Neurasthenia and Shell Shock

[Robert Dunlop]

Myers... "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."... The Lancet on Feb. 13, 1915 (pp 316-20).

Prior to the war, Charles Myers was a Lecturer on Experimental Psychology at Cambridge University. After the war, Myers became President of the Section of Psychiatry at the Royal Society of Medicine This background is important when examining Myers' paper. After war broke out, Myers served as a Captain in the RAMC, holding the position of Registrar at the Duchess of Westminster's War Hospital in Le Touquet until at least March 1915 (which is the latest date for an article that describes his position and location of work). Apart from his paper on 'shell shock', Myers was second author on a very important paper about trench foot. The paper identified that prolonged exposure to cold water was more significant than frostbite.

Myers' paper in The Lancet discussed three men who developed a pattern of symptoms and signs after exposure to shell fire or its effects. The specific circumstances were: 'shells bursting about him when hooked by barbed wire; shell blowing trench in; shell blew him off a wall'. All of the men had problems with their eyesight. Myers used the term 'amblyopia', which in this series of cases refers to poor vision. One of the men described it as 'blindness'. When examined all of the men could only see the test object when it was almost directly in front. Peripheral vision, ie the ability to pick up things off to the side when looking straight ahead, was severely restricted. Only one of the soldiers experienced partial deafness. All of them had problems with being able to smell things: one had complete loss of the ability to smell (anosmia); one lost the sense of smell on one side only; and one man had partial loss of smell. The sense of taste was also affected, being 'almost total' in one case and 'reduced...' in the other two. Two men had significant loss of memory for the event; the other man's memory was 'apparently slightly affected'. There were no abnormal movements, tremors, or other effects, such as weakness or altered sensation, elsewhere in the body. In other words, the three men had problems with some, but not all, of the special senses in the head, associated with varying degrees of retrospective amnesia.

The reductions in the field of vision were quite striking. The original paper includes reproductions of the charts that showed the initial limitations in perpipheral vision. These were carefully plotted on the special charts, with subsequent measures showing a gradual improvement.

Myers continued to observe the men for a period of time. In summary, all three men experienced 'gradual improvement by rest and [the process of] suggestion', with two men also improving through hypnosis.

At the end of the detailed descriptions, Myers wrote:

"Comments on these cases seems superfluous. They appear to constitute a definite class among others arising from the effects of shell-shock. The shells in question appear to have burst with considerable noise, scattering of much dust, but this was not attended by the production of odour. It is therefore difficult to understand why hearing should be (practically) unaffected, and the dissociated 'complex' be confined to the senses of sight, smell and taste (and to memory). The close relation of these cases to those of 'hysteria' appears fairly certain."

Robert

[Robert Dunlop]

Myers' paper raises several issues:

1. He specifically mentions that the three cases constitute "a definite class among others arising from the effects of shell-shock". As I read this, Myers was alluding to a broader understanding of shell shock. Put another way, he was not defining this new entity.

2. The specific mention of the shell explosions being "not attended by the production of odour" could be a reference to the debate mentioned earlier. There seemed to be a small body of opinion that argued against concussive effects being involved. The alternative view was that toxic gases might play some role, perhaps acting as poisons on the nervous system.

3. Myers had difficulty accounting for the problems with vision, smell, taste and memory in the absence of significant hearing problems (though one soldier did have some hearing impairment). Myers reaction to this unexplainable (by him) symptom complex was to relate the problems to 'hysteria'. He was probably drawing on his primary expertise, which was psychology medicine, not on a detailed understanding of neurology. The responses to 'suggestion' and 'hypnosis' may have reinforced his view. There are alternative ways to interpret the findings and the responses to 'treatment'. It is not the purpose of this thread to raise these alternatives but rather to provide the base evidence from which we can better interpret what was understood at the time.

Robert

[headgardener]

I think that is a very interesting and helpful assessment regarding Myers' paper.

I feel that I have to take issue with you about this section (particularly the sentence that I have highlighted);

Myers had difficulty accounting for the problems with vision, smell, taste and memory in the absence of significant hearing problems (though one soldier did have some hearing impairment). Myers reaction to this unexplainable (by him) symptom complex was to relate the problems to 'hysteria'. He was probably drawing on his primary expertise, which was psychology medicine, not on a detailed understanding of neurology. The responses to 'suggestion' and 'hypnosis' may have reinforced his view. There are alternative ways to interpret the findings and the responses to 'treatment'.

