Jump to content
Free downloads from TNA ×
The Great War (1914-1918) Forum

Remembered Today:

Neurasthenia and Shell Shock


Robert Dunlop

Recommended Posts

Thanks very much for the references, Martin. Your point about the importance of attitudes is well made. So is the point about delays in knowledge acquisition. This is still a problem today. The purpose of this thread is not to denigrate these factors in any way. It is merely to establish what the potential knowledge base was at the time. Thanks again for your efforts, especially around shell shock.

Robert

Link to comment
Share on other sites

The purpose of this thread is merely to establish what the potential knowledge base was at the time.

And, possibly, what the actual knowledge base was among those making the diagnoses? Although specialist doctors would be au fait with the latest theory and practice, should we bear in mind that, in battalions, CCSs and perhaps FGHs, that specialist knowledge of neurologists and psychiatrists might not be available? Much depends on the level of specialization at which a typical shell shocked man could expect diagnosis and treatment.

Link to comment
Share on other sites

Phil, this type of analysis should come later, IMHO. Firstly, we may find that there was a spectrum of expert and other opinions. Second, it is extraordinarily difficult to understand what knowledge and other factors were in play for a particular situation. Recently, for example, a study was conducted to assess the levels of expertise in pain management. Cancer specialists came out top in their understanding of the use of morphine and other opioid painkillers. When the performance of this specialist group was studied, some interesting facts emerged. Women, patients from minority ethnic groups, and older patients were much more likely to have poorly controlled pain.

So the focus should be on the knowledge base first and foremost. What was available to be known in the period leading up to and during the war?

Robert

Link to comment
Share on other sites

8. Anon Madness in Armies in the Field BMJ 1904 Vol 2
This article was published in the July 2 edition of the 1904 BMJ. The essence is captured in these two quotes:

"Dr Paul Jacoby... strongly urges the necessity of a special psychiatric service for soldiers on campaign. ...if arrangements could be made for the immediate treatment of insane soldiers in separate tents under special care they would have a good chance of recovery."

There is mention of something akin to shell shock:

"Dr Jacoby compares the sinking of ironclads by the explosion of torpedoes and mines to earthquakes and volcanic eruptions which, it is well known, are accountable for much mental disorder."

Robert

Link to comment
Share on other sites

Neuroses and Psychoses of War by Turner W A , text of the Bradshaw Lecture, Royal College of Physicians 7 July 1918, the Lancet 9 Nov 1918 p 617
This is an interesting paper. The lecture began with a review of 'neuroses and psychoses' in soldiers undergoing training:

"In more recent times, under compulsory service, many men have entered the army who are constitutionally and by upbringing and education unable to adjust their outlook to service conditions. In other words, the young soldier becomes neurasthenic owing to a failure of adaptation to a continued emotional cause... This failure may take the form of either a nervous or a mental disability.

In the neurasthenic type the symptoms are those well known in the neurasthenia of civil life - fatiguability, digestive disturbances, vague myalgic pains, and hypochondriacal feelings. This is a nervous reaction to camp life, and is frequently accompanied by fears and dreads in anticipation of what may happen when the soldier proceeds on active service, such as death or serious incapacitating wounds."

Turner then discusses the "pyschoses" that occured during wartime. He noted that at least 10% of men admitted to military mental hospitals in the UK from overseas had "had a previous attack of uncertified insanity".

Turner continues his metaphorical walk "through the wards". The next "class of case" presented "very definite objective signs, such as we are accustomed to see more commonly in the neurological hospitals at home. Probably the biggest class would show speech defects, such as mutism, deaf-mutism, aphonia and stuttering. Others would present diverse types of tremors and tic-like movements. We would see various forms of paralysis, especially of the lower limbs, with disturbances of gait... Examination would reveal the fact that these symptoms were of a functional or hysterical character, and that many of the patients had been admitted to hospital in a state of stupor following a shell explosion or burial."

Robert

Link to comment
Share on other sites

The next section of Turner's presentation is entitled 'Stupor, Delirium and Amnesia'. He starts with a description of "the cases in the next group...', describing them as the 'especially interesting, as they demonstrate what may be regarded as the most acute expression of psychoneurotic symptoms, due to fear, horror, and profound emotional or commotional causes. Stupor and delirium are the outstanding features. The symptoms of the stupor type are quite distinctive. In the more severe cases the patient is entirely unconscious of his surroundings; he lies motionless in bed and makes no reply to questions; his eyes show no recognition of what is before them... A close examination reveals in many cases some rigidity of the limbs of the catatonic type. The deep reflexes may be normal or exaggerated [suggesting a malfunction in the brain or higher levels of the spinal cord]; the pupil light reflex may be impaired or lost [suggesting damage in the brain stem or brain]; the plantar response may be flexor [normal] or abolished [indeterminant significance, except this finding cannot be faked by a patient]. Urine may be passed normally, or catherisation [sic] may be necessary for a day or two. Swallowing is effected usually without difficulty.

