World War I (1914-1918)

Summary

The First World War — fought between 1914 and 1918 across Europe, the Middle East, and beyond — was the first industrialized mass conflict, and its consequences for Western medicine were as sweeping as its casualties. Shell shock forced military psychiatry to acknowledge psychological trauma as a genuine medical problem, not a moral failing, and the debates it provoked drove major developments in psychoanalytic theory. On the Eastern and Balkan fronts, typhus operated as a military force in its own right, killing over 150,000 Serbians before the first winter ended and later devastating Russia on a scale not seen since the Middle Ages. The blockade that cut off British access to German-sourced pharmaceutical herbs triggered an emergency mobilization of botanical resources that left lasting marks on British herbalism. And the war’s vast wound burden accelerated reconstructive surgery in ways that would define the specialty for decades.

Background: Western Medicine in 1914

By 1914, Western medicine had consolidated around the German laboratory model. The Flexner Report of 1910 had restructured American medical education, closing forty-six colleges within ten years and cementing the research-university ideal. (Porter, 1997) Harvey Cushing’s brain surgery mortalities had fallen from roughly forty percent to eight percent by 1915, a reduction that stood as evidence of what meticulous operative technique could achieve. (Porter, 1997) The discipline that would enter the war was confident, perhaps overconfident, in its scientific foundations.

The war also generated an unprecedented organizational achievement in military medicine: integrated, hierarchical medical services with clear chains of command, efficient division of labor between stretcher-bearers, casualty clearing stations, and base hospitals, and standardization of supplies and clinical procedures — a bureaucratic rationalization of battlefield care that transformed the scale on which modern medicine could be delivered under extreme conditions.(Jackson (ed.), 2011)

In psychiatry, the picture was less settled. By 1900 the therapeutic optimism with which the nineteenth century had opened had largely collapsed: asylums filled with incurable patients, and psychiatry had turned increasingly toward the policing of the boundary between sane and insane rather than the treatment of either. (Porter, 1997) Freud’s psychoanalytic movement, meanwhile, had just survived the shattering breakaway of Jung and Adler. When war came in the summer of 1914, the movement’s journals collapsed, its practices dried up, and its correspondence was cut off. “What Jung and Adler left intact of the movement is now perishing in the strife among nations,” Freud wrote. (Makari, George, 2008)

Combat Psychiatry: Shell Shock and War Neurosis

The Crisis and Its Scale

The psychiatric crisis generated by the Western front was without precedent in scope. Soldiers developed bizarre functional symptoms: incongruous paralyses, mutism, deafness, tremors, and overwhelming panic attacks at odds with their proximity to any single shell burst. These were collectively termed “shell shock,” though the name carried an embedded organic hypothesis: that concussive blast waves from exploding shells had produced physical damage to nervous tissue, a claim that would prove contested from the start. (Makari, George, 2008)

The numbers were hard to ignore. Between August and December 1914, 157 cases were recorded. Cases peaked at 16,138 during the second half of 1916, concurrent with the Battle of the Somme. The scale of psychiatric casualties forced the military and medical establishments to reckon with psychological trauma as a mass phenomenon. (German E. Berrios & Roy Porter (eds.), 1995)

Frederick Mott advanced a pathoanatomical theory, arguing that blast waves caused microscopic hemorrhages in the brain. This organic account competed directly with psychological interpretations, and it carried institutional utility: if no visible lesion could be found, no legitimate injury need be acknowledged, and pension claims could be resisted accordingly. (German E. Berrios & Roy Porter (eds.), 1995) Hermann Oppenheim, the leading German neurologist, similarly argued that war neurotics had been somehow physically wounded and should not be returned to combat, a position the military authorities found strategically inconvenient. (Makari, George, 2008)

The British military’s administrative response was characteristic. In 1917 the shell shock diagnosis was officially disallowed, replaced by the bureaucratic designation “Not Yet Diagnosed — Nervous” (NYDN). Suppressing the name did not reduce the cases; it shifted how they were recorded and treated. (German E. Berrios & Roy Porter (eds.), 1995)

The Somme as Turning Point

The cultural meaning of shell shock shifted during the war itself. Before the Battle of the Somme, the condition was framed primarily within a moral order: shell shock was interpreted through the lens of courage and cowardice, and the implicit accusation was one of weakness or malingering. After the Somme — where industrialized slaughter on a scale no individual courage could withstand was simply inescapable — a scientific and medical order of neurosis progressively displaced moral judgment, legitimizing psychological casualty as genuine illness. (German E. Berrios & Roy Porter (eds.), 1995) The condition became, in Michael J. Clark’s formulation, a cultural symbol crystallizing broader anxieties about industrial warfare, masculinity, and the limits of military discipline. (German E. Berrios & Roy Porter (eds.), 1995)