At Cambridge University Myers was taught by, and was subsequently the assistant of, the eminent psychiatrist and neurologist W.H.R. Rivers. He was Rivers' research assistant for about 7 years ('02-'09), and his teaching assistant for much of that time. Rivers specialized in the neuro-physiology of the special senses and during the period that Myers was working with him he was credited with revolutionizing the teaching of this subject which had previously been poorly understood within British medicine. Rivers drew much of his knowledge from the German school of neurophysiology/neurology. While he may not have been a neurologist I would suggest that, having been taught by Rivers and been his teaching assistant, Myers had a very well-developed understanding of neurology. His particular interest in the special senses is clearly demonstrated in the paper that you have posted here.

Myers interest in psychology was developed during his time with Rivers. I'd suggest that, at that time, neuro-physiology and neurology were Myers' areas of primary expertise. His interest in the field of psychological medicine was already well-developed by then, and was developed much further by his experiences during the war.

[Pete1052]

Around 25 years ago I read that the medical profession in the Western world in 1914 believed that most histrionic or highly emotional reactions to disturbing emotional events were mainly confined to women, such as Victorian women having fits of the "vapours." I don't remember the author's name or the title of the book. What the Great War did was to show that it happens to men put into stressful situations as well, too. From what I've read the German Army seems to be more accepting of transient cases of the inability to function due to emotional trauma than the British or American ones.

[Old Tom]

I have been following this discussion with interest and perhaps a little understanding. My only knowledge of this field is a recollection of the literary works of Sassoon and Graves with regard to the attention received by Sassoon, which I think have influenced some works of fiction. May I ask if and when the discussion is complete there is an intention to summarise the results in, if possible, laymans terms?

Old Tom

[headgardener]

Around 25 years ago I read that the medical profession in the Western world in 1914 believed that most histrionic or highly emotional reactions to disturbing emotional events were mainly confined to women, such as Victorian women having fits of the "vapours." I don't remember the author's name or the title of the book. What the Great War did was to show that it happens to men put into stressful situations as well, too. From what I've read the German Army seems to be more accepting of transient cases of the inability to function due to emotional trauma than the British or American ones.

It's a very well-documented issue. Many modern studies on shell-shock have commented on it. It was even touched on in one of Robert's earlier posts on this thread (No. 61), when he was describing Beard's theory regarding features of neurasthenia (fine hair, shape of the hands, artistic temperament, and the 'mental activity of women'). There appears to have been a persistent tendancy in contemporary medical discourse to link feminine characteristics with hysterical tendencies. Hence the difficulty in equating a model of masculinity (a soldier) with a feminine trait (hysteria). The army medical establishment (and the British medical establishment in general) clearly had difficulty with it. An author called Elaine Showalter has written several books and articles which have focused on 'shell-shock' as being a principally gender-based diagnosis (specifically, it's easier to describe a soldier as being 'shell-shocked' than hysterical; the diagnostic category of 'neurasthenia' tended to be reserved for officers).

The term 'hysteria' comes from the same root as the Greek word 'hystera', meaning 'uterus'. Hysteria was considered at one time, and by certain strands of medical opinion, as being a 'disease of the womb', and therefore an essentially female condition. This thinking persisted for a very long time, and some of the instincts that underpinned this notion are still with us to some degree (flustered middle-aged men in a state of collapse and with shortness of breath are more likely be thought of as having a heart attack than their female counterparts). That's a whole other discussion.

You're right about the German military authorities having a more nuanced approach to the subject. I disagree that WW1 showed that men could also be hysterical; that had been fairly well established in (most particularly) German and French medical discourse. I would say that WW1 led to a greater acceptance of the notion.

[Robert Dunlop]

I feel that I have to take issue with you about this section (particularly the sentence that I have highlighted);

Excellent. Thank you for the challenge, and for taking the time to add the extra details. The selection of cases is explained by a background in neurophysiology of the special senses. The three soldiers fit squarely into this domain. It is interesting, however, that Myers did not make the connection between the visual problems, loss of smell and loss of taste, without significant effects on hearing (except in one case). Neurophysiology is not the same as neurology, as you say. Very interesting.

Robert

[Robert Dunlop]

May I ask if and when the discussion is complete there is an intention to summarise the results in, if possible, laymans terms?

Certainly, Old Tom. There is still quite a lot of material to come. I will undertake, however, to summarise things. Please feel free to pull me up if the material or explanations are too technical. It is good to have this feedback.

Robert

[Robert Dunlop]

Apologies but I forgot to mention another paper that appeared before Myers' article. It was written by Lieutenant Elliot, RAMC, in December 1914. The paper was entitled 'Transient paraplegia from shell explosions', published in the British Medical Journal. The first two paragraphs read as follows:

"Among the injuries caused by high shell explosions [sic ?meant to be 'high explosive shells'] in the present campaign on the Continent is a form of transient paraplegia which has already led to mistakes in diagnosis in its early stages, and which will be still more difficult to recognize in the men who are invalided home with only the history that they can give as a guide to a correct opinion.