In milder cases stupor is less profound. The patients may carry out simple actions, but in a slow and hesitating way. They present a dazed or confused appearance, are startled easily, and take little or no notice of what is going on around them.

In the other type the delirium is accompanied by gestures. These patients would appear to be living as in a dream through a recent terrifying experience. When information has been obtained as to the onset of the symptoms it has been found to be connected with psychical shock, such as the mutilation or burial of a comrade or friend in a shell explosion.

With the disappearance of the stupor [which may last a few hours to several days] the soldier may find that he is mute, deaf, paralysed, or unable to walk without assistance, the subject of a tremor, or, very commonly, the victim of an anxiety condition in which intense headache, battle dreams, insomnia, vertigo, lack of mental concentration, and fatigue are prominent symptoms. The memory for the stupor period and probably also for some days antecedent to it is obliterated.

The majority of cases of stupor and delirium are examples of psychoneurotic mental states, attributable to fear and horror, but phenomena essentially identical to them may be found in men who have been exposed to a cerebral concussion or commotion."

Robert

Link to comment
Share on other sites

...a spectrum of expert and other opinions.
Phil, Turner's lecture goes on to illustrate this very point. I have quoted his description of men who presented with various degrees of stupor or delirium. Turner categorised this group as 'being examples of psychoneurotic states', which condition he differentiated from concussion injuries:

"At all times there may be a difficulty in the differential diagnosis of the concussion from the so-called emotional cases, but such diagnosis is more easily effected the earlier a patient is brought under observation. A careful examination of men who have been exposed to the effects of shell or mine explosion or who have been buried and are suffering from loss of consciousness, stupor, mental confusion, delirium, or paralysis would in some instances reveal the physical signs of minor structural lesions of the brain or spinal cord."

It would seem as if there were two schools of diagnosis, at least in Turner's mind: concussion associated with signs of damage to the nervous system; or 'psychoneurotic states' where such evidence was lacking. But the problem of medical interpretation was even more interesting. Turner goes on to note:

"In some writings of the earlier observers on this subject, and in some at the present time, there is a tendency to attribute some of the phenomena of shell shock and the war neuroses to physical causes, such as concussion, fatigue [note that this is a characteristic symptom of 'neurasthenia'], or gas-poisoning, and perhaps to ignore, or at all events under-estimate, the influence of the psychical factor. A school of French neurologists in particular has laid stress upon the importance of 'cerebral commotion' in the causation of the psychoneuroses of war [note the mention of French neurologists, who had a very high reputation for neurology. It also shows the cross-national transfer of medical knowledge].

The modern school of psycho-pathologists, on the other hand, may incline too much in the contrary direction, and claim all the symptoms of the war neuroses to be of psycho-genetic origin. This school maintains that the neuroses of war arise from an inability on the part of the soldier to react to his environment; in other words, they are brought about by a failure of psychological adaptation and to the repression of one of the conflicting emotions which arise therefrom."

Here we see a clear distinction being made between the body versus the mind schools of causality. We must bear in mind that this is Turner's perception of the dicotomy in opinion. Perhaps it will be possible to examine this in more detail as the thread progresses, drawing in evidence from other contemporaneous sources that supports (or refutes) Turner's view. Assuming he is correct, however, then we must face the conclusion that clinicians could 'justify' one of two diammetrically opposed views of 'shell shock'. Both views were promulgated by experts in their respective fields. This situation is not uncommon in medicine.

Robert

Link to comment
Share on other sites

Hi Robert - the comments in my last post were not meant to be a criticism in any way smile.gif. It is an admirable approach and I understand what you are trying to achieve. I think the MODS should consider a Medical SubSection on the Forum.

There are many more references I could post, many of them are TNA sources referred to in the text of Harrison's Book and also in Blindfold and Alone, but much of it touches on the attitudes towards mental patients with regards to care and pensions etc rather than a clinical understanding of their condition. There is lots on early binary concepts that one was sane or 'insane' with no (early) idea that 'sane' people could become afflicted. Also it seems that what we understand as a psychiatrist is very different from one in 1914; a medical superintendent in charge of a lunatic asylum. What was known, what was available in print and what was adopted by the RAMC are all different things it would seem. Edit: I would imagine all military knowledge would have found its way into the Journal of the Royal Army Medical Corps which was founded in 1903.

