Neurasthenia and Shell Shock

[headgardener]

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.

Hermann Oppenhiem? That's a good name to drop in my opinion.....!

TBI was a much later diagnostic label, so I guess that we'll save that for later in the thread. Interestingly fMRI studies have recently (2008?) demonstrated similar changes in brain function in subjects with TBI and those with emotional 'shock', so there may be a physiological link between the two that helps explain the clinical similarities between them. I'll send you details if you like (and if I can find them...!).

Edit; it's all very much in keeping with some of Oppenheim's theories, btw.....

[John Gilinsky]

Hello all. Since about 2005 onwards I have researched the history of shellshock especially in the Canadian Expeditionary Force (CEF) from 1914 onwards and secondarilly shellshock resources for the USA, Russia, Germany, Austria-Hungary, France and Italy. "Shellshock" is such a misused, misunderstood and mishandled term that I am very hesitant to use it myself. Indeed one could easily do a fullsome Master's thesis alone on the epistemiological basis of this single term in the medical literature through now over 100 years.

For this post I will confine myself to some simple but frequently overlooked observations:

1) The United States government built with taxpayer's dollars between 1919 to 1941 33 separate "mental health" treatment centers for its primarilly WWI vets (i.e. AEF) - I invite the interpretation of this significant expenditure of the American health care dollar and its justification or not by anyone.

2) Conflating legal medicine, forensic medicine, military law and general tenets of military discipline in war is a common problem manifested in several previous postings to this thread especially when different authors from different geographical areas concurrently used differing terms to refer to essentiall the "same" symptomology from a medical point of view and concurrently used the same terms usually unwittingly to refer to different medical symptoms. This has created a mental nightmare of its own for medical historians alone!

3) Cultural anthropological considerations for psychiatry are frequently overlooked by everyone: e.g. Russian popluar and folk cutlure and folk remedies and explanations for strange or odd behavious in stressful times.

4) Trans-national or cross-cultural comparisons between "shell-shock" for WWI are badly overdue.

John

Toronto

[Robert Dunlop]

...here are 3 good references from my own notes...

Thanks for these references. I have one of them. The other two are available in the Royal Society of Medicine's Library. I will follow-up.

Robert

[headgardener]

In terms of British literature, specifically focused on war-related trauma, here's a short list of interesting papers for you to have a look at when you're at the RSM library;

'A contribution to the study of shell-shock. Being an account of the cases of loss of memory, vision, smell and tatse admitted to the Duchess of Westminster's War Hospital, Le Touquet', Charles Myers, Lancet, 1915

'Repression of war experience', W.H.R. Rivers, Proceedings of the R.S.M. (Psychiatry section), 1917

'A case of hysterical paraplegia', A. Abrahams, Lancet, 1915

'Some notes on battle psycho-neuroses', E. Ballard, Journal of mental science, 1917

'Neurasthenia; what it costs the state', J. Collie, J.R.A.M.C., 1916

'A discussion on shell-shock', H. Head, Lancet, 1916

'Remarks on cases of nervous and mental shock', W.A. Turner, BMJ, 1915

[John Gilinsky]

The British Medical Journal is available for free here:

http://www.bmj.com/content/by/year

The Lancet is available for free here:

http://www.thelancet.com/journals/lancet/issue/current?tab=past

Journal of the Royal Society of Medicine (Proceedings) is available for free here:

http://www.ncbi.nlm.nih.gov/pmc/journals/256/

CURRENTLY the online website for the Journal of the Royal Army Medical Corps only has past issues going back to 1999.

Hope this facilitates people in reading the original and full articles.

John

[Robert Dunlop]

John, the RSM Journal content is free. The full content for past editions of the Lancet has to be paid for. As a BMA Member, I can get full PDF BMJ content free but I don't know if this is the case otherwise. The past editions of RAMC Journal are available at the Royal Society of Medicine Library and probably the BMJ Library. I haven't checked the latter yet.

Robert

[John Gilinsky]

Robert: Thanks for the London based additional information on personal paper access. ALL 3 periodicals given are indeed available for FREE online without registration etc.... It is only the Journal of the Royal Army Medical Corps that is not online.