The chief features of the condition are as follows:

Numbness and complete paralysis of the legs are complained of when the injured man receives help from his comrades immediately after the explosion, and yet there is no manifest wound of the body. The arms are generally unaffected, but the legs remain powerless, so that the patient has to be carried from the field on a stretcher. Within a week movement and sensation are returning in the legs, and after the lapse of a fortnight the soldier as a rule can walk about again, though he continues to complain of extreme tenderness in the lumbar region [low down in the back], and aching pains that shoot up the back. There is rarely any trouble with the sphincters [these are the muscles that control the ability to pass urine and open the bowels. In severe spinal cord injury, patients loose control of the bladder and bowels]. During the paralysis the leg muscles are slightly flaccid [limp, which is an early sign of damage or injury to the spinal cord. 'Slightly' means that the damage was minor.], and both the superficial and deep reflexes are depressed [deep reflexes are the ones that a doctor tests with a reflex hammer, eg tapping just below the knee cap to make the lower leg jerk. Superficial reflexes involve stroking the skin in certain areas of the body, which triggers a reflex contraction of the muscles just under the skin. 'Depressed' reflexes fit with minor damage to the spinal cord or to the nerves leading out of the spinal cord], while there is nearly always an area of hyperalgesia [increased sense of pain when the skin is gently pricked with a pin] encircling the abdomen above or below the level of the umbilicus [the tummy button. This is an important sign of partial damage to the spinal cord]. The plantar reflex is never extensor [The plantar reflex occurs when a key or similar object, typically the other, pointy end of a reflex hammer, is pushed firmly along the outer edge of the sole of the foot, starting at the back and moving forward to the thick pad just behind the big toe. This movement causes the big toe to move down automatically, which is caused a flexor response. If the toe moves up, which is the extensor response, then this is a sign that the spinal cord has been completely or almost completely severed, with time for the initial shock of the injury to wear off]."

In summary, the author has described another class of cases (to use Myers' expression) that involve partial spinal cord injury following shell explosions. There are signs [what the doctor detects on examination] present that cannot be faked. Nevertheless, Elliot went on to note:

"The slightness of the objective signs and the prominence of the subjective features of pain and tenderness, especially in the lumbar spine, lead naturally to the belief that the paraplegia was functional [ie not due to actual damage of the nerves in the spinal cord] and the residual tenderness is neurasthenic. That diagnosis is often made, and it is the most likely one to be chosen when the invalided man is first met with in England. In some cases it is undoubtedly correct, for hysterical and neurasthenic breakdowns are frequently met with in men who have been exposed to the shattering effects of great German shells. An example of this is quoted later to illustrate the points of distinction between the true and the functional paraplegia."

Elliot also addressed the issue of toxic fumes, as opposed to concussion, as the cause:

"A second diagnosis that is tentatively made at times is that of 'gassing', which ascribes the weakness to a toxic action of the fumes evolved in the explosion. I have not heard any suggestion made by men returning from the trenches that they have suffered [from what Elliot regarded were the signs of gassing] from the German shell fire and the explanation cannot be applied to the type of injury with which this account deals."

Robert

[Robert Dunlop]

Elliot went on to describe four cases of soldiers who had developed some degree of paraplegia are shell explosions. In one case, the soldier died two days after the event. A post-mortem was carried out but this did not show any visible signs of damage to the spinal cord. It should be noted, however, that signs of nerve injury may not be visible to the naked eye. The swelling and inflammatory changes may only be visible under microscope examination.

The four cases illustrated, in Elliot's view, a spectrum ranging from clear physical damage through to 'hysterical simulation of... true paraplegia, which can at once be recognised by the state of the deep reflexes, and a... speedy recovery which will emphasize the distinction between it and the more prolonged results of real injury. Functional disorders of the nervous system [ie problems where no physical cause can be found] are far from rare in the fright caused by a big shell explosion, and they assume very diverse forms. The man may become blind, or deaf, or dumb; he may be seized by a violent and coarse tremor that shakes the body for days; or he may be paralysed with a hemiplegia [weakness down one side of the body] or paraplegia [weakness in the lower half of the body].'

The last case was of a soldier who suffered loss of consciousness when the shell exploded, killing the man next to him. As the soldier came to, he was 'paralysed in the legs'. Three days later he was examined at the base hospital, when it was noted that the legs were 'incapable of movement, but not atonic [ie completely limp and floppy with no muscle tone at all. This would normally be expected in the earliest phase of total paralysis from severe spinal cord injury.]. Deep and superficial reflexes all increased [the opposite of what would be expected]. Hands tremulous.' Five days after the injury, he was 'up and walking about freely. Practically well.'