The Chapter in Blindfold and Alone on Mental Health in Britain is very interesting and well researched, going into very fine definitions at the time (1914). There was no differentiation between mental deficiency and mental disease, similarly no distinction between acutely insane and the chronically insane. It also explores the Mental Deficiency Act of 1913 (not repealed until 1950) and the Royal Commission which looked into mental health in the early 1900s. It also touches on GPI (General Paralysis of the Insane) the name then given to tertiary syphilis., suggesting 10% of asylum inhabitants had this condition in 1914 - just to give an idea of the lack of understanding. It touches on 1916 clinical definitions by J Rogues de Fursac on 'constitutional neuropaths' 'moral insanity' , 'weakness of judgement', 'absence of perseverence' and 'impulsiveness'. Earlier pioneering work by William White in his Outlines of Psychiatry (1909) seem to be the earliest attempts to provide robust definitions, classical groupings. He established detailed protocol for the examination of a patient with 'insanity' and includes a chapter on psychoneuroses and discusses Neurasthenia, describing it as 'constitutional, or acquired by exhausting or debilitating conditions'... It also explains how in 1914 there was no differentiation between neurology, neurophysiology and psychiatry and concludes that (1914) British society equated mental illness with lunacy, so shell-shock victims had little sympathy and it took many years for these attitudes to change. Attitudes in Europe and America were more advanced. It does not give any indication the extent to which 'available' knowledge was harnesses by the British Military Medical authorities. Implicitly the work of Charles S Myers appears to have had greatest influence in Britain. He was mentored by the aptly named Henry Head, the neurologist at Cambridge. http://en.wikipedia....wiki/Henry_Head (usual Wiki caveats apply).

So there is a host of material on public 'attitudes' for want of a better word rather than articles or lectures on the clinical (medical) understanding of the affliction. I think I understand that you are after the clinical knowledge base. Interestingly the British still have different attitudes to the Americans on the subject of mental health. I spent the last 18 months living in NY where New Yorkers talked freely about their therapist (they all seem to have them). Something I still can't quite imagine happening at a British dinner party.

Any mistakes are mine. MG

Link to comment
Share on other sites

This is an interesting paper. The lecture began with a review of 'neuroses and psychoses' in soldiers undergoing training:

"In more recent times, under compulsory service, many men have entered the army who are constitutionally and by upbringing and education unable to adjust their outlook to service conditions. In other words, the young soldier becomes neurasthenic owing to a failure of adaptation to a continued emotional cause... This failure may take the form of either a nervous or a mental disability.

Robert

It seems to imply that conscripts had different susceptibilities to mental disability than volunteers and that ubringing and education (read Class) was a factor too. I would be amazed if there was any clinical evidence to support this view. An interesting concept on 9th Nov 1918 when conscription had been in place for 2 years and the end of the War in France was only 2 days away. It perhaps illustrates how little these issues were understood even after 4 years of War. MG

Link to comment
Share on other sites

No one who has met or seen a sufferer from shell shock would ever try to minimise the personal impact on the man and his family. That said, I think that there is a case to be made for considering the attention paid to shell shock as disproportionate. The number of casualties who were diagnosed with some form of shell shock was very small when compared to other classes of casualty. Gun shot wounds, injuries from artillery, even trench foot afflicted a lot more men and accounted for the vast majority of casualties. The long lists of references underline the fact that shell shock received more attention than a strict proportionality would lead us to expect.

Link to comment
Share on other sites

No one who has met or seen a sufferer from shell shock would ever try to minimise the personal impact on the man and his family. That said, I think that there is a case to be made for considering the attention paid to shell shock as disproportionate. The number of casualties who were diagnosed with some form of shell shock was very small when compared to other classes of casualty. Gun shot wounds, injuries from artillery, even trench foot afflicted a lot more men and accounted for the vast majority of casualties. The long lists of references underline the fact that shell shock received more attention than a strict proportionality would lead us to expect.

See earlier post No.20

Link to comment
Share on other sites

Martin, I did not perceive your comments as a criticism in any way. The clinical focus is important but 'clinical' is not restricted to the organic. Psychological considerations were very important.

Your point about experiences in New York is interesting. The concept of neurasthenia was first promulgated by a physician working in New York. He was a neurologist, however, not a psychiatrist.

Robert

Link to comment
Share on other sites

It seems to imply that conscripts had different susceptibilities to mental disability than volunteers and that ubringing and education (read Class) was a factor too.
It might imply this. Then again, it might imply that Turner only ever observed conscripts being trained.

Robert

Link to comment
Share on other sites

It might imply this. Then again, it might imply that Turner only ever observed conscripts being trained.

Robert

And it might also imply that by 1916 they were more adept at spotting potentially vulnerable people as their knowledge grew...... and by the middle of 1916 the recruits were all technically conscripts whether they would have volunteered or not...