John

[Robert Dunlop]

Turning now to neurasthenia again, the original description came from Dr George Beard in the 19th Century. He wrote 'A practical treatise on nervous exhaustion (neurasthenia): Its symptoms, nature, sequences, treatment'. The book quickly ran to several editions. As has been noted previously, copies are available online, for example here. It has also been noted that almost immediately after the book was first published, Beard was invited to be a guest speaker at the annual conference of the British Medical Association.

Before reviewing the book, it is important to examine Beard's credentials. He was a practising neurologist. This is very significant. Neurology is the study of the nervous system, which comprises the brain, spinal cord, peripheral nerves (i.e. the nerves that run to and from the spinal cord to the skin and the muscles) and the autonomic nerves. The latter are associated predominantly with the internal organs but also with the regulation of blood flow to the skin for example. The feeling of dry mouth when very anxious, along with the butterflies sensation and the hurried urinary and/or intestinal functions, are mediated in large part by the autonomic nervous system, for example. The nervous system as a whole is very complex. It can be affected in a multitude of ways. These factors combine to make neurology one of the most scientific of medical specialties. Even in the absence of things like MRI and CT scans, the specialty has long been recognised as requiring great skill and extensive training. It is no surprise, therefore, that Beard held a number of fellowships and memberships, including Vice-President of the American Academy of Medicine. More importantly, it means that Beard was likely to be approaching the problem from a 'body' rather than a 'mind' perspective. Neurology is deeply rooted in the study of lesions or damage to the nervous system, and how this subsequently expresses itself through physical, and sometimes 'psychological', findings. To gain some idea of the workings of neurology, I would strongly recommend the writings of Oliver Sachs. He is best known for the book that prompted the film 'Awakenings' but his other books, such as 'The man who mistook his wife for a hat' and 'Seeing voices', give some fascinating insights. Neurology involves attention to detail, which comes through in Beard's works.

Beard gave a lecture on neurasthenia to the New York Academy of Medicine in 1878, which is the date associated with the 'discovery' of the concept. His preparatory work, however, pre-dated this by many years. Beard published a paper 10 years before, for example. This demonstrates how the Beard's detailed studies had taken a lot of time. By the time Beard presented in 1878, he had accumulated 'several hundred cases of neurasthenia'. Almost certainly, it was this attention to detailed study by a neurologist that led to the rapid recognition of his work, even across the Atlantic in Britain. Whatever else one may think of his writings from a 21st Century perspective, there is no doubting the effort and medical analysis that characterised Beard's work.

In his book, Beard's opening remark was:

'There is a large family of functional nervous disorders that are increasingly frequent among the in-door classes of civilised countries… but of which our standard works of medicine and our lecture-rooms give little or no information'.

It is worth pausing for moment. To a neurologist, 'nervous' does not mean 'anxious' or 'worried'. 'Nervous disorders' is short for 'disorders of the nervous system'. In other words, something causing a malfunction of the nervous system. This is totally different from the idea that the symptoms are just in the person's 'mind', i.e. not real in a medical sense. 'Functional' means that the malfunction of the nervous system is not associated with any demonstrable lesion or damage to the nervous system. Again, this does not mean, from a neurologist's perspective, that the problem was 'just in the mind'. It meant that there would be nothing to see if the brain or other parts of the nervous system were examined at post-mortem, for example. By Beard's time, it was well known that individual nerves could malfunction without being physically damaged. Furthermore, there were numerous neurology syndromes that were clearly described where nervous system function was affected but no physical damage could be detected with the various methods of the time.

Beard then notes:

'The centre and type of this family of functional nervous diseases is neurasthenia, or nervous exhaustion.'

As noted above, the use of 'nervous' does not refer to being 'anxious' or 'worried' in the lay sense. Thus 'nervous exhaustion' is being used to describe the fact that the nervous system has become exhausted, in much the same way as one might say that the musculoskeletal system, specifically the muscles, becomes exhausted after prolonged and vigorous exercise. I apologise for repeating this point about 'nervous' but it is so crucial to not misinterpreting what Beard is trying to say.