Elliot discusses how to distinguish between functional and organic [due to damage] paralysis:

"Diagnosis is, therefore, easy in the first or second week after the injury. The functional [emphasis in the original] paralysis reveals itself by an increase of tone in the leg muscles and by exaggeration of the knee and ankle jerks, with a tendency to clonic [jerking] or coarse [very noticeable movements of the affected part/s of the body] tremors. Tenderness and pain may be complained of, but they are felt all over the back, and not localized to the area from which spring the nerves that supply the paralysed limbs [in other words, there are signs and symptoms in different parts of the body, not associated with the original or main injury]. Organic damage, on the other hand, depresses all the reflexes and lowers the tone of the muscles. There is generally a band of hyperalgesia at the upper limit of the area of numbness, and the back is acutely tender, but only over the corresponding spines [the boney prominences that you can feel in the centre line of the back. Each 'spine' can be linked to a band around the body which the nerves from that part of the spinal cord supply]. The worst cases may conceivably show change of electrical reaction [presumably referring to the recording of abnormal electrical signals by putting fine needles into the nerves that are connected to a recording apparatus - an example of the study of neurophysiology mentioned earlier in this thread], and subsequent wasting of muscles [muscles need nerves to enable them to stay healthy. If the spinal cord is permanently damaged, then the muscles gradually lose bulk] but I have not been able to examine this point. Nor have the men been sufficiently long in France to follow the later history of their recovery."

Despite the attention that has been drawn to Myers' paper, it was Elliot who first described many of the features that later came to be known as 'shell shock'. Although Elliot was focused on paraplegia, he listed things like tremor. He also drew attention to complex and unusual [from a medical perspective] combinations of signs and symptoms being a pointer to functional rather than organic causes.

He concluded:

"The clinical diagnosis of injury is important, for it is only fair to the injured men that they should not be classed as neurasthenic or hysterical."

Robert

[headgardener]

Myers... "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."... The Lancet on Feb. 13, 1915 (pp 316-20).

The selection of cases is explained by a background in neurophysiology of the special senses. The three soldiers fit squarely into this domain. It is interesting, however, that Myers did not make the connection between the visual problems, loss of smell and loss of taste, without significant effects on hearing (except in one case).

There are 3 possible interpretations of Myers' observations;

1) While I have no reason to doubt Myers ability to recognize a neurological injury, he could have allowed his interest in psychology to 'bias' his interpretation of these men's symptoms.

OR

2) There may have been good reason for him to understand that there was a psychological origin to these men's symptoms (i.e. from their general medical condition and demeanour) but that this may not have been recorded as such in his report

OR

3) There may have been a 'mixed' picture which may not have been easy to diagnose, and that Myers' observations are based partly on their response to treatment. As you rightly point out, there may be varying explanations for such responses.

One of Myers' greatest 'claims to fame' is that he coined the term 'shell-shock' The paper that you've cited was the first recorded use of the term. As an aside, it's interesting to consider how widely understood the term is, in much the same way that Shakespearean quotations have worked their way into everyday language.

[headgardener]

Apologies but I forgot to mention another paper that appeared before Myers' article. It was written by Lieutenant Elliot, RAMC, in December 1914. The paper was entitled 'Transient paraplegia from shell explosions', published in the British Medical Journal.

Elliot went on to describe four cases of soldiers who had developed some degree of paraplegia are shell explosions.

Despite the attention that has been drawn to Myers' paper, it was Elliot who first described many of the features that later came to be known as 'shell shock'. Although Elliot was focused on paraplegia, he listed things like tremor. He also drew attention to complex and unusual [from a medical perspective] combinations of signs and symptoms being a pointer to functional rather than organic causes.

Elliot's paper is very interesting. What I think is particularly interesting about it is that he uses the term 'hysterical'. In effect, he confirms that there was already an understanding that some men reacted hysterically, or become neurasthenic, when exposed to shell-fire. It's true that he mentions it when saying that "it is only fair..... that (injured men) should not be classed as neurasthenic or hysterical" (my emphasis), but this also illustrates that an attempt was already being made to draw a distinction between 'true' injuries (i.e. men with measurable neurological injuries of some kind) and those that simply 'went to pieces'. It also illustrates that neurasthenia was a reasonable diagnosis in this situation.

I think we'll find ongoing attempts to distinguish between 'shell-shock' as an 'acquired' condition, and neurasthania as a 'constitutional' predisposition.

Also, in the first line of the report, he highlights the key problem in diagnosing 'shell-shock'. He says "Among the injuries caused by high shell explosions in the present campaign on the Continent is a form of transient paraplegia which has already led to mistakes in diagnosis in its early stages, and which will be still more difficult to recognize in the men who are invalided home with only the history that they can give as a guide to a correct opinion." (my emphasis). Basically he's saying that the doctor may be forced to rely largely (maybe exclusively?) on the patient's own testimony rather than physical findings because the physical findings may be confusing or contradictory. Indeed, there may not be any obvious findings at all.

