This article discusses the question of whether military psychiatry had an impact on the evolution of civil psychiatry. It is based on the case of Belgian soldiers who suffered from nervous and mental diseases during and after the First World War and it is part of a large study on mental cases in the Belgian army.
Before the war
Neuropsychiatry was one of the first specialities acknowledged by the Belgian Army. In the 19th century a neuropsychiatric facility was established in a special hospital in Mechelen. This centre examined soldiers suspected of mental illnesses, and treated nervous and mental cases. It also established medical experts' reports and evaluated new recruits.1 The selection of recruits or volunteers was very rudimentary: a certificate, signed both by the father and a doctor, asserting that the young man did not suffer from mental troubles was sufficient for him to be enlisted.
However, the Belgian alienists, just like their colleagues in other countries, did not underestimate the importance of soldiers' mental health. On the eve of the First World War Frans Meeus, MD, director of the hospital in Geel (where insane patients were placed in host families), for instance was worried about mental health issues in the Belgian Army. He considered that good mental health was important for keeping up both discipline and moral standards in the army. He thought that mentally inadequate and degenerate candidates were to be ejected and that only the best and most solid (strong) brains were to be recruited. Against the backdrop of a recruiting system where all young men from all layers of society were incorporated Dr. Meeus demanded a strict selection. Moreover, modern warfare was becoming increasingly technical, thus requiring more discipline and self-control of the soldiers; but it was also more violent as had become evident during the Boer wars and the Russian-Japanese war. "Most of the cases take place at the end of the war, when exhaustion, deprivation, violent emotions finally overcome the brains of the best constitution; at the beginning only the originally ill-formed brains succumb."
That is the reason why Meeus insisted that all military doctors had to receive psychiatric training in order to be able to make an accurate selection. Even officers should follow such a training, to understand that a soldier might act irresponsibly (or even commit an offense) when under pressure.2 But his opinion was ignored and as we will see the same questions reappeared after the war.
During the war
When the war broke out Belgium had to react to the violation of its territory and was forcibly drawn into a war it had not chosen to wage. The Belgian army and the medical service were not prepared to face war. There was a serious lack of officers, arms, ammunition, and equipment for the newly expanded army which was composed of enlisted citizens. The medical service was heavily reliant on the assistance of the Red Cross to fulfil its duty. Between August and November 1914, the Belgian army had to retreat to the coast, where it installed itself behind the river Yser for four years. The medical service withdrew to Calais, in the north of France. Apart from military doctors, the Belgian army also enrolled many civil alienists. As early as December 1914, the army opened a neuropsychiatric centre in Calais to diagnose and treat Belgian soldiers suffering from mental and nervous illnesses. The director was a civil alienist, Dr. Léon Spaas. A second centre opened in Le Havre in 1916, also directed by a civil alienist, Dr. Michel Vanden Weghe. Other psychiatrists were working in special Belgian hospitals based in France and established in former cloisters. It was indeed not possible to treat psychiatric cases anywhere near the front because in the remaining free Belgian territory there was not sufficient space to establish such a hospital. Some of the most severely affected patients were placed in French psychiatric wards.
The Belgian doctors were thoroughly aware of the pathological impact of the war on the mental and nervous equilibrium of fighting soldiers. They underlined the disastrous consequences of life in the trenches, of excessive fatigue, of repeated shocks, of fear and mourning. The circumstances of war did not make them change their sympathetic attitude towards soldiers. However, some alienists were inclined to favour heredity and predisposition, innate factors (family alienation, debility) or acquired factors (alcohol abuse, infections, fatigue) as determining elements in the appearance or increase of mental illnesses. They considered the war as the triggering element in a latent, pre-existing condition for mental sufferings.
But doctors recognized that for Belgian soldiers the war situation was especially bad due to the separation from their loved ones who lived in occupied Belgium. Any contact between the soldiers and their home was forbidden. Very often a soldier's family ignored the fate of its son or husband during the entire war. They were only informed after the war when the Belgian army returned home. Doctors realized that this complete separation and the soldiers' worries about their families could be a cause for mental troubles.
The separation of Belgian soldiers from their families lasted until the end of the war, when the soldiers finally returned home and joined their loved ones. But the return also meant a reunion of persons with very different war experiences: soldiers returning from the front, and civilians who had endured four years of hard occupation or who came back from exile. They had not been able to share their experiences during the war and did not understand each other. Officially all Belgians had shared the same war experiences, and commemorations as well as monuments were dedicated to soldiers and civilians alike and paid them equal tribute. But in private life, in the intimacy of familial reunion, it was different. A wife who had suffered four years of malnutrition and extreme poverty might not wish to or be able to pay attention to the traumatizing experiences of her husband. Each of them might think that his or her own suffering weighed more heavily.