Beard then goes on to make one of the most significant points in his whole treatise, IMHO:

'First of all, the symptoms of neurasthenia are largely of a subjective character, and to one who does not suffer from them, appear trifling and unreal; many of them do not appeal directly to the senses of the scientific observer: the physician can only know of their existence through the statements of the patient, or through his conduct. Unlike the existence of surgical and acute and inflammatory diseases, the phenomena of which the physician can see and feel, and for the study of which he is little, if at all, dependent on the patient's intelligence and honesty, they do not appeal directly to the eye or ear or touch, and are in fact quite out of the range of all modern appliances to supplement the defects of the senses, as the ophthalmoscope and laryngoscope, or even the spectroscope. It is the tendency of the partially trained mind everywhere to reject or doubt what cannot be confirmed by the eyes or ears; forgetting that the capacities of the five senses of man are so meagre that the great natural forces, as light, heat, electricity, magnetism, gravity, are quite beyond the reach of any one of the senses, or all of them combined, scientific men have allowed themselves to ignore and despise some of the most remarkable, interesting, and instructive phenomena of the nervous system both in health and disease, for the only reasons that they cannot be seen and felt.'

Beard is validating the importance of information provided by patients (symptoms) in the absence of objective evidence that can be observed by doctors (signs). Coming from a neurologist, this is especially significant. It is, IMHO, the most significant contribution that Beard made, given that he went on to describe how the multitude of symptoms were related to a physical cause.

The list of symptoms (the 'symptoms of nervous exhaustion') was very extensive:

'...sick headache and various forms of head pain; pain, pressure and heaviness in the head; …disturbances of the nerves of the special senses; …noises in the ears; …mental irritability; …hopelessness; morbid fears; …fear of lightening; …fear of places; …fear of open places; …fear of closed places; …fear of contamination; …fear of everything; …sleeplessness; bad dreams; insomnia; drowsiness; deficient thirst…; heaviness of the loin and limbs; shooting pains…; difficulty of swallowing; sensitiveness to weather; sensitiveness to cold or hot water; a feeling of profound exhaustion unaccompanied by positive pain; ticklishness; vague pains and flying neuralgias; general or local itching…; general and local chills and flashes of heat'.

Beard also described various signs, i.e. things that could be observed by a doctor:

'…dilated pupils; …congestion of the conjunctiva; …dryness of the skin; …abnormalities of the secretions; abnormal dryness of the skin, joints and mucous membranes; sweating hands and feet with redness; …tremulous and variable pulse and palpitation of the heart; rapid decay and irregularities of the teeth...'

Clearly, these symptoms and signs could be associated with a range of other conditions. Beard was very clear on this point, emphasising the importance of meticulous examination and diagnostic efforts to exclude other causes:

'The importance of making a differential diagnosis between symptoms of neurasthenia… and the symptoms of organic or structural disease of the brain and spinal cord and peripheral nerves, is incalculable. Very many of the symptoms of functional and organic disease are the same, or apparently the same, and there is an easy liability to confound them, especially when, as is often the case, the patient or the doctor is disturbed in his judgement by severe apprehensions. To make such a differential diagnosis is sometimes the severest test to which a neurologist can be brought...'

Beard provided pointers to making the diagnosis:

'1. The symptoms of organic disease are usually fixed and stable, while very many of those of neurasthenia and allied states are fleeting, transient, metastatic [move from one place to another], and recurrent.

2. There are certain, though not well known or always recognised symptoms of neurasthenia and allied states which do not often, if at all, appear in structural disorders.

3. In organic disease, reflex activity is generally diminished; in functional disease, reflex activity is generally increased.

4. Neurasthenia and allied troubles are most likely to occur in those in whom the nervous diathesis predominate [signs of 'nervous diathesis' were described as 'fine, soft skin, fine hair, delicately cut features, and tapering extremities…']'

He discussed differential diagnosis is some detail. Conditions such as anaemia, tuberculosis, and syphillis were contrasted with neurasthenia.

I will discuss Beard's hypothesis about the cause of neurasthenia in another post.