[Guest]

There's an interesting book on archive .org

The remaking of a mind; a soldier's thoughts on war and reconstruction By Henry De Man

It contains this passage, which might be relevant to this discussion, on methods of coping under stress.

" It was otherwise with me, for the consciousness of danger never left me and I almost continuously used reasoning to improve my chances of remaining unhurt. This even developed into a mania. I often caught myself carefully weighing in my mind all the chances of being hit by some missile in some particular spot as compared with another spot a couple of yards away, taking into account almost imponderable circumstances, to the utmost extent of my intellectual ability. The disproportion between the intellectual effort and the irrelevancy of the object of my analysis often struck me and eventually made me realise that I had gotten into the habit of using reflection as a means to bridle my imagination and to distract fear. I have known a few other soldiers who confessed to me that when "alone with

their thoughts" in some more or less dangerous spot they used the same method. They also were afflicted with a power of imagination above the average. It is worth noting that the fear they would have felt if they had given their fancy the rein would not at all, in view of the anodyne circumstances, have paralysed or handicapped them for action. Therefore, I would rather ascribe this desire of escaping the effects of even slight fear to the intuition that any degree of "funk" results in considerable nervous strain. One's instinct to save himself useless fatigue made one naturally try to avert this. With the large majority of soldiers, however, whose power of imagination did not exceed the average, and in whose every-day actions individual reasoning played but a small part, there were but two great antidotes to fear: habit and anger.

I had never fully realised the power of habit untill I saw the miracles it worked at the front. The effect of heavy shellfire, for instance, that constantly threatens sudden, cruel laceration by a mass of steel that may explode anywhere about you without any forewarning, is beyond expression nerve-racking to any normal human being. In the earlier stages of the -campaign, the effect on our brave but unprepared troops was such that a position was usually evacuated as "untenable" as soon as any volume of artillery fire began to concentrate around it. A few months later, the same amount of shellfire would be faced with almost absolute equanimity. I remember how one day the trench mortar positions I commanded had been shelled to such an extent that with a little bad luck half of iny men might have been wiped out. Fortunately, there was no worse damage than the explosion of a couple of tons of our ammunition. The whole "show" had no stronger effect on my men than to make them grumble at the prospect of the work they would have to do with sandbagging and bomb-carrying. "

Mike

[Robert Dunlop]

Yes, there are two parts to Elliot's review of the paraplegia cases. In the first instance, there is the difficulty of making a diagnosis when physical signs are present. When the patient is seen just after the event, signs are likely. In some cases, the signs were clear and consistent. The diagnosis of a physical cause was possible. In some cases, the signs were unusual, unclear or inconsistent. In these instances, doctors faced a diagnostic dilemma. Although Myers' cases were different, they illustrated this problem. Myers was puzzled by the lack of effects on hearing. Finally, there were those cases where signs were absent or were so unusual as to be clearly 'psychological' rather than 'physical' in origin.

Elliot's second point related to the situation where patients' signs had resolved. The evidence from early examinations and close follow-up showed that signs could wane quite quickly. With wounded men transferring along the chain of medical services, it was possible for another doctor to examine a soldier later and not find any signs. In this situation, the examining doctor would have to rely on the story of the illness. Many doctors would not have come across transient paraplegia. The idea that a soldier had been unable to walk and was now mobile with no residual signs might seem incredulous. Elliot was obviously concerned that these men were being labelled as hysterical or neurasthenic. These two diagnoses were not synonymous.

Robert

[Pete1052]

Most men, 95 percent of them, want to be seen as being brave and bold and if for some reason their courage fails them it brings up embarrassing issues of vulnerability and sensitivity. Sometimes there are hints of homosexuality.

Losing one's composure and self-confidence in a stressful situation when other people are watching can be like farting a smelly one in public -- the ridicule and contempt of one's peers can lead to a downward spiral of self-contempt. If the process goes on long enough you might have a psychiatric casualty who can't function any longer.

[Robert Dunlop]

A very brief diversion. Colonel Sir Anthony Bowlby, a surgeon from Barts Hospital, wrote about his experiences in France. His article "The Work of the 'Clearing Hospitals' During the Past Six Weeks" appeared in the BMJ December 19 1914. Bowlby described the range of cases that he saw, which did not include (in his written description) any men who had experienced 'shell shock'. It was interesting to read the following:

"I cannot close these notes of the clearing stations without a word as to the demeanour of the patients. Nothing could be more admirable than the sang-froid and cheeriness of men and officers alike. Many of them were cold, wet, and hungry. All of them had more or less pain. Some of them had suffered exceedingly during their transit from the front… A few were obviously dying. Yet no one grumbled or made querulous complaints. Their spirit was not broken by their misfortune, and they were still as steady and self-reliant as when they endured the shell fire in the trench or advanced to a counter attack. 'The men are splendid,' said Sir Redvers Buller fifteen years ago, and this is still true today."

