were neuropsychiatric casualties of WWI (Thom, 1943; quoted by Leed, 1979). 

In contrast to the enormous attention military psychiatrists gave to acutely traumatized combat soldiers—with the explicit mission to get them back to the front as soon as possible—there are virtually no post-WWI psychiatric studies on chronically traumatized war veterans. As far as we know there was only one follow-up study. This 1920 American study consisted of 760 men out of a larger group of pensioners suffering from war neuroses, and revealed that more than 60% were troubled with symptoms of psychotic illness and nearly 40% were unfit for any form of employment (Salmon, 1921; quoted by  Babington, 1997). 

Night (Post WWI Berlin) by Max Beckmann

Nevertheless, psychiatry did learn one extremely important lesson: the development of mental disorders could be related directly to traumatic experiences. Whereas initial medical reports emphasized premorbid characteristics, including heredity, as the main factors in the development of these disorders, it was subsequently understood that every man had his breaking point. Hart (1929), ‘‘a veteran of five years working in ‘shell-shock’ hospitals  in England’’ (Shephard, 1999, p. 494), wrote: 

During the recent war a great mass of illness occurred which, christened at first by the misleading name of ‘‘shell shock,’’ came ultimately to be known as the psychoneuroses of war. This change of nomenclature was due to the rapidly won recognition of the psychological origin of these conditions. Indeed it may be said that, whatever else the war has done, it has at least conclusively demonstrated the existence and  importance of psychogenic disorder. (p. 64) 

The mental disorder most commonly associated with the Great War, was,  of course, shell shock. Myers was not the only WWI psychiatrist to explain  shell shock, or the war neuroses, in terms of a dissociation of the personality  (e.g., Brown, 1919a & b; Ferenczi, 1919b; McDougall, 1926; Simmel, 1919). 

For example, Brown (1919a) stated that ‘‘viewed from the psychological point of view, hysterical disorders all fall under one heading, as examples of dissociation of psycho-physical functions (walking, speaking, hearing, remembering certain experiences, etc.) following upon a diminution or loss of higher mental control’’ (p. 834). Likewise, Myers (1940) formulated the concept that the ‘‘ ‘functional’ nervous disorders are assignable . . . to a dissociated personality and its results’’ (p. 71). 

We believe that Myers’ (1940) distinction between what he referred to as the ‘‘emotional’’ or traumatized personality (EP) and ‘‘apparently normal’’ personality (ANP) provides a clear theoretical notion that greatly enhances our understanding of trauma-related dissociation. We would, however, emphasize that in no way is our intention to reify separate entities when using the term ‘‘personality.’’ Hart (1929) correctly stated that these pheonomena are ‘‘in reality absolutely devoid of any actual spatial aspect, and the introduction of a spatial metaphor . . . can only lead to erroneous deductions unless its purely descriptive and illustrative function is rigidly controlled’’  (p. 162). Structural dissociation is both a metaphoric and a theoretical construct, neither of which reflects complete reality, since all language—scientific or metaphoric—only approximates reality. 

Nonetheless, we are persuaded by clinical experience and growing empirical data that the clearest understanding of trauma-induced dissociation and its treatment to date is the view of ANP and EP as metaphoric descriptive labels of mental systems that have failed to integrate. The essence of this failure to integrate, i.e., dissociation, is represented in Janet’s definition of hysteria that was the 19th-century category of dissociative disorders in a generic sense: ‘‘A form of mental depression characterized by the retraction of the field of consciousness [involuntary and intense narrowing of attention] and a tendency to the dissociation and emancipation of the systems of ideas and functions that constitute  personality’’ (Janet, 1907, p. 332). The EP and ANP that Myers (1940) observed in traumatized soldiers constitute major examples of these dissociated ‘‘systems of ideas and functions.’’ They had their own sense of self, however rudimentary (McDougall, 1926; Mitchell, 1922), and exhibited a concurrent retraction of their field of consciousness that further reduced mental integrative capacity already impaired by dissociation. 

"Somatoform Dissociation in Traumatized World War I Combat Soldiers: A Neglected Clinical Heritagem" by Maarten Van Son et al., JOURNAL OF TRAUMA & DISSOCIATION; Vol. 1(4) 2000