Link to comment
Share on other sites

See earlier post No.20

Exactly my point. In terms of overall casualties, shell shock would only warrant an article or two in Lancet. Quite a few of the old soldiers I knew were very sceptical about its extent. If the men who shared the experiences of the genuine sufferers were sceptical, who could blame the MOs ? Incidentally, I made the acquaintance of a man who was still afflicted with incapacitating tremors some 40 years after the war and it was his comrades who cast doubt on how wide spread the actual occurrences were. From a medical point of view, it was a serious problem and has proved intractable up to the present day. Militarily, it was of very little significance. It made medical and military sense to concentrate on problems which could be treated successfully.

Link to comment
Share on other sites

Exactly my point. In terms of overall casualties, shell shock would only warrant an article or two in Lancet. Quite a few of the old soldiers I knew were very sceptical about its extent. If the men who shared the experiences of the genuine sufferers were sceptical, who could blame the MOs ? Incidentally, I made the acquaintance of a man who was still afflicted with incapacitating tremors some 40 years after the war and it was his comrades who cast doubt on how wide spread the actual occurrences were. From a medical point of view, it was a serious problem and has proved intractable up to the present day. Militarily, it was of very little significance. It made medical and military sense to concentrate on problems which could be treated successfully.

From what I have read the statistics from the US Civil War, the South African Campaigns, the British, German, and French experiences in WWI are of the same order of magnitude - low single-digit per cent. The reasons it attracts a 'disproportionate' interest are manifold. I think your point that it has been intractable is one of them. It is easy to understand the causes of trench foot and provide a medical solution. It has not been as easy to fathom the precise causes of shell shock and neurasthenia and less easy to provide cures. While we understand more than we did in 1914, there remains an enormous gap in our knowledge and understanding of mental illnesses. This will naturally draw interest from the specialists.

Much of the medical knowledge in 1914-1918 seems to have been aimed at identifying the problem earlier and preventing it from becoming worse (and preventing 'contagion'), rather than attempts to 'cure'. Lord Moran's articles on morale and the bank account of courage address this point well. His book was in my day (1980s) still required reading at Sandhurst.

Your point on concentrating on what could be treated successfully has to be a major factor too. I do not know what 'success' rates for curing shell-shock were (I am guessing very low single digit %) and how many men returned to the field (even lower), but the long recovery period and the fragility of the patients would have consumed a disproportionate amount of limited medical resources. Success rates would also have had high uncertainty and a low predictability. So stretched were the medical facilities in 1915, than men loaded onto hospital ships in the Dardanelles often had no medical attention throughout their voyages home. Prioritising resources towards this type of 'easy fix' was probably a better policy however brutal that may sound. The stats for survival rates of battle casualties and non battle casualties suggest to me that the authorities had their priorities right; for British troops in France and Flanders (1914-1918) only 7.61% of battle casualties died after being admitted to medical units and 0.91% of men admitted with disease died*. These strike me as being remarkably low death rates and a testament to the RAMC.

Any mistakes are mine. MG

* Source: History of the Great War - Medical Services : Casualties and Medical Statistics of the War by Mitchell and Smith

Link to comment
Share on other sites

A school of French neurologists in particular has laid stress upon the importance of 'cerebral commotion' in the causation of the psychoneuroses of war...
I have tracked down a copy of Roussy and Lhermitte's work in English translation (thanks in no small part to Mike). Interestingly, the concept of 'cerebral commotion' is, IMHO, a mistranslation of commoti cerebri. This can be translated as 'cerebral concussion' or 'cerebral disturbance'. More significant, however, is the fact that Turner has somewhat misrepresented the 'school of French neurologists'. Their work makes fascinating reading. It is also well illustrated. Roussy and Lhermitte are both famous in their own right, but the book is a veritable Who's Who of French neurologists in what was the golden age for this specialty in that country. Names like Babinski and Guillain crop up throughout the book.

I will try and condense the material, providing the translations for the medical aspects so that it may be more understandable to all Pals. Neurology is still one of the most technical of medical specialties. This makes it difficult to appreciate fully what they studied and what their conclusions were if you are not familiar with the field.

Robert

Link to comment
Share on other sites

As a preliminary step, I have looked back into medical literature before WW1.

One approach was to look at articles on the effects of any trauma on the brain. In 1904, for example, a neurologist named Judson published a paper entitled 'Trauma in Relation to Disease of the Nervous System':

"Concussion of the brain... may follow a shaking or concussion of the intracranial contents as produced by a blow or a fall on the head. The anatomical effects of such concussion are manifold; they may be slight and temporary, as when limited to a sudden displacement of the cerebro-spinal fluid [the clear fluid surrounding the brain and spinal cord] with ensuing or concomitant changes in the quantity of blood in the cerebral vessels, or they may be severe and more or less permanent and demonstrable at necropsies. Such conspicuous pathological results may be classified as follows: haemorrhage... inflammatory changes... laceration of the brain... new growths..."