The evidence on malingering, when it was carefully gathered, did not support the accusations. Fairbairn’s clinical assessment, based on WWII experience but tracing a lineage directly from WWI, was that no more than one percent of war neurosis cases reaching hospital could plausibly be regarded as true malingerers. (Fairbairn, W. Ronald D., 1952) The neurotic soldier genuinely suffered; the question was whether his suffering traced to individual psychopathology or to the conditions in which he had been placed.

Psychological Interpretations: Rivers and the British Tradition

W. H. R. Rivers, anthropologist, neurologist, and clinician, had been working at Maghull Military Hospital in the autumn of 1915, investigating what he called “the mental effects of the stress and strain of trench-warfare.” (Rivers, W. H. R., 1924) He would subsequently treat officers at Craiglockhart War Hospital, among them Siegfried Sassoon. Rivers worked from a modified Freudian framework but reached his own clinical conclusions. The war neuroses, he argued in a lecture delivered in 1919, demonstrated on an enormous scale that most functional nervous disorders depended on purely mental rather than physical causes. (Rivers, W. H. R., 1924) Where he departed from orthodox Freudianism was in the mechanism: the war neuroses, he contended, lent no support to the exclusively sexual origin of neurosis. What was suppressed in these cases was the self-preservation instinct under unbearable conditions, not libido. (Rivers, W. H. R., 1924)

Rivers identified three principal agencies in effective psychotherapy: self-knowledge (autognosis), self-reliance, and suggestion. Repressed painful experience, he argued, did not cease to exist when suppressed: it produced distressing dreams and other symptoms as its most direct consequences. The therapeutic task was to help the patient face what he had suppressed rather than avoid it. (Rivers, W. H. R., 1924) This was the clinical position that later generations, reading the war neuroses backward from PTSD, would recognize as a precursor to trauma-focused approaches.

Psychoanalysis and the War Neuroses

In the German-Austrian sphere, the shell shock crisis opened an unexpected door for Freudian psychoanalysis. Ernst Simmel, director of a military hospital at Posen, treated approximately two thousand war neurotics using a combination of hypnosis, dream analysis, and catharsis. His method was pragmatic rather than theoretically orthodox, but it worked, and by 1918 Freud wrote excitedly to Ferenczi: “German war medicine has taken the bait.” (Makari, George, 2008)

Simmel’s Budapest findings, reported at the Fifth International Psychoanalytic Congress in September 1918, had an unexpected theoretical consequence. The dreams of his war neurotic patients were not wish-fulfillments in the Freudian sense but repetitive, failed attempts at catharsis: nightmares that replayed traumatic experience without resolution. This observation contradicted Freud’s pleasure principle directly and planted the seed that would grow into Beyond the Pleasure Principle (1920). (Makari, George, 2008)

The Budapest Congress itself was an extraordinary moment. Official representatives of the German, Austrian, and Hungarian governments attended, and the Prussian War Ministry and Budapest Military Council promised to establish psychoanalytic treatment stations in the field. Then, before a single clinic could be opened, the Central Powers collapsed. (Makari, George, 2008)

The war had also forced Freud to confront the problem of human aggression at a scale his pre-war theory could not absorb. His earlier accounts had subsumed aggression under sexuality, linking it to sadism and the Oedipus complex, but by 1918 this was untenable. (Makari, George, 2008) Wilhelm Stekel had long argued, and Freud now reluctantly began to credit, that the bond between men might be hatred rather than love, that Eros and Thanatos were genuinely paired. (Makari, George, 2008) This reconsideration would eventually produce the structural revision of psychoanalytic theory in Beyond the Pleasure Principle and The Ego and the Id.