The wounded and sick soldiers who returned to Belgium were sent to hospitals. The mental and nervous cases were grouped in the new military neuropsychiatric centre that moved to the civil psychiatric ward in Zelzate north of Ghent in March 1919. This military centre was hosted by the congregation of the Brothers of Charity who headed the majority of psychiatric wards in Belgium. Between October and December 1919, these soldiers were demobilized and sent to psychiatric institutions all over Belgium where they were dispersed among other patients like criminals, poor people and those deemed to be incurable.3So the ex-servicemen did not live in special military psychiatric wards and therefore did not receive any specific treatment. However, at international conferences and in press articles some people suggested gathering all soldiers suffering from mental and nervous illnesses in one single institution and where they could be among their comrades and get a specific treatment. But this was never put into practice as the overall aim was to reintegrate patients as quickly as possible into their families and into social life.4
In addition to the sick who were placed in psychiatric institutions, many soldiers returned to their families and tried to resume their pre-war lives. But war was not easy to forget, the reunion with their family turned out to be difficult, and sometimes nervous crises provoked mental breakdowns. In order to help these men recover, the Organization of War Invalids offered its members a one-month stay in the countryside so that they could breathe fresh air and live in rural peace, without material or moral concerns, and remote from busy and exhausting cities.5 Private institutions offering this kind of psychotherapy were spread all over Belgium, but these facilities were quite expensive and did not accept any patients suffering from insanity.6
Unfortunately we do not know much at all about these sick ex-servicemen. Sometimes they became visible and known to the psychiatric apparatus when their behaviour put them in touch with the police and with the psychiatric section of a civilian hospital. This could then be the beginning of a short or long stay in a psychiatric ward where doctors usually did not propose any special treatments for war veterans.
The treatments in use after the war were identical to those applied before the war. There were very few drugs, most of them mere tranquillizers. Some doctors treated their patients by infecting them with malaria (the so-called fever treatment). In order to calm down symptoms of insanity, patients were exposed to long, hot baths; to bed-rest, gymnastics or other physical exercise; to gardening; or to craft workshops. Some of the sick played music or took part in theatre performances. The more restless among them were removed to isolation cells, sometimes under restraint, or received electrical shocks as a punishment, especially when the soldier was suspected of being a malingerer. Conversations with doctors were rare. Usually, the alienist did not have time to observe and study each case properly, or to pay attention to each sick person individually. Often one single alienist had to deal with between 300 to 400 patients. The observation notes preserved in the medical registers were rudimentary, incomplete and betrayed a lack of personal contact between the alienist and his patient.7
Alienists do not seem to have used their specific war-time experiences to invent and perfect new treatments. It rather seems as if they considered war like a mere parenthesis and once war and its specific circumstances were over, they believed that war-related troubles would probably vanish as well. Belgian doctors did not see that new pathologies had arisen from war. They thought that the fundamental character and course of a soldier's psychosis was no different from a civilian's.8 As to the high number of mental cases during the war, they explained them as the ineffective screening of the recruits.
That is the reason why military doctors after the war tried to improve the selection of future soldiers. They were fully aware of the impact of war on health. They found that the physical and mental conditions of young men, called for conscription, left to be desired. They attributed these to poor diet endured during the war, to the increase of alcoholism, to the excessive use of tranquillizers, to the irritability caused by the fears of the war. Finally, the morally and physically exhausted parents had fathered children suffering from "degeneracy."9 That was the reason why military circles stressed the importance of a psychological evaluation of future soldiers. Their war experiences taught them that for recruitment good psychological tests were essential. Contrary to mobilization during the war, they had to perform a severe selection in order to avoid the enlistment of feeble-minded and mental cases. They also pleaded for psychiatrists or at least for doctors familiar with psychiatric issues to attend the recruitment commissions. They recommended that even officers receive some notions of psychiatry.10 Several military doctors pleaded for a better psychological evaluation when recruiting future soldiers and asked for mental tests like the ones applied by the American army in 1917. They hoped that this would help to turn down all mental cases, whom they considered not only useless but even harmful for the army.11 The military doctors dreamed of building an army that would show the health and strength of the nation. But their recommendations were still ignored on the eve of the Second World War. Outside military circles, war no longer seemed to be a preoccupation for Belgian alienists, even the ones who served in military psychiatric wards during the war.