Judson noted "The symptoms and results of these various lesions are to be found in the textbooks, and it would be out of place to attempt their systematic description [in my lecture] to-night. My object is rather to bring before you types of cases which have impressed me as of great practical importance, and especially those which illustrate some of the later effects of head injuries."

He presented a series of cases. The most pertinent case related to 'traumatic neurasthenia':

"The symptoms of typical neurasthenia, whether the result of trauma, of prolonged mental strain, or of other causes, are well known, and constitute a clinical condition which as a rule is readily diagnosed. In all probability the condition depends on molecular changes in certain groups of cortical cells, changes which are closely allied to those which have been shown to follow great fatigue or prolonged experimental stimulation."

Note that Judson believed the cause of neurasthenia to be organic, not functional. He explores this further:

"I will omit all reference to the diagnosis of malingering, to traumatic hysteria, and to the transient forms of neurasthenia which, even apart from bodily injury are met with after railway accidents, as results partly of tie terror or horror incident to the catastrophe, and partly of the mental anxiety associated with litigation. This, together with repeated medical examinations and suggestions from friends and lawyers, leads the patient to conscious or unconscious exaggeration of his symptoms, and frequently to the simulation of serious disease.

Passing now to more permanent forms of neurasthenia, it is, I think, open to question whether they have yet received adequate recognition. I allude to cases which, whether the result of railway or other accidents involving compensation for damages received do not recover after the cessation of legal irritation, and after claims for loss of work and health have been duly met.

Two groups may be distinguished. The one group comprises cases which clinically closely resemble those of nontraumatic neurasthenia. As a rule, there is inherited predisposition to neurosis - that is, the intimate structure of the cortical [higher brain] centres is easily deranged, and molecular changes started by head injuries tend to pathological increase, while the chemical products of cell disintegration may set up sclerosis [scarring] of the surrounding tissue.

I have said that clinically these cases resemble those of ordinary neurasthenia. No doubt this is so at first; but as time goes on the tendency to exaggeration of individual symptoms gives way to mental dullness and to other signs of cortical deterioration [ie problems with higher brain functions such as memory, etc]. The other group comprises cases where from the first there are signs of cortical lesions, these occurring either beneath the injured spot or on the side of the brain opposite to the injury as a result of contrecoup [due to the brain being pushed by the injury and striking the skull on the opposite side from the site of the injury, eg the injury is to the front of the head but the brain injury is at the back]. The lesions are various, including minute lacerations, punctiform [like a small dot] haemorrhages, and other changes which collectively constitute contusion [bruising] of brain tissue. In severe cases these lesions, as already stated, may be associated with meningeal haemorrhage [bleeding into the membranes that surround the brain]. Now, the symptoms of a bruised brain may closely resemble those of the later stages of the first group of cases which are dependent on molecular changes and slight degrees of cortical sclerosis [scarring], hence a certain diagnosis of the pathological condition can only be attempted soon after the accident, when notable differences may be observed between the symptoms of a bruised brain and those of ordinary neurasthenia."

Robert

Link to comment
Share on other sites

'I have only witnessed the effect of the shock of the explosion once...'
This comment was contained in a report about the battles of Modder River and Magersfontein. The one case of 'shell shock' was in the context of more than 1,400 casualties from these two battles.

The report itself was one of a regular weekly series about the war in South Africa. The series was reinstated in the BMJ when WW1 commenced. Each report featured a variety of topics, submitted by various 'correspondents'. Reports included updates from various of the hospitals back in England, as well as descriptions of cases of interest, examples of how the various services such as motor ambulances and casualty clearing stations worked, etc.

The reports were intended for the general readership of the British Medical Journal. They were not the same as internal reports and records created and circulated within the BEF. Nevertheless, the BMJ reports, along with the articles published at the same time, give a flavour of what medical issues were emerging as the war evolved.

Without question, and not suprisingly, the main focus is on the huge number and variety of wounds. There are graphic drawings in some cases, designed to highlight the effects of rifle fire at close range and shrapnel. Some of the earliest original articles pertained to the management of sepsis, which was a major problem. Tetanus, gas gangrene, and other wound infections feature prominently.

The following snippets were gleaned from a systematic study of every copy of the BMJ published after the war started through to the end of December 1914.

The earliest mention of anything that is relevant to this thread is from Nov 7 1914:

"Mental and Nervous Shock Among the Wounded.

We hope the public will give Lord Knutsford the £10,000 for which he is asking. Among the men who are coming home are some, wounded or unwounded, who are suffering from several mental or nervous shock. In addition to exposure and the severe strain and tension of the fighting line, the depressing effect of the horrible sights and sounds of modern battlefields have to be reckoned with. Officers returned wounded say, for example, that the rending clang of a bursting shell produces a special kind of auditory impression which in time becomes very oppressive and almost physically painful. It is not surprising that there are a good many men suffering from mental and nervous shock, and it is true that such cases are not suitable for general hospitals. They require rest and quiet under special medical care. It is proposed to get a large quiet home in London and a convalescent home in the country. The scheme has received the sanction of the War Office, and the following is a list, arranged alphabetically, of the names of [22] physicians who are willing to help and form a committe of management..."