The Lineage toward PTSD

The clinical history traced by Merskey and colleagues identifies a continuous thread from railway spine (Erichsen, 1866) through shell shock to the concentration camp syndrome of World War II and the Vietnam-era codification of post-traumatic stress disorder. The three core themes remain constant across these contexts: the causal relationship between a traumatic event and subsequent symptoms; common patterns of anxiety and involuntary reliving; and far-reaching, slowly emerging effects. (German E. Berrios & Roy Porter (eds.), 1995) Shell shock did not create this lineage, but it gave it its first truly mass expression, and Merskey argues that the condition did more than Freud’s clinical writings to drive the popular acceptance of psychological medicine in British culture. (German E. Berrios & Roy Porter (eds.), 1995)

Fairbairn’s object-relations analysis, developed from WWII military work, extended the theoretical account in a direction that had been implicit in the war neuroses since 1914. The starting point was an observation that would have surprised neither Rivers nor Simmel: war neuroses had no distinctive symptomatology differentiating them from peacetime psychoneuroses. What was distinctive was not the form of breakdown but the precipitating condition: military service activated pre-existing, latent psychopathological factors rather than producing disorders from nothing. (Fairbairn, W. Ronald D., 1952) Fairbairn identified separation-anxiety as the universal and only invariably present symptom in war neurosis: the soldier became ill because he craved to go home, not the reverse. (Fairbairn, W. Ronald D., 1952) War neurosis, in this account, was not simply a disorder of individual soldiers: it was systematically linked to unit morale. The incidence of breakdown within military units varied inversely with morale: the more cohesive the group, the less the incidence of breakdown. This meant the problem was fundamentally social rather than individual. (Fairbairn, W. Ronald D., 1952) Germany’s collapse in 1918 illustrated the inverse proposition: when a state’s capacity to provide security gave out, the individual’s infantile attachments revived en masse, producing the breakdown of morale that Fairbairn characterized as collective separation anxiety. (Fairbairn, W. Ronald D., 1952)

Disease on the Fronts: Typhus and the Eastern Theater

The Western front, despite the universal lousiness of trench soldiers, was free of typhus throughout the war. Both sides knew what typhus could do, and both maintained effective delousing measures. The Central Powers in particular took the utmost precautions against introducing the disease with troops transferred from the East, recognizing that a typhus epidemic would lose them the war. (Zinsser, 1935)

The Eastern and Balkan fronts told a different story. Serbia experienced one of the worst typhus outbreaks in recorded history during the first winter of the war. The country had fewer than four hundred doctors, and the disease moved through them as it moved through the army: 126 physicians died. In less than six months, over 150,000 people died of typhus, and the epidemic held the Austrian border at the most critical early phase of the campaign. Zinsser, writing in 1935, argued that the epidemic’s military effect was decisive: typhus, not military resistance, held the Austrian advance. (Zinsser, 1935)

Russia experienced the disease on a medieval scale. Tarassewitch’s careful calculations suggested no fewer than 25 million cases with 2.5 to 3 million deaths in Soviet-controlled territory between 1917 and 1921, making this post-war epidemic one of the largest typhus catastrophes in recorded history. (Zinsser, 1935) The only official relationship between Russia and the rest of Europe during the most turbulent phase of the Revolution was the exchange of epidemic disease information, coordinated through the League of Nations Health Commission — a striking reminder that disease surveillance could persist where diplomacy had entirely failed. (Zinsser, 1935)

The Western front’s typhus-free status was itself a scientific achievement, made possible by Charles Nicolle’s 1909 discovery of louse-borne transmission. Nicolle’s work had given military medical authorities their first rational basis for a planned defense: if lice were the vector, systematic delousing was the intervention. The principle held. (Zinsser, 1935)

The Botanical Pharmacopoeia Under Blockade

The war exposed a structural vulnerability in British pharmaceutical supply that almost no one had anticipated: England was almost entirely dependent on German-sourced herbs for mainstream pharmaceutical production. Not only were British pharmaceutical firms reliant on German-grown herbs; they purchased through German suppliers herbs that originated from other parts of the world. The blockade closed this supply simultaneously. (Stapley, 2012)

Within two months of the outbreak of war in August 1914, the Board of Agriculture and Fisheries issued a leaflet on The Cultivation and Collection of Medicinal Plants in England, addressed not to herbalists or druggists but to the general public. (Stapley, 2012) The herbalist community was already positioned to respond. Maud Grieve had established the Whins Medicinal and Commercial Herb School and Farm at Chalfont St Peter in 1905; during the war she published pamphlets on the cultivation of specific herbs required by pharmacies now cut off from their German suppliers. (Stapley, 2012)

