The will of war

The declaration of war in August 1914 was greeted on all sides with a euphoria so delusional German psychiatrists dubbed it Mobilisation Psychosis (Mobilmachungspsychose). Public opinion was united in the belief there could be no better cure for 'nerves dried up…from years of peace' than the 'mighty healing power of the iron bath [Stahlbad] of war.'

During the early months of fighting it seemed such optimism might be justified. Psychiatrist Otto Binswanger recounted how, in the year leading up to the outbreak of war, he had treated a 'whole series of weak-nerved youths …who amounted to nothing more than whiners. Then came the war. The illnesses fell away in an instant…the great purifier war has done its work'.

As the swift victory, initially predicted on all sides, turned into the stalemate of trench warfare, it rapidly became apparent that mechanised conflict broke minds as well as bodies. Within months, the hospital wards of combat nations were filled with soldiers who, although physically uninjured, were blind, deaf, dumb, or mute, paralysed, plagued by tics and tremors, had limbs contorted by violent seizures or bent at an acute angle (a condition known as Camptocormia).

By the winter of 1917, neuroses had risen to the point of parity with physical injuries – up from 14 per cent of all injuries in 1914 to 45 per cent three years later. 'Their number has grown and grown,' psychiatrist Robert Gaupp reported late in 1917. 'Scarcely is one nerve hospital opened than it fills up and space must be found somewhere else…nerve hospitals are practically the only ones that are always full.'

The rise of 'Railway Brain'

German doctors initially attributed the seemingly incomprehensible disabilities confronting them to what they termed 'railway brain'. This had been coined during the 1880s by Germany's most eminent neurologist, Hermann Oppenheim. After treating numerous survivors of collisions between speeding trains, he concluded the tremors, tics, stutters and partial paralyses from which they suffered were caused by minute and undetectable brain lesions. After war broke out, he extended his theory to include the effects of explosions from bombs, mines, grenades and artillery shells.

Reluctant to accept their soldiers could ever suffer anything as 'unworthy' (unwürdig) as a mental breakdown, German doctors eagerly accepted this theory and even began distinguishing between the different types of lesions. Some, they thought, were caused by Granaterschutterung (shell explosion), others by Granatexplosionslahmung (shell paralysis) or Granatfernwirkung (the indirect effects of an explosion).

Oppenheim's theory was not seriously challenged until the summer of 1916.  In an influential paper, published in The Lancet, Dr Harold Wiltshire, a captain in the Royal Army Medical Corps, wrote that his patients' disabilities were the result not of 'lesions' but the fact their psychological resistance had been exhausted by the stress of combat.

Although initially rejected by the military, Wiltshire's conclusions received support from other front-line doctors and psychologists. Among those who supported his view was Charles Myers, a medically trained psychologist, based at a hospital in Boulogne, who first coined the phrase 'shell shock'.

The rise of hysteria

For clinicians who found the notion of 'microscopic lesions' unhelpful, a second and more ancient diagnosis was open to them. Hysteria.

The Ebers papyrus, an Egyptian medical treatise dating from 1550 BC, describes how emotional disorders among women are caused by their womb moving from its normal position in the body and disturbing the natural motions of the mind. Centuries later, Greek physicians took the same view and named such disturbances 'hysteria' from their word hysteron for womb.

From the 18th century onwards hysteria was increasingly viewed as a disease not of the uterus but of the nerves.  By the early 20th century, doctors were using hysteria to explain away any disturbance of bodily function for which no organic cause could be discovered.

For many German doctors, hysteria's root cause was a failure of the will. As Karlsruhe physician Willy Hellpach put it: 'The A to Z of hysteria is the will'.

The nature of the will    

Germans regarded 'will' as a sublimely masculine quality associated with patriotism, obedience, discipline, and comradeship. 'The activity of the will is raised to the highest conceivable level through love of Fatherland', wrote neurologist Alfred Goldschieder in 1915.

Doctors began attributing disabilities to Willenssperrung ('inhibition of the will'), Willensversagung ('failure of the will') or Willenshemmung ('an arrest of the will'). As a result, soldiers diagnosed as 'hysterics' were viewed not merely as having 'inferior nervous systems' or 'degenerate brains', but as a threat to national unity and the war effort.

The German Psychiatric Association stated as its official policy that a doctor's sole mission was 'to serve our army and our Fatherland' by ensuring every soldier they treated was returned, as swiftly as possible, to the battlefield. In pursuit of this policy, they were given licence to practice any treatment, however extreme, they believed might restore and strengthen a soldier's will.

The rise of active therapies

An early form of treatment was hypnosis. A major advocate was Munich psychiatrist Max Nonne, who claimed to perform lightning cures for even the most seemingly intractable disabilities. He had a 16mm training film made to demonstrate his successes (to watch Nonne at work go to www.triumphofthewill.info).   

