Before WWI, the concept that trauma could damage a person’s mind and emotions was practically inexistent. Even with its many shortcomings, the high number of servicemen and women who suffered from what was called shell shock allowed a new concept to emerge: that wounds could be other than physical. 

Since the first great battle of WWI, the Battle of the Marne, it was observed that soldiers coming to the clearing stations, although clearly damaged, didn’t present any visible wounds. 
The symptoms observed by the doctors and nurses were similar. Case notes often read: “Palpitation – Fear of fainting…”; “Now feels worn our & has pain in the region of heart.”; “Depression – overreaction – Insomnia – Headaches.”; “nervousness, lassitude, being upset by sudden noise”; “Patience fears gunfire, death and dark… In periods of wakefulness he visualises mutilations he has seen”.
Inability to control physical functions was common, too, as were psychosomatic reactions to warfare. Soldiers who had bayoneted men in the face developed hysterical tics on their own faces. Snipers lost their sight. Terrifying nightmares of being unable to withdraw bayonets from an enemy’s body could occur. 

Estimations indicated that four fifths of the soldiers and officers who suffered from shell shock were never able to go back to the fight. Interestingly, officers who suffered from shell shock were proportionately in higher numbers than soldiers. This may have different explanations. 
Officers suffered a greater emotional pressure, being them who order their men over the top, and being in a position to see whether what they order was useful or a total madness. But also, simple soldiers who suffered from the same ailment were often just considered cowards or shirkers. 
Because these patients couldn’t show wounds for their sickness, the suspect that they were merely pretending never disappeared during the war. 

How Shell Shock was understood in the Great War

It was called ‘Shell Shock’ for the first time in the British medical journal The Lancet in 1915. It was observed that these patients, who may not show any visible wound, had been close to an explosion. The first commonsense conclusion was that this damage was ‘commotional’, deriving from the severe concussive motion of the shaken brain inside the skull of a soldier who had been ‘blown up’. It had, therefore, a physical origin. 
But by 1916, military and medical authorities became convinced that many soldiers (in fact, the majority) who showed the symptoms had been nowhere near an explosion. The cause was not physical but psychological. That is, their condition was one of ‘neurasthenia”, a weakness of the nerves, or – as we would say today – a nervous breakdown precipitated by the dreadful stress of war. 

Shell shock was then linked more often than not to neurasthenia or to hysteria. These two conditions had become very common in the psychology discourse of the end of the 1800s but suffered a very strong ideological position linked to degeneration. 
Hysteria was a diagnosis based on symptoms, not the presumed cause. It seemed to present all the characteristics of the shellshocked soldiers, from the fear of loud noises to nightmares, tremors, even convulsions and incapacity to concentrate. Neurasthenia was diagnosed when the prominent symptom was nervous exhaustion, though, during the war, doctors ended up using this term for all sorts of mental ailments originating in fear. 
There was also another significant difference. Neurasthenia was thought to emerge for external causes, whereas hysteria was explained with the patient’s weakness of character. Hysteria was a form of congenital sickness, finding roots in the idea that hereditary pathologies could cumulatively corrupt and overwhelm entire families, community, even nations. The diagnosis of neurasthenia was therefore considered less stigmatic than that of hysteria, and it’s maybe not surprising that officers – who came from upper-class families – were often diagnosed with neurasthenia, whereas soldiers were diagnosed with hysteria, especially when coming from humble backgrounds. 

Patients were initially distinguished in ‘Shell shock (wound)’ when the cause was concussion or commotional shock deriving from a blast, and ‘Shell Shock (sick)’ when the shock was more emotional. Like all wounds, the first case of shell shock warranted a war pension, while in the second case, where the war wasn’t the cause of the sickness, no pension was granted. 
Later in the war, all references to the war were eliminated for fear that soldiers would try to feign sickness and in the attempt to grant a lower number of pensions. By 1917, medical officers were instructed to avoid using the term’ shell shock’ and designated probable cases as ‘Not Yet Diagnosed (Nervous)’.

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Treatments normally addressed the symptoms and were generally ineffective. Only towards the end of the war, some specialised hospital started to use more psychological cures that showed more positive results. 
The ineffectiveness of the treatment was well-known among the soldiers, to the point that, if the symptoms weren’t severe, soldiers often tried to self-medicate. Alcohol and drug were very common methods to treat immediate symptoms. 

Stigma

Because shell shock didn’t show visible wounds, and because its manifestation was often taken for cowardice and a sign of weakness of character, soldiers who suffered from it tried to hide it as best they could. And when they couldn’t, they were often treated like and called cowards. 
Showing signs of shell shock became a stigma that soldiers carried home with them. Shellshocked soldiers were often considered a stain for their family, something to be ashamed of. 

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RESOURCES

Enzo Travero, A ferro e fuoco. La guerra civile europea (1914-1945), Il Mulino, Bologna, 2008

International Encyclopedia of the Frist World War – War Psychiatry and Shell Shock
International Encyclopedia of the Frist World War – Medicine and Medical Service
Smithsonian Magazine – The Shock of War
The Psichologist – Masculinity, trauma and ‘shell-shock’
IWM – Voices of the First World War: Shell Shock
BBC – Shell Shock During World War One
The Conversation – What World War I tought us about PTSD
Psychiatric Tmes – The First World War and the Legacy of Shellshock
Yale University Library Online – Medicine in World War I: the Stress of War

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