Robert

[ian.sumner]

There's an index to a number of contemporary French medical journals, with links to the article on Gallica, at http://tsovorp.org/histoire/Themes/Guerre14bases.html

It includes, for example:

Revue scientifique (Revue Rose)

1916, p.118 'Les maladies de guerre du système nerveux et les Conseil de réforme'

1916, p.568 'Phénomènes résultants de la fatigue et du shock du système nerveux central observés sur le front en France'

1917, p.535 'Les base physiologique du schock'

Bulletin de l'Académie nationale de médicine

74 (1915) p.166 'Appareils pour "Blessés Nerveux"'

More generally, there are these:

Revue neurologique October 1915 'Les Procédés d’Examen Clinique et la Conduite à tenir dans les cas où l’on peut suspecter d’Exagération ou la Simulation de certains symptômes chez les Blessés nerveux' (G. Ballet)

Revue neurologique 1916 'Les maladies nerveuses et les maladies mentales de la guerre' (R. Benon)

Revue neurolgique 1916 'La guerre et les pensions pour maladies mentales et nerveuses' (R. Benon)

Revue neurolgique 1918 'La dégénérescence mentale et la guerre. Classification des maladies mentales et nerveuses ' (R. Benon)

Revue de Paris 15 June 1916 'Les troubles nerveux et la guerre' (Dumas)

Presse médicale 1 April 1915 'Les psycho-névroses de guerre' (J. Grasset)

Revue neurologique 1916 'Les Névroses et Psychonévroses de guerre; conduite à tenir à leur égard' (J. Grasset)

Presse médicale 29 April 1915 'Troubles nerveux psychiques de guerre (à propos d’un récent article du professeur Grasset)' (G. Roussy)

Revue Neurologique 1915 'A propos de quelques troubles nerveux psychiques observés à l’occasion de la guerre' (G. Roussy)

Presse médicale 1915 'Troubles nerveux et psychiques de guerre' (G. Roussy)

Presse médicale 8 April 1915 'Troubles Nerveux Psychiques,Hystérie Hystéro-traumatisme,Simulation' (G. Roussy)

'Les Psycho-névroses de guerre' by G. Roussy and J. Lhermite (Paris, 1918)

Ian

[David Porter]

I came across this yesterday in the service record of Arthur Reginald Heard.

He was admitted to 2/1st Southern General Hospital, Dudley Road, Birmingham on 03-04-18 with what was thought to be Cerebral Tumour. Within a week he had "very greatly improved" and the diagnosis was changed to Neurasthenia. He was transferred to the Military Convalescent Hospital, Wearde Camp, Saltash but after just 4 days had a epileptic type of fit and died. He did indeed have a Cerebral Tumour. Therefore one can assume that the symptoms for Cerebral Tumour and Neurasthenia must have been regarded as similar.

[Robert Dunlop]

Beard's earliest work contained very little information about the cause of neurasthenia. Beard was saving this detail for a second book, more of which anon. Nevertheless, there was an hypothesis proposed about what was happening in the nervous system. Pathology refers to the possible way in the nervous system malfunctioned in neurasthenia:

"Pathology and Rationale - In regard to the pathology of neurasthenia, my view, as expressed in my first paper on the subject, is that there is an impoverishment of the nerve-force, resulting from bad nutrition of the nerve-tissue on the metamorphosis of which the evolution of nerve-force depends; as in anaemia, there may be a deficiency in quantity or impairment of quality of the blood; so in neurasthenia there is, without question, deficiency in quantity or impairment in quality of the nerve-tissues; hence the exhaustion, the positive pain, the unsteadiness, the fluctuating character of the morbid sensations and phenomena, to which the term neurasthenia is applied.

In neurasthenia, the balance between waste and repair is not justly maintained in the central nervous system, however it may be in other parts of the body.

The patient may be fleshy, may weigh more than when in health; but it is not unreasonable to believe that the expenditure of nerve-matter is sometimes greater than the supply, and that, consequently, there is a constant poverty of nerve-force.

It is certain that there is an instability of the nervous system, as the symptoms show, and notably in extreme cases that have gone on to neurasthenia and hystero-epilepsy.

In these cases, everything is changing - there is constant oscillation - the essential factor in these cases indeed being perpetual mutation from bad to worse, or vice versa, from day to day, and in some cases from hour to hour.

The fatigue and pain that temporarily follow excessive toil, or worry, or deprivation of food or rest, are symptoms of acute neurasthenia, from which the chronic form differs only in permanence and degree."