The supply gaps were specific and technically demanding. Belladonna had come primarily from Germany, with one grower there exporting 30,000 pounds annually to England. British belladonna, when cultivated, was found to yield more atropine than the German variety, but belladonna could not be harvested until the fourth year of growth, so the shortage would persist for years regardless of immediate efforts. (Stapley, 2024) By 1916, Continental supplies of foxglove leaves had ceased entirely; Ada Teetgen documented that foxglove, properly dried, could retain its colour and biological activity for eleven years, and demonstrated viable techniques for British cultivation. (Stapley, 2012)

The most practically successful improvisation was sphagnum moss as a wound dressing. The moss, used in folk medicine as what Griggs calls “the peasant’s bandage” for centuries, absorbs twenty to twenty-two times its own weight in liquid, making it superior to cotton wool in absorptive capacity. Gertrude Jekyll organized gardeners to grow Calendula and shipped the herb to France for men in the trenches; moss was gathered from Scotland, Wales, and the Lake District, and the Duke of Atholl lent shooting-lodges to accommodate gatherers in Perthshire, with Presbyterian ministers exhorting their congregations to gather on the Sabbath. (Stapley, 2024) By the end of the war, up to a million dressings per month were being sent to military hospitals. (Stapley, 2012) Garlic found similar wartime validation: it was widely used at front-line casualty stations as an antiseptic dressing for suppurating wounds, and in 1916 the government requested tons of bulbs at one shilling per pound, a high price reflecting genuine demand. (Griggs, 1981)

The herbal pharmacy crisis had institutional consequences that extended beyond the war itself. The wartime pamphlets produced by Maud Grieve formed the core of what would become, with Hilda Leyel’s editorial work, A Modern Herbal (1931), the twentieth century’s most influential English-language reference on botanical medicine. (Stapley, 2012) The war had also demonstrated that Britain’s pharmacological dependency on Germany was structural, not incidental. The pharmaceutical consequences fell differently across traditions: under the 1917 Trading with the Enemy Act, German patents for barbital, novocaine, and arsphenamine were transferred to American companies to exploit, effectively seeding the American synthetic pharmaceutical industry. (Griggs, 1981)

The herbalist professional community itself had been on the verge of concrete advances before 1914: by 1907 the National Association had published a directory of 152 members, and registration legislation seemed within reach. The war interrupted that momentum. (Stapley, 2024) Ada Teetgen captured the wartime paradox of the herbalist trade in 1916: herbalists flourished in the northern country districts, consulted by many, yet “few people except the Society of Apothecaries, the wholesale herb dealers, and their own particular clients, seem to know much about present-day herbalists.” (Stapley, 2024) Botanical practitioners had no recognized professional standing, and the war, despite validating the practical utility of herbal materials, did not change that.

The National Association of Medical Herbalists protested in 1917 that the allopathic Salvarsan treatment for syphilis was producing lethal side-effects: jaundice, kidney disease, optic atrophy, anaphylactic shock, and severe arsenical dermatitis; while its members had treated syphilitic cases successfully for fifty years, “in hundreds of cases after the Registered Practitioners had failed to cure.” (Griggs, 1981) The protest was the kind of institutional counter-claim that wartime conditions made easier to articulate; it was no more successful in changing policy than its peacetime predecessors.

Surgery and the Wound Burden

The war’s surgical legacy was shaped by the volume and character of its wounds. Gas gangrene in the anaerobic environment of shell craters and trenches posed challenges that antiseptic protocols developed for clean hospital surgery did not adequately address. Harvey Cushing, whose brain surgery mortality had already fallen from forty percent to eight percent by 1915, continued his clinical development in France, bringing neurosurgical technique to bear on the wounds produced by modern artillery. (Porter, 1997)

Critiques of the prevailing wound treatment circulated from outside orthodoxy. Writing in 1918 as the war was drawing to a close, Henry Lindlahr claimed that in seventeen years of practice he had treated severe wounds — including cases that had progressed to necrosis under antiseptic management — by exposing them freely to air and light and washing them with diluted lemon juice, without antiseptics of any kind.(Lindlahr, Henry, 1918) Lindlahr’s position was that antiseptic agents suppressed the natural inflammatory response that the body used to clean and repair wounded tissue, and that fresh air and sunlight activated the body’s own healing forces more effectively. This critique was eccentric relative to the surgical consensus that Lister’s antiseptic revolution had established, but it found a wartime audience among Nature Cure practitioners who had developed their own wound-treatment protocols over the preceding decades.