I don't know how common this view/expectation was. What a contrast, perhaps, the cases described so far must have seemed. No evidence of physical wounds, in sharp contrast to the vast majority of patients being seen at that time. Variable symptoms that were often transient. Unusual tremors. Perhaps fearful and other emotional reactions. Quite a contrast.

It is worth bearing in mind that this early phase of the war was characterised by shell shortages and limited numbers of the heavy guns. As the war progressed, the numbers and calibres of heavy artillery increased significantly. The British forces were increasing in number and would take over more of the front line in the years to come.

Robert

[Robert Dunlop]

Back to shell shock. Myers' paper triggered a series of responses from other specialists in diseases of the eyes, ears, and other special senses. These articles are worth considering as they illustrate how doctors sought to understand the condition.

Within a month, the Neurological Section of the Royal Society of Medicine had organised a meeting to review the issue. The meeting featured a presentation by Mr Parsons, a surgeon. The talk was entitled "The Psychology of Traumatic Amblyopia following Explosion of Shells" (amblyopia refers to poor vision in one or both eyes). Parsons referred to Myers work when describing a 'typical case':

"The history of a typical case is briefly as follows: A man after more or less prolonged fatigue, induced by marching and exposure in the trenches, is incapacitated by the explosion of a shell in his immediate vicinity. He may be merely knocked down, or thrown into the air and more or less seriously injured or wounded by concussion, shrapnel bullets, or shell splinters. Consciousness is lost for a variable time, but often not so far as to prevent automatic movements, so that the man may walk in a dazed condition to a dressing station. The mental equilibrium at this stage is much disturbed, and al memory of this phase is usually lost. The most striking feature of the case is that the man is instantaneously struck blind. The blindness may be associated with deafness, loss of smell and loss of taste, but all these are less frequent than the blindness. On examination it is found that there is intense blepharospasm [uncontrolled twitching of the eyelids, often showing up as excessive blinking] and lachrymation [lots of tears, as in the effects of lachrymatory shells]. The [eye] lids are opened with great difficulty and examination of the eyes is almost impossible. I am not aware of any record of the condition of the pupils at this stage [this is an important point, as the size, shape and reaction of the pupils can help to diagnose the cause of vision problems. Parsons had not examined patients in the immediate aftermath]. In the course of a week or two the blepharospasm diminishes and it becomes possible to examine the fundi [these are the tissues at the back of the eyeball. Doctors use the ophthalmoscope, which has a bright but narrow light, to look at the fundi through the pupils]. Of course, there may be local injury to the eye, but in uncomplicated cases the eyes are found to be normal. The pupils react to light [which is normal], though in some cases the reactions are sluggish, and sometimes one pupil differs from the other, being larger or more sluggish in its reactions [these signs cannot be 'faked' or triggered by psychological effects. They are signs of some physical problem with the eyes or the nerves]. The fundi appear to be absolutely normal [so no signs that an explosion caused damage to the retinae]. By this time probably some restoration of sight has occurred. Light is perceived and large objects may be distinguished. As improvement occurs the patient manages to grope about, usually with his hands outstretched before him, but it is noteworthy that he does not usually stumble up against objects in his path [this is a very significant as the usual types of blindness result in people walking into things that they cannot see]. As soon as it is possible to take the fields of vision [how far a person can see to either side, up and down, when the eyes are looking straight ahead. This tests whether areas of the retina have lost the ability to 'see' or whether there is damage to the nerves that carry the signals from the eye to the part of the brain that results in us seeing things] it is found that they are markedly contracted [which is what Myers found], and that indeed to a degree which seems scarcely consistent with the avoidance of obstacles in walking.

The recovery of vision is slow, but eventually it seems always to be complete. In the later stages I have had cases in which the right eye is more affected and recovers more slowly than the left.

Now there are several suspicious symptoms in many such cases. The eye to recover last is often the shooting eye. Some patients show an obvious disinclination to return to duty. Some candidly admit to being in a "blue funk." In all there has been a complete mental upset, sometimes accompanied by hysterical symptoms-outbursts of weeping, &c.- in the early stages. These features render it only too easy to jump to the conclusion that there is often a large element of shamming in the case. It is because there is very grave danger of cruel injustice being done to men who have " faced the music " and come battered out of the ordeal that I wish to attempt an explanation of the underlying psychology."