As mentioned above, Beard was hypothesising that neurasthenia results when nerve tissue (which means groups of nerves) uses up more energy than it receives. This causes the nerves to malfunction. Beard recognised that this imbalance in 'nerve-force' was not due to a general problem with malnutrition but due to a specific over-activity of 'nerve-tissue'. He discussed the causes of this over-activity in this book 'American nervousness, its causes and consequences; a supplement to nervous exhaustion (neurasthenia)', published in 1881. Beard summarised his conclusions as follows:

"To those who are beginning the study of this interesting theme the following epitome of the philosophy of this work may be of assistance, as a preliminary to a detailed examination.

First. Nervousness is strictly deficiency or lack of nerve-force. This condition, together with all the symptoms of diseases that are evolved from it, has developed mainly within the nineteenth century, and is especially frequent and severe in the Northern and Eastern portions of the United States. Nervousness, in the sense here used, is to be distinguished rigidly and systematically from simple excess of emotion and from organic disease.

Secondly. The chief and primary cause of this development and very rapid increase of nervousness is modern civilisation, which is distinguished from the ancient by these five characteristics: steam-power, the periodical press, the telegraph, the sciences, and the mental activity of women.

Civilization is the one constant factor without which there can be little or no nervousness, and under which in its modern form nervousness in its many varieties must arise inevitably. Among the secondary and tertiary causes of nervousness are climate, institutions - civil, political, and religious, social and business - personal habits, indulgence of appetite and passions.

To compress all in one sentence; nervousness is a physical not a mental state, and its phenomena do not come from emotional excess or excitability or from organic disease but from nervous debility and irritability."

Basically, Beard goes on to elucidate how the stresses of modern 'civilization' cause neurasthenia.

With respect to this thread, it is clear that neurasthenia was not considered to be due to some sudden severe shock, such as occurred with shell explosions in WW1.

Robert

[Robert Dunlop]

Therefore one can assume that the symptoms for Cerebral Tumour and Neurasthenia must have been regarded as similar.

David, thank you for presenting this very interesting information. Two things need to be taken into account when making such a differential diagnosis, bearing in mind that this was in the days before there were easy methods for imaging a brain tumour.

The first issue is the symptoms and signs. Assuming there were no localising signs (such as a persistent weakness down one side with abnormal reflexes) then the symptoms would have been the only clue. From Beard's description, there are symptoms of neurasthenia that occur with brain tumours, such as headaches for example.

The second key thing is what happens to the symptoms over time. Normally, the symptoms of a brain tumour are steady and get progressively worse. Beard noted that neurasthenia symptoms fluctuate in severity. Given that Arthur Heard presented with symptoms that then improved, it is not surprising that the diagnosis was changed. In other words, it was the course of the symptoms that was the determinant of diagnosis, not the symptoms per se.

Assuming that the final diagnosis of brain tumour was correct, it is not hard to speculate on why the symptoms seemingly improved. Given that the terminal event was associated with an epileptic fit, it is highly likely that the first presentation followed a fit as well. It is not uncommon for a fit to cause residual symptoms that take a little while to settle completely. Another possibility is that there was a haemorrhage into the the brain tumour. This would have caused a sudden deterioration with acute symptoms, which then resolved. The final fit could have been another sign of a second fatal bleed into the tumour.

Robert

[headgardener]

With respect to this thread, it is clear that neurasthenia was not considered to be due to some sudden severe shock, such as occurred with shell explosions in WW1.

I agree with your conclusion insofar as it is true of the basic conception of neurasthenia being a state of nervous 'exhaustion' or 'depletion', but several diagnostic categories developed, including 'traumatic neurasthenia' which was considered to be the result of sudden severe shock.

More than 30 years elapsed between Beard's writings and the outbreak of war, and during that time there was a sustained debate as to the nature of the condition. The basic somatic (i.e. 'physical', for the lay reader) concept of 'nervous exhaustion' remained the underlying premise, but a variety of possible causes were proposed.

It's interesting to note that Beard includes references to hereditary factors ('fine' physical features, etc) and social factors (the 'stresses' of modern society, etc).