Here is a study that is also relevant:

"NOTES ON 130 CASES OF WOUNDED FRENCH, BELGIANS, AND GERMANS.

By ALBERT WILSON, M.D.

Air Concussion.

The following is a case of injury to the internal ear from the explosion of a "105" [calibre] shell. The mnan was slightly wounded in the knee with shrapnel, and had synovitis [inflammation of the joint lining]. There was a wall between the soldier and the explosion [important in establishing that the effect was indirect blast]. The left [ear drum] was ruptured; there was bleeding from the ear, and blood came into the throat. This occurred on October 8th. I saw him three days later; during the whole of the interval he had been in the train. He could not hear a watch, even applied to the left half ofthe skull. Conversation 4 or 5 ft. off was only heard if very loud. A watch placed on the middle line of the skull was heard on the right side [a test that is used to distinguish the cause of a hearing problem on one side. This result suggests that the left sided hearing loss was due to nerve damage, either in the hearing organ and/or the acoustic nerve]. After the accident he had giddiness, with a sense of rotation to the right. This passed off, but he had nystagmus [jerking movement of the eyes, which can occur when the inner ear is damaged. It is the cause, in this case, of the sense of rotating to the right.] looking laterally, most when to the right side; not at all when looking up or down. Romberg's sign [a test of balance, linked to the inner ear function] was not present. On October 26th all symptoms except deafness had subsided; he could catch words of loud conversation 6 or 8 ft. off. Probably there was haemorrhage in the labyrinth [inner ear].

Air concussion acts often like a heavy solid blow, causing pain and bruising to soft parts. It was common to find tenderness of the lumbar region, or of a shoulder, or intense headache. Pain was an important factor; the soldiers call it rheumatism. Other effects of explosion, without wound, occurred from flinging the man 10 or 15 ft. in the air. One man fell on his shoulder and had a large haematoma [collection of blood] under the deltoid.

The nerve-racking effects of explosion are worthy of notice. In one case a Belgian officer had pain in his left leg, and what might be called "neurasthenia." After some days' rest, though he walked erect, he could only step 6 or 8 in. at a time and one step every three seconds. Another man was so exhausted that his life was in danger; the pulse was 42, on the next day 48, and then 52. I had to get his mate to shout at him. Sensation was almost gone in the legs, but he could after three seconds feel a hard pain in the arm. The knee-jerks were normal, and the pupils reacted normally. These cases form a nerve group by themselves, diagnosed and named accurately "fitiblesse." They get well with rest.

Stage fright occurred in a youth of 17, a "volontier," who had slain two Germans... He almost cried with fear, but after two days in bed insisted on returning to the front.

Occasionally men are dumb, but they understand all that is said to them. I saw one such case."

Robert

Link to comment
Share on other sites

Without question, and not suprisingly, the main focus is on the huge number and variety of wounds. Tetanus, gas gangrene, and other wound infections feature prominently.
Just to emphasize this, the following is from November 1914:

"MEDICAL ARRANGEMENTS OF THE BRITISH EXPEDITIONARY FORCE.

[Fromn a Special Correspondent in Northern France.]

WOUND CHARACTERISTICS.

I do not often see English papers, but when I do it sometimes seems to me that even now the British public does not realize that what is going on in France and Belgium at the present time is a war and not a game played according to definite rules, with every move foreseen. They seem to forget sometimes that at least a million men on each side are trying to kill one another with singularly efficient weapons; that in the course of the struggle the survivors are constantly moving from place to place; and that meantime they have to be fed, kept fully supplied with ammunition, and the wounded and dead removed out of the way as rapidly as possible.

At any rate, it is quite certain to my mind that the majority of the public and many members of the medical profession have but a very slight idea of the nature of the wounds that are being received in this war by the combatants on both sides, and of the circumstances in which medical men engaged at the front have to deal with the cases placed in their charge. Some of the wounds - indeed, a considerable proportion - are relatively slight, but many others - possibly a majority - are of almost incredible severity. To me what seems remarkable is not that deaths take place, nor that tetanus and emphysematous or gas gangrene occur, but that any considerable portion of men so wounded ever reach home at all. Some of the lesions, especially those of the trunk and lower limbs, are so extensive and grave as to lead one to wonder how the patients were ever got out of the fighting line alive, and then sadly to conclude, though often quite erroneously, that at any rate they will never get any further than the base - or other fairly distant hospital at which they come under final treatment. They are of such a kind that, if seen at home in civil life, they would create a buzz of excitement among the whole staff of the institution to which they were admitted.