Institutional Consequences

The war did not merely consume existing medical resources; it reorganized institutional priorities in ways that persisted for decades. In psychiatry, Merskey’s account is blunt: shell shock did more than Freud’s writings to drive the acceptance of psychological medicine in British culture. (German E. Berrios & Roy Porter (eds.), 1995) The sheer scale of psychiatric casualties, and the cultural visibility of officers breaking down in conditions that could not be dismissed as cowardice, legitimized psychological medicine as a field with something to offer beyond the asylum.

In pharmacology, the war demonstrated that the German domination of synthetic pharmaceutical production was not merely a market convenience but a strategic vulnerability. The transfer of German patents to American firms under the Trading with the Enemy Act accelerated the development of an independent American pharmaceutical industry organized around synthetic chemistry rather than botanical sources. (Griggs, 1981) This shift would, within two decades, produce the consolidation that Morris Fishbein could celebrate at the Journal of the American Medical Association: that “the great deluge of modern scientific chemotherapy is about to wash away the plant and vegetable debris.” (Griggs, 1981)

In public health, the contrast between the typhus-free Western front and the catastrophic Eastern and Balkan epidemics illustrated, as starkly as any controlled experiment, what organized delousing could accomplish once the vector was known. The League of Nations Health Commission’s role in coordinating typhus surveillance through the Russian Revolution demonstrated that epidemic disease control could create functional international cooperation even when every other diplomatic channel had collapsed. (Zinsser, 1935)

Colonial troops served on the Western front alongside European forces, and French military psychiatrists’ response to psychiatric casualties among North and West African recruits was organized by a racial framework that attributed homesickness and psychological breakdown to congenital “idiocy,” which hereditary racial theory took for granted in African people. (Thomas Dodman, 2018) This intersection of war psychiatry with colonial medicine passed without comment among contemporaries and has received belated critical attention from historians.

See Also

• w-h-r-rivers (Craiglockhart, war neuroses treatment, 1915-1919)
• sigmund-freud (wartime theoretical productivity, Beyond the Pleasure Principle)
• shell-shock (clinical history of the condition and its diagnostic contested status)
• typhus (Zinsser’s account of the disease as historical force)
• maud-grieve (wartime botanical mobilization, A Modern Herbal)
• black-death (comparative mass casualty and epidemic context)
• flexner-report-1910 (pre-war reorganization of American medical education)
• world-war-ii (subsequent conflict; many of these themes continued and intensified)
• hungarian-congress-1918 (Budapest Psychoanalytic Congress)
• post-traumatic-stress-disorder (the eventual diagnostic category this period fed into)

Sources

• Makari, George. (2008). Revolution in Mind: The Creation of Psychoanalysis. HarperCollins. (source_id: makari-revolutioninmind-2008)
• Fairbairn, W. R. D. (1952). Psychoanalytic Studies of the Personality. Tavistock. (source_id: fairbairn-psychoanalytic-studies-1952)
• Rivers, W. H. R. (1924). Medicine, Magic and Religion. Kegan Paul, Trench, Trubner. (source_id: rivers-medicine-magic-religion-1924)
• Berrios, G. E. and Porter, Roy, eds. (1995). A History of Clinical Psychiatry. Athlone Press. (source_id: berrios-porter-historyclinicalpsychiatry-1995)
• Dodman, Thomas. (2018). What Nostalgia Was: War, Empire, and the Time of a Deadly Emotion. University of Chicago Press. (source_id: dodman-whatnostalgiawas-2018)
• Stapley, Julie. (2012). A History of Plant Medicine: Western Herbs from BCE to the Present. Aeon Books. (source_id: stapley-history-of-plant-2012)
• Stapley, Julie. (2024). A History of Plant Medicine: Western Herbs from BCE to the Present. 2nd ed. (source_id: stapley-history-of-plant-2024)
• Griggs, Barbara. (1981). Green Pharmacy: A History of Herbal Medicine. Jill Norman and Hobhouse. (source_id: griggs-green-pharmacy-1981)
• Zinsser, Hans. (1935). Rats, Lice and History. Little, Brown. (source_id: zinsser-rats-lice-history-1935)
• Porter, Roy. (1997). The Greatest Benefit to Mankind: A Medical History of Humanity. W. W. Norton. (source_id: porter-greatestbenefit-1997)

Editorial Notes

Gaps the encyclopaedia compiler flagged for future evidence work, collected from inline markers in the body and frontmatter.

Disease on the Fronts: Typhus and the Eastern Theater

Surgery and the Wound Burden