[Robert Dunlop]

I agree with your conclusion insofar as it is true of the basic conception of neurasthenia being a state of nervous 'exhaustion' or 'depletion', but several diagnostic categories developed, including 'traumatic neurasthenia' which was considered to be the result of sudden severe shock.

Thanks. I should have been more clear. My comment was directed at the initial definition of neurasthenia by Beard. The development of the concept is something that I want to pursue in this thread, both from the English and French literature sources.

Robert

[headgardener]

I came across this yesterday in the service record of Arthur Reginald Heard.

He was admitted to 2/1st Southern General Hospital, Dudley Road, Birmingham on 03-04-18 with what was thought to be Cerebral Tumour. Within a week he had "very greatly improved" and the diagnosis was changed to Neurasthenia. He was transferred to the Military Convalescent Hospital, Wearde Camp, Saltash but after just 4 days had a epileptic type of fit and died. He did indeed have a Cerebral Tumour. Therefore one can assume that the symptoms for Cerebral Tumour and Neurasthenia must have been regarded as similar.

I'd like to add to Robert's comments about this very interesting case posted by David. I think it encapsulates an important aspect of this debate.

An essential aspect of the diagnosis of 'shell-shock' (and neurasthenia, hystero-epilepsy, or whatever other diagnostic labels were attached to the sufferers) was that these men commonly exhibited apparently physiological symptoms in the absence of an identifiable physical pathology. It was this that drove the debate about such conditions.

A brain tumour or neurasthenia might both be reasonable diagnoses for a man suffering from any one (or more) of a variety of symptoms (such as persistent headache, seizures, hallucinations, strange behaviour, memory loss, visual symptoms, apparent difficulty in self-expression or in comprehension, etc). As Robert says, a relatively narrow range of diagnostic tests were available at that time, so a diagnosis in this particular field of expertise might rely as much on the 'art' of medicine as the 'science'; that is to say, a diagnosis is essentially one person's opinion based on the available evidence, their own experience and, to a degree, their own biases.

Hence the debate about the nature of 'shell-shock', and (perhaps) the differing diagnostic approaches in this particular case.

[John Gilinsky]

I contend that the wrong questions are asked by many when considering "shell shock." The most recent posts to this thread focussed on "neurasthenia" exemplifies this. "Neurasthenia" was and is NOT "shell shock." "Neurasthenia" was used by "military doctors" (read civilian doctors wearing military uniforms) in stressful circumstances often during emergency or crisis situations in less than ideal medically clinical venues in officially "disposing" / "handling" certain "soldiers" the vast majority of these "soldiers" (read civilians many but not all of course compelled to serve)being essentially civilians and hardly professional soldiers. The vast majority of medical personnel and those being psychiatrically/psychologically labelled were medically untrained, inexperienced in military/war medicine and in particular the mental health sciences. Falling back on "experts" in rear areas or far more frequently in fact the home front to officially handle perplexing behaviours expeditiously was hardly unusal. The real histories of "shell shock" focussed on actual combat service soldiers in theater(s) and the same soldiers who returned during the war to their respective home fronts AND the post-war histories of such veterans should be the real foci of much "shell shock" research.

John

[John Gilinsky]

Ian Sumner - If you have done extensive research into French military medicine of the war and/or French shellshock resources and you wish to share these then please get in touch with me via PM or otherwise.

Thanks, I truly appreciated your good post regarding French contemporary sources (periodical articles, laws/decress) on French military medicine.

John

[headgardener]

I contend that the wrong questions are asked by many when considering "shell shock." The most recent posts to this thread focussed on "neurasthenia" exemplifies this. "Neurasthenia" was and is NOT "shell shock." "Neurasthenia" was used by "military doctors" (read civilian doctors wearing military uniforms) in stressful circumstances often during emergency or crisis situations in less than ideal medically clinical venues in officially "disposing" / "handling" certain "soldiers" the vast majority of these "soldiers" (read civilians many but not all of course compelled to serve)being essentially civilians and hardly professional soldiers. The vast majority of medical personnel and those being psychiatrically/psychologically labelled were medically untrained, inexperienced in military/war medicine and in particular the mental health sciences. Falling back on "experts" in rear areas or far more frequently in fact the home front to officially handle perplexing behaviours expeditiously was hardly unusal. The real histories of "shell shock" focussed on actual combat service soldiers in theater(s) and the same soldiers who returned during the war to their respective home fronts AND the post-war histories of such veterans should be the real foci of much "shell shock" research.