Few Belgian alienists published their experiences and if they did so, they only explained the symptoms and described the different cases, but they never elaborated on their views on mental disorders or suggested new treatments. When one reads specialized reviews (Bulletin de la société de médecine de santé mentale belge; Journal de Neurologie et de psychiatrie) published by psychiatric and neurological societies, or when one refers to the medical files of psychiatric institutions, one is astonished to find no comment whatsoever about the war and its impact on the Belgian population. One should indeed not forget that the civil population had also suffered from violence, deprivation and fear.12 Not one alienist seemed to speak about the trauma of war in Belgian population.13
Even if not clearly expressed, the experience of war nevertheless led to the development of the ideas of eugenics and hygienism in Belgium, just as in other parts of the world. In this context the Ligue nationale belge d'hygiène mentale (the Belgian League for mental hygiene) was founded in December 1922. It aimed to improve both hygiene and mental health in Belgians and to protect them against degeneration. The League gave lectures all over the country, teaching the population the rules of healthy life. But the League never recommended the sterilization of mentally or physically deficient patients to protect the health of the nation. It had a more educational and positive approach: it fought alcoholism and drug addiction, it gave tips to avoid exhaustion and even to build up a good relationship at work.14
Among the members of the League there were many alienists, some of whom were active in the army during the war. Aware of the difficulties experienced by numerous compatriots in life, they noted that mental diseases could improve, even if they didn't recognize a new pathology. To cure these cases, they wanted to multiply the number of new clinics where the patient could be tested and treated without having to be placed in a psychiatric institution. Indeed, the procedure to place a patient was hard (with a police public inquiry) and often shameful for the family. It had to be made possible for non-severe mental cases and curable ones to avoid placement. As Dr. Auguste Ley, alienist in Brussels, said, the war had taught that if the patient was quickly diagnosed and treated, he could be perfectly cured.15But it was not always easy to make a distinction between a mild mental case and an incurable one.
The same went when determining the disability of veterans. The doctors had to determine whether the nervous or mental disorder was the consequence of the war or was due to predisposition and heredity. Doctors saw the war as the triggering element in a latent, pre-existing condition. If the war was not a determining element in the appearance or increase of problems, there was no pension! Indeed, after the war, neuroses became a subject matter for pension commissions and lawyers, rather than for doctors.
In November 1919, a new law allocated a disabled pension for troubles having appeared during or increased by the war. According to the gravity of symptoms, the frequency of crises, and the nature of troubles, the disability percentage could vary between 5 and 80 percent. If the soldier was placed in a psychiatric institution, the percentage was 100. To obtain the recognition of their disabilities, the soldiers had to create a file with their medical certificates and the name of the various hospitals where they were treated during the war. Often they did not remember what happened and did not recall their stories. They also had to appear before a medical commission that had to decide on the reality of the troubles. But recognition was especially difficult for soldiers suffering from nervous and mental crises arisen years after the war. All along the interwar period, invalids tried to improve their pensions, against the will of a Belgian government faced with a disastrous economic situation.
In this troubled interwar atmosphere, among all of the disabled soldiers, the ex-servicemen suffering from mental and nervous disorders were often invisible. Recluses in their families or behind the walls of a psychiatric ward, they had no place in the commemoration celebrations, in the cult of the hero. They had no public image. One could hardly find a picture, a bill, or a drawing of a soldier with post-traumatic disorders. The only ones to care were their fellow-soldiers of the Organization of War Invalids. They watched over them; helped them to defend their rights and receive their pension money; visited them in the institutions; and never forgot them. But for the community, even for the alienists, they seemed to have disappeared.
In spite of the full understanding of the extent of the phenomenon of war neuroses, Belgian psychiatry did not evolve and treatments remained unchanged. After the war hardly any mention was made, even in specialized publications or in the registers of psychiatric wards, of the war and its consequences on the mental state of the Belgian population. This is all the more surprising as both the Belgian soldiers and the Belgian citizens suffered, but neither psychiatrists nor neurologists seemed to take that fact into account. One cannot say that neurologists did not want to see the consequences of war on the mental equilibrium of the Belgian population, but one can hardly find any mention or remark about this problem. It is not clear if this was a deliberate attitude to deny the link or if they were convinced that the war was only a parenthesis. Only the military doctors, with their war experience, pleaded for a better psychological evaluation when recruiting future soldiers.
In Belgium, war trauma and psychiatry never became fashionable. Shell shock and the related disorders never became famous, as was the case in Great Britain (with the parliamentary inquiry) or in France and Austria with large trials against alienists using electric therapy. Belgian literature never even mentioned a shell-shocked hero.