Note that there are parallels to Elliot's paper, even though the area of the body is different. Immediately after the shell explosion, the soldier is knocked unconscious or becomes dazed, with no memory of the event. There are striking symptoms. Blindness in this instance but often associated with other symptoms as well, including the rapid blinking and tears. There may be signs of physical damage but the symptoms seen out of proportion to the signs. The symptoms and signs improve quite quickly, which means that doctors back in England see a different picture when the patient is transferred. Emotional responses are common. Given that symptoms often improve, the emotional reactions seem all the more prominent.

Robert

[Robert Dunlop]

Parsons began discussing the possible causes of poor vision or loss of vision following a shell explosion. He started by identifying the diametrically opposed physical causes versus malingering:

"In the first place it is necessary to segregate these cases from allied conditions due to organic lesions or to malingering. It is not always easy to eliminate organic lesions of the type which cause so-called retrobulbar neuritis [inflammation of the nerve, known as the optic nerve, that carries the signals from the retina of an eye back to the brain. It may be caused by multiple sclerosis for example.]. It is still less easy to eliminate malingering, but as this depends upon a knowledge of the psychology of the individual it forms a prime object of the following discussion."

He then put forward a profoundly important hypothesis:

"Since there is no demonstrable organic lesion these cases may be regarded as examples of injuries or wounds of consciousness. This does not imply that there is no neural lesion to account for the psychological disorder, but merely that it has hitherto escaped observation. Without entering into a disputed question, which is largely metaphysical, we will adopt the view of parallelism between physiological neural processes and psychological events or changes in consciousness."

Parsons is suggesting that, even though it may not be possible to identify a physical cause, there may still be some sort of damage to nervous system. His mention of 'parallelism' refers to the fact that psychological changes have some connection to physical changes - the two go hand in hand. Parsons wasn't sure how these things were connected but he explored the hypothesis in some detail. I will summarise, to the best of my ability, in the next post.

Robert

[Robert Dunlop]

Parsons embarked on a long discussion of the evolution of the nervous system. The details are not important. He discussed the primitive reflexes, such as withdrawing the hand when touching a very hot surface. Layered on this are the more complex reflexes, such as the emotional response to such an injury. Finally, there is the notion of conscious control of emotions, coupled with the other 'higher' functions such as the ability to think and reason. Parsons provided an example of the effects of 'shock':

"The effects of an intense emotional shock on this highly complex system may, a priori, be expected to be manifold and complex. Let us consider the effects of a blinding flash of light. In the first place, it will produce certain definite reflex results, sudden closure of the eyes, retraction of the head, perhaps recoil of the whole body, and so on. Actual damage may be done to the delicate retinal structures [that part of the eye that is responsible for converting light into nerve impulses so that the brain can 'see'], resulting in temporary or permanent defect of vision. But apart from these effects the strong light stimulus will have other far-reaching results. Sudden and unexpected visual sensations play an important part in the sensational complex which give rise to the emotion of fear. They are less potent as a rule in this respect than auditory stimuli [things like loud noises that affect hearing]. Nevertheless, they arouse an emotional state which varies from mere surprise to actual fear. Doubtless, the natural instinct of flight is suppressed in the adult by the intervention of the self-regarding sentiment, and manifests itself only in a sudden start. If the blinding flash is accompanied by a loud noise the emotion of fear is still more powerfully aroused; if also accompanied by an offensive smell the emotion of disgust is aroused and gives rise to repulsion."

Parsons seems to have chosen two aspects of an explosion to illustrate how the various aspects of the nervous system can be affected: 'blinding' light and loud noise. He goes on to postulate that there is a personal element to the reaction as well - not everyone reacts in the same way:

"The response of an individual to such a shock depends, therefore, essentially upon the degree of development of his self-regarding sentiment. As we have seen, this depends upon his disposition-i.e., the sum of al his innate instincts, his temperament, and the modifications and control which these have acquired as the result of his environment and experience. We cannot, however, isolate the sensational complex which causes the shock from the concurrent circumstances. The response will vary also according to these conditions-e.g., according to whether the individual is alone or one of a crowd, and so on."

It was important to explain the differences in response to a major explosion. Although the focus is on men who presented to the military medical system with major symptoms and problems, not all soldiers left the battlefield (which is not to say that these men were not affected).

The next paragraph describes Parsons' perception of the military context in which shell shock occurs:

"In the case of a soldier under shell fire the conditions are unique. The man is usually bodily fatigued, whereby his control is impaired. He has "the fear of death before his eyes," and is in a state of acute excitement, whereby his normal judgment is impaired. These conditions conspire to give his innate instincts ungoverned play. On the other hand, positive self-feeling, aided by suggestion and imitation, and the sentiments of patriotism, the honour of the regiment, his own honour, and so on, enforce his volitional control. At last, however, the shock comes which strikes him unconscious. It is not to be supposed that he is there by anaesthetised to these emotional storms. It is rather to be conjectured that he is rendered " subconscious," and hence the more a victim of his lower instincts. This view is supported by the emotional behaviour of the men in the early stages, and by the fact that many of their actions can be revived by hypnosis."