John

John,

I wouldn't disagree with you, but surely we're looking at the background to the whole issue of 'shell-shock'? For any meaning discussion I'd say that we have to look at the whole background to psychological and psychiatric medicine of that era, and that will by necessity include the contemporary understanding of neurasthenia/hysteria/post-traumatic stress. I suspect that Robert wants to hold the debate that you're opening up until later in the thread; at least I think that it would work better that way, but that's just my opinion.

The only way in which I would slightly disagree with you is that I believe that we will find that neurasthenia became such a vague and disputed diagnostic category that it was extended by some (although not by others) to cover what may be considered to be 'shell-shock'. I am sceptical that a undisputed and meaningful differentiation between these 2 diagnostic categories will be established. But Maybe that's a discussion for later in the thread. Let's see what come up.

[John Gilinsky]

Tx headgardener - (still am computer actual name unsavy!). As an interesting point - U.S. medical researchers due to the casualties of the guerrilla war and terorist actions waged against U.S. personnel in Iraq in the early and mid-2000's publicized their contention that "shell shock" a propos Dr. C. Myer's original early 1915 published articles on same referring to at least one major category of patients as being actually physically harmed in their brains by physical affects of explosives is quite correct AND drawing direct cause/effect relationships with deleterious social-psychologically harmfull after-affects of those casualties.

John

[headgardener]

Tx headgardener - (still am computer actual name unsavy!). As an interesting point - U.S. medical researchers due to the casualties of the guerrilla war and terorist actions waged against U.S. personnel in Iraq in the early and mid-2000's publicized their contention that "shell shock" a propos Dr. C. Myer's original early 1915 published articles on same referring to at least one major category of patients as being actually physically harmed in their brains by physical affects of explosives is quite correct AND drawing direct cause/effect relationships with deleterious social-psychologically harmfull after-affects of those casualties.

John

That's an interesting bit of research, and it is consistent with some key issues pertaining to this thread. Is the diagnostic category of 'shell-shock' describing a single condition or an overlapping spectrum of conditions ranging from psychological states to a true neuro-pathology? That's a rhetorical question, btw.

The title of this thread is 'Neurasthenia and Shell-shock; Clinical information from before and during the Great War', so let's see what contemporary info we can dig up. I'll post some other references later today.

[John Gilinsky]

From an American perspective including pre-war, during and immediate post see:

Schuster, David G. "Neurasthenic Nation: America's Search for Health, Happiness, and Comfort, 1869-1920"

Cloth ISBN: 978-0-8135-5131-9 224 pages

Publication Date: September 2011

http://rutgerspress.rutgers.edu/acatalog/neurasthenic_nation.html

and for his earlier Ph.D. - Schuster, David G. "Neurasthenic nation: The medicalization of modernity in the United States, 1869–1920 ." University of California, Santa Barbara, 2006, 337 pages. 3238802;

and for Imperial Russia pre-war:

Goering, Laura "Russian Nervousness": Neurasthenia and National Identity in Nineteenth-Century Russia" in - 'Medical History' 2003, pp. 23 - 46

John

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1044763/pdf/medhist00004-0028.pdf

[John Gilinsky]

The abstract to the Schuster 2006 Ph.D. is apropos the discussion in this topic very appropriate:

Abstract (Summary)