Furthermore, not only are the wounds of the utmost gravity on account of the extent and the nature of the lesions produced, but they are infected from the very beginning, that is to say, the wound and the infection are caused simultaneously."

Robert

Link to comment
Share on other sites

Air concussion acts often like a heavy solid blow...
This comment reflects the early attempts to understand how heavy shells caused their effects. There were alternative hypotheses, for example relating to the toxic effects from the gases and smoke produced by explosion. On Nov 21 1914, there was an article on the toxicity of turpinite, a high explosive used in some French shells:

'...so far as the effects of the almost equally high explosives used by the Germans are concerned, there are stories which cut both ways in their bearing on the turpinite question. They relate mainly to the shells that our soldiers dub "coal-boxes" and "Black Marias," and for narration I choose one told me yesterday by an old South African acquaintance. In the course of a long account of his experiences between Mons, the Meaux, the Aisne, and Ypres - that is to say, from the beginning of the war up to a few days ago - this soldier, who is a very level-headed man, told he that twice a "coal-box" had fallen within a few yards of his trench, and, in fact, dug a large hole in the ground just outside it. On neither occasion did he suffer any harm, though startled by the extreme loudness of the detonation. On the other hand, a few miniutes later he began to feel irresistibly sleepy, and did, in fact, go to sleep, waking up several hours later without headache and feeling perfectly well.'

Robert

Link to comment
Share on other sites

Among the men who are coming home are some, wounded or unwounded, who are suffering from several mental or nervous shock.
From Dec 12 1914:

"Medical Aspects of Severe Trauma in War

Considerinig the stress of conditions at the front, it is wonderful that there were not more cases of insanity;

I saw only two, both at the Aisne.

(a.) A man who had distinguished himself by his bravery. He was brought to the dressing station and was then oblivious of the nature of his surroundings, mildly agitated and speaking or muttering continuously. He called to mind the appearance of those who suffer from auditory hallucinations, and these may have been present. He was not violent. I do not recollect whether or not he refused food.

(b.) A man who had the aspect of profound melancholy which looked like most cases of melancholia. He was similarly devoid of initiative, but quiet and gave no trouble. It was not possible in the circumstances to enquire if these cases were hereditarily predisposed to insanity.

Terror (like the unreasoning terror of a child frightened by the dark) was not often seen. It is not the same as "funk" and I would call attention to the following differences:

Terror is not abated for some time after reaching a place of safety; it is an unreasoning process, ancd it is produced by some, sudden and unexpected happening. Funk abates in a place of safety unless there is a prospect of having to return to one of danger (terror continues even if the man has a wound which will certainly prevent any further service). Funk is essentially a reasoning process, and in fact depends largely on imagination for its full development, and it has no necessary relation to anything that has happened recently and suddenly. But a man suffering from funk is the more prone to terror. Of the latter I can give two examples:

(a.) A certain regiment newly out from home came almost direct to the firing line, and was immediately attacked in force. Ignorance of the ground and of the whole conditions of this warfare were probably largely to blame for the failure of the defence. Many men were wounded and were brought to us. A certain number of these showed what I describe as "terror". They showed a tendency to faint, which was allayed by an assurance that there was no need for them to do so. More than one, if not supported, would have fallen to the floor. They could give no coherent account of what had been happening. They looked at their wounds with a solicitude out of all proportion to their severity or else with an aloofness and curiosity which might have made one think the wounds belonged to someone else. One man stated that he was wounded in the leg, and was enormously excited about it, but on examination no sign of any wound here or anywhere else was discovered. He may, of course, have been hit by some piece of stone or material thrown up by a shell. In the case of officers an exaggerated solicitude for their kit and its safety sometimes took the place of any anxiety about their still undressed wounds - this had reference to articles of kit which they had not brought with them, and which in the nature of things could not be sent for until the more immediate business of attending to the wounded had been seen to. What I have here called " terror " seems to be a sort of temporary insanity - a pathological state.

(b.) a shell fell and burst amongst a column of men marching in fours along a road which was comparatively safe - that is by comparison with the trenches to which they were going.

They had all been in action before. Some eight men were killed or wounded, and one of these - an officer - had three wounds, one of considerable severity. He was extremely agitated, and was only with difficulty persuaded to submit quietly to the necessary dressings; he spoke and called out continuously, but could give no account of what had happened (he was possibly not in a position to know). He proved susceptible to the influence of morphine. He died from his injuries a few days later.