Despite his enthusiasm, and his claim to have successfully treated around 1,500 patients over the course of the war, a majority of doctors found hypnosis unreliable and difficult. As a result, most favoured what they termed 'active therapies'. These ranged from isolation in mental hospitals and prolonged immersion in warm baths to the injection of saline placebos and even pseudo-surgery.

One of the most alarming active treatments was invented by Essen laryngologist Otto Muck, for use on hysterically dumb soldiers. It involved thrusting a one-centimetre-diameter steel ball into the back of the throat. It was then pressed forcefully against the larynx until the patient, fearing suffocation, let out a wild shriek of terror. Muck claimed a high success rate for his method and reported that, far from being upset by the violent assault, his patients expressed only gratitude for what he had done.

Another eminent psychiatrist, Otto Binswanger, employed social isolation. Patients were commanded to remain completely silent at all time and punished, by being deprived of food, if they even whispered.

Berlin psychiatrist Ewald Stier used solitary confinement cubicles inside a mental asylum. Patients were warned that, if they failed to make swift recoveries, they would be transferred to a ward filled with violently disturbed inmates. When soldiers protested they were not mentally ill, Stier would retort brusquely: 'He who does not have control over his body belongs in the asylum.'

The 'Kaufmann Method'

The most widely used form of 'active therapy,' however, involved administering prolonged and painful electric shocks. This was known as the Kaufmann method.

In 1903, while working at Heidelberg's nerve clinic, psychiatrist Fritz Kaufmann watched a young girl with hysteria make an immediate recovery after receiving a 'merciless' ten-minute burst of electric current accompanied by strong verbal commands. Twelve years later, in the overcrowded wards of Mannheim's nerve clinic, he decided to use the same procedure to create an 'assembly-line' method for treating neurotic soldiers.

A powerful electric current was applied, in bursts of between two and five minutes and for up to two and a half hours, directly to the affected part of the body. A soldier with a paralysed leg, for example, would have the electrodes attached to his thigh or calf.

Once begun, the procedure could end only once the hysterical condition had been completely eliminated. To stop prematurely, Kaufmann warned, ran a risk of convincing the patient he was incurable and so making his condition permanent.

While claiming a high degree of success for his treatment, which he called Gewaltsuggestionsmethode (method of violent suggestion), and despite it being responsible for the deaths of at least 20 soldiers, Kaufmann admitted that none of his patients had ever been fit enough to return to the Front Line.

It was not until towards the end of the war that resistance by patients (in one instance leading to a mutiny) became so widespread and well-publicised that electric therapy was finally prohibited by the medical authorities.

While these treatments now seem appalling to us, it must be remembered that doctors of the period had minimal understanding of psychological trauma and their treatment options were very limited. It should also be borne in mind the Germans executed only 18 soldiers for cowardice. The British shot 306, including some teenage boys, many of whom were undoubtedly suffering from PTSD.

Between 1914 and 1918, German psychiatrists and psychologists were, in the words of American historian Paul Lerner: 'Judge, teacher, and disciplinarian . . . [able] to exercise a decisive influence over the fates of thousands of soldiers. They used their…control and authority over the patient to promote medical views of German manhood, which were based on duty, obedience and, most of all, productivity.'

With the best of intentions and the most honourable of motives they inflicted pain, suffering and sometimes death on men crippled by the horrors of the Front. In attempting to treat mental problems they did not understand, they wrote one of the darkest chapters in 20th century psychiatry.

- David Lewis-Hodgson is a former lecturer in psychopathology in the Department of Experimental Psychology at the University of Sussex, and Chairman of Mindlab International, based in the University's Science Park.  His latest book, Triumph of the Will? (MLI Press), discusses the ways mentally ill soldiers were treated during the first war and how this played a role in the political career of Adolf Hitler.

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Key sources

Key sources on war enthusiasm in UK and Germany include: M. Eksteins, Rites of Spring; R.N. Stromberg, Redemption by War; and R. Rürup, Der Geist von 1914 in Deutschland.
Gaupp, R. (1911). Über den Begriff der Hysterie. Zeitschrift für die Gesamte Neurologie und Psychiatrie, 5, p.464.
Goldschieder, A. (1915). Über die Ursachen des günstigen Gesund- heitszustandes unserer Truppen im Winterfeldzuge. Zeitschrift für Physikalische und Diatetische Therapie 19, p170.
Lerner, P.F. (1996). Hysterical Men: War, Neurosis and German Mental Medicine, 1914 -1921. Unpublished PhD thesis. Colombia University, Graduate School of Arts and sciences.
Rather, L.J. (1965). Mind and Body in Eighteenth Century Medicine. London: Wellcome Historical Medical Library.
Wiltshire, H. (1916). A Contribution to the Aetiology of Shell Shock. Lancet 1, p1208-1209.
Weichbrodt, R. (1918). Einige Bemerkungen zur Behandlung von Kriegsneurotikern. Monatsschrift für Psychiatrie und Neurologie Vol. 43, p266.