This dissertation proposes a metaphor for the years 1869 to 1930 drawn from medicine and unique to the period itself. This metaphor is the disease neurasthenia, a nervous condition affecting the mind and body that was thought to be unique to modern societies. Whereas past studies of neurasthenia have typically relied upon medical articles or literary accounts to understand the disease, this dissertation adds to the analysis patent medicine advertisements, newspapers stories, archived correspondence between physicians and patients, the work of progressive reformers, and archived clinical patient records. By situating neurasthenia at the intersection of private and public life in American society, this dissertation seeks to show how neurasthenia went from being a medical condition defined and diagnosed by professional physicians to being a popularized condition defined and diagnosed by advertisers, journalists, teachers, faith healers, managers, and, importantly, patients themselves. Once popularized, neurasthenia helped create conversations, both public and private, that went beyond narrowly defined medical issues to help people negotiate changes commonly associated with "modernity," including urbanization, the growth of white-collar jobs, professionalization, the rise of the leisure industry, therapeutic religious movements, the commercialization of popular culture, the reevaluation of gender roles, and mass public education. Ultimately, this dissertation seeks to define the United States, as it emerged from the nineteenth century, as a "Neurasthenic Nation," a place where people saw their personal health inextricably linked to the pitfalls and possibilities of the changing world around them.

John

[Robert Dunlop]

Beard's work introduced the concept of neurasthenia in the late 19th Century. As mentioned before, it will be important to trace the development of the concept in the medical literature leading up to the war. Meanwhile, I would like to return to the concept of 'shell shock'. The term is first attributed to Charles Myers, whose article "A Contribution to the Study of Shell Shock: Being an Account of Three Cases of Loss of Memory, Vision, Smell and Taste, Admitted to the Duchess of Westminster's War Hospital, Le Touquet." appeared in The Lancet on Feb. 13, 1915 (pp 316-20). Before examining Myer's paper in more detail, there is an article from the Jan. 13 1900 edition of the British Medical Journal that is worth reviewing. I thought that I had quoted it earlier in the thread but I can't find the detail. The article was written by Marsh Beadnell, who was a surgeon with the Naval Brigade in Lord Methuen's force. Beadnell wrote about the Battles of Modder River and Magersfontein, which took place on November 28th and December 13th 1899 respectively. He briefly touches on the potential effects of lyddite, which was a newly developed high explosive:

"LYDDITE.

Our lyddite shell from the 4.7 naval gun has a magnificent effect to the eye, sending up a vertical column of earth and debris to a height of about 50 or 60 yards. It is claimed by the inventor to kill by concussion within a radius of 34 yards from the site of the explosion."

This is a reminder that the concept of concussion was understood before the war, as well as a pointer to the concept that concussion from a high explosive shell could kill.

Beadnell went on to note:

"I have only witnessed the effect of the shock of the explosion once; it was in the person of a Highlander. A shell exploded about ten yards over his head, he was untouched by any fragments, but the concussion must have produced some curious pathological change in his nervous system, as he has never ceased (now ten hours) swaying his head to and fro with a pendulum-like motion similar to that of the china dolls with the nodding head so commonly seen in the London streets."

In the same edition of the BMJ, there was another mention the concussive effects of lyddite, written by 'A South African Campaigner':

"With regard to the effect of lyddite as an explosive in warfare we are still rather in the dark. We are told that a lyddite shell exploding will destroy life within a considerable area by the mere force of concussion; on the other hand, a certain Mr. Preller, writing to the Volkstem, a South African Dutch newspaper, says -

'We were standing close to Long Tom, which was, as always, attracting the enemy's shell fire. One of the British guns fired at us, and the shell fell close to us with at tremendous noise. It struck just behind our guns, and sank 4 feet into the solid ground, making a hole big enough to bury one horse and one man standing. Everyone expected that he would be the first victim of this wonderful lyddite's terrific power. Well, the fatal smoke cloud arose, and fragments of shell snarled around us in all directions. We stood and looked with bated breath. The smoke cleared way, and we found that not a man of us had been hurt. So there was another bubble burst. The lyddite smoke was proved to be non-fatal, and its general effect altogether less terrifying than we had been led to believe.'"

Robert

[ian.sumner]

Ian Sumner - If you have done extensive research into French military medicine of the war and/or French shellshock resources and you wish to share these then please get in touch with me via PM or otherwise.

Thanks, I truly appreciated your good post regarding French contemporary sources (periodical articles, laws/decress) on French military medicine.

John

PM on its way

Ian

[Robert Dunlop]

There's an index to a number of contemporary French medical journals, with links to the article on Gallica, at http://tsovorp.org/histoire/Themes/Guerre14bases.html

Ian, thanks very much for the list. I missed it first time round.

Robert