Possibly cases of "hysterical paralysis", deafness, etc. should be mentioned here, altlhough I am unable to agree with the term "hysterical" as applied to them. They tend to recover gradually without any such treatment as given to hysterical patients. I can only call to mind at all definitely one such case. A physicallv splendid man was - wounded in the shoulder by a shrapnel bullet (apparently). There was no wound of exit, amid there was no sign of the bullet (the wound was not deep, and it is probable that the bullet had not stayed in the body. Both legs were paralysed - that is, he was unable to move them). Time did not allow of any prolonged examination, but in the absence of any rigidity or pain in the spine there was no reason to hypothecate a spinal injury. The case was not followed. Deafness and blindness were also met with in other patients, but the writer did not examine any cases.

Terror is one of the most distressing phenomena - with which the medical man has to deal in war - at least this is my experience."

Robert

Link to comment
Share on other sites

The last reference of interest in 1914 was in the December 5th BMJ. There is a brief snippet on:

"Injury to Nerves.

There have been several cases of concussion of nerves causing loss of sensation and motion. In one instance a shell exploded close to a man without striking him, but the general shock and concussion caused facial paralysis."

From the general medical literature, the impressions so far are:

1. The clinical features of traumatic head injury (falling from a height, being kicked by a horse, etc) were understood before the war began.

2. Before the war, there were sporadic mentions of unusual reactions to explosions (ie more than just the reactions to traumatic head injury), with a couple of instances in the Boer War. At least one doctor postulated that, on the basis of findings in the Russo-Japanese War, the next major war would see new types of injuries from more powerful high explosives.

3. The first months of the war saw huge numbers of gunshot and shrapnel wounds, with significant focus on managing the complications of infection.

4. Occasional reports began to appear about a variety of effects from German high explosive shells.

5. Occasional reports also appeared about psychological trauma, with at least one benefactor seeking to establish a convalescent centre.

More reports were published in 1915. It should be recalled, however, that the numbers of British troops involved in the various battles were quite small, by comparison with the French for example. Not surprisingly, therefore, the French began to build up more experience with the effects of shell fire. The most well-known British report was Myer's paper in the Lancet: "A Contribution to the Study of Shell Shock"; Feb 13, 1915. I will present the various reports, and discuss Myer's paper in more detail, upon returning from our holiday.

Robert

Link to comment
Share on other sites

I don't have copies of the actual papers, but here are 3 good references from my own notes on the subject that go some way to illustrating some of the early thinking on 'shell shock' (I'll try to get hold of the original papers again if I can);

'A special discussion on shell shock without visible signs of injury' by the neurologist Frederick Mott (Proceedings of the Royal Society of Medicine, 1916).

'Cases of nervous and mental shock observed in the base hospitals in France' (W.A. Turner, R.A.M.C. Journal, 1915).

'Mental hygiene in shell shock during and after the war' (Frederick Mott, Journal of Mental Science, 1917).

When considering what was known in relation to 'shell shock', I'd like to make the point that 'shell shock' did not stand alone as an entirely novel concept. I'd like to add to Robert's earlier comments regarding European neurologists by saying that psychological/neuro-psychological explantions for the symptoms associated with 'shell shock' were proposed by various people in the late 1800's, such as the French neurologist Charcot and the German neurologist Hermann Oppenheim, and I wonder if those views were adequately reflected in British medical culture and literature. There had certainly been a sustained debate in Europe about a variety of similar conditions ('railway spine' and traumatic neurasthenia, among others) throughout the latter part of the C19th so, in theory at least, a medical framework did already exist by which to interpret the physical and/or mental symptoms that were common to these various diagnoses.

It might be helpful to think of the term 'shell shock' as simply a reference to the observed mechanism of injury rather than it being a distinct condition in itself. There was a spectrum of diagnostic labels (such as traumatic neurasthenia, 'railway spine', 'soldiers heart' and 'windage') which attempted to categorize a range of similar, apparently neurological, symptoms which arose in the presence of physical trauma but which failed to give rise to an identifiable injury.

And Neurasthenia was certainly a common diagnosis, and was much in use during WW1, but perhaps that's a subject for later in the thread.

I'm sceptical that a truly objective distinction will emerge between 'shell shock' and neurasthenia.

Link to comment
Share on other sites

I'd like to add to Robert's earlier comments regarding European neurologists by saying that psychological/neuro-psychological explantions for the symptoms associated with 'shell shock' were proposed by various people in the late 1800's, such as the French neurologist Charcot and the German neurologist Hermann Oppenheim, and I wonder if those views were adequately reflected in British medical culture and literature.

It might be amusing to mention that Dr. Hermann Oppenheim is a relative of mine.

That said, as someone who works with veterans of various conflicts, TBI is one thing I would think should be given more mention, including concussive TBI. The behavioral manifestations of a closed TBI often get misidentified and confused with mental illness, even today. People with TBI can have psychotic and/or mood disturbances that can be quite significant. Of course, there is nothing to say that one can't have trauma-induced mental illness as well as a TBI...very often they can be co-ocurring.

This thread is very interesting...well done all!

Daniel

Link to comment
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
×
×
  • Create New...