Robert

[John-B-Rooks]

Hi all.

From Index of Differential Diagnosis of Main Symptoms, Herbert French (ed), John Wright and Sons, Bristol 1912.

"Traumatic neuresthenia may follow after surgical operations or comparatively slight injuries to the head, back, or testicle, in addition to the severer traumas [being hit by a train or similar] and strains already mentioned.; and it must be noted that a delay of one or more weeks, an incubation period, may intervene between the receipt of the injury and the development of neuresthenic pains. It would be unfair to take such a delay as evidence of a hysterical factor in the case or of malingering."

'Neuresthenia ' has about 30 sub-headings in this volume and can therefore be considered a researched disease before 1914. With the number of minor mishaps possible while living in a trench it might be seen as surprising that there were not higher numbers of people claiming this form of 'Nervous debility' (Hadden's Pocket Vocabulary of Medical Terms, Henry Payne, Hadden Best and Co, London 1892).

John

[Robert Dunlop]

Thanks John. Some very helpful extra material. The number of sub-headings is particularly interesting.

Robert

[Robert Dunlop]

Parsons provides his explanation for the eyesight problems:

"The 'unconsciousness' in these cases is to be explained physiologically by an abrogation of the functions of the highest level cortical cells."

This is saying the nerve cells in the brain that control consciousness stopped working immediately after a nearby explosion, which caused the soldier to become unconscious.

"Recovery shows that the cells are not irretrievably damaged... [i.e. the effect is temporary] Consciousness returns, but there is blindness. So far as objective evidence goes the lower visual paths are intact and function normally. The optic nerves carry their impulses, at any rate as far as the pupil reactions are concerned."

Parsons is noting that the 'blindness' is not due to damage to the eyes or to the nerves that carry the information from the eyes back to the part of the brain that enables us to 'see'. The fact that the pupils react to light [i.e. contract down when a bright light is shone in the eye - you can mimic this test by standing in front of the mirror, covering both eyes and then removing one hand. You should see the pupil of that eye contract down] means that the eyes perceive the light and the nerves from the eyes carry those signals to the part of the nervous system that controls the pupils' reactions.

"The condition resembles uraemic amaurosis. I have seen it also in children after post-basic meningitis."

Here Parsons is trying to relate the problem to other medical conditions that he has observed before. As a specialist in eye diseases, Parsons had seen similar effects in people with kidney failure and in children who had recovered from meningitis. In both examples, the pupil reactions are present but the person cannot see things.

"The block is somewhere above the so-called primary optic centres- external geniculate bodies, optic thalami and superior coliculi. It, too, is probably the synapses of the cortical cells; in this case the synapses of the fibres of the optic radiations."

This is a typical example of how a neurologist will try to work out where the nervous system is malfunctioning. Parsons is referring to other parts of the 'circuit' that links the eyes to the part of the brain that enables us to 'see'. i.e. the visual cortex. There is an example of the 'cabling' back to the visual cortex here. This image here shows a horizontal 'slice' of the left hand side of the brain. You are looking down onto the slice from above. The back of the brain, where the visual cortex lies, is at the bottom of the image. The dark purple 'optic radiation' is that portion of the cabling that runs from the geniculate bodies (highlighted in the previous image) back to the visual cortex.

The next section provides a nice example of the issue, using an experience that all of us will recognise:

"Sometimes such a block occurs [normally], and it is probably to be explained in the same manner. Everyone knows what may happen when reading an uninteresting book whilst the attention is diverted by some other train of thought. A paragraph is read and one suddenly becomes conscious of the fact that nothing has been conveyed to the mind; yet on reading it again one may recall certain sentences as undoubtedly having been read, though they failed to reach the fully conscious mind."

Parsons has, IMHO, made an excellent attempt to understand how the problem may have arisen through some sudden 'shock' to the nervous system. The initial effect is for the higher functions of the brain that are responsible for thinking and consciousness to be temporarily disabled. This results in the loss of consciousness. As the person recovers, parts of the brain continue to have a problem processing information, in this case information about what the eyes are looking at, and making that information conscious. In other words, the eyes can see but the person cannot 'see'. These days, the problem is known as cortical blindness (inability to see due to a problem with the visual cortex at the back of the brain) or, more commonly, cortical visual impairment (CVI for short). The area of the visual cortex is highlighted in red in this picture of the brain here (the front of the brain is on the left). This picture here shows the back of the brain, with the area of the visual cortex highlighted in red. It should be noted that a violent concussion to the front of the head, sufficient to cause the person become unconscious, will cause the head to jerk backwards. When the head stops moving, say when the person hits the back of the head on the ground, the brain continues to move backwards. The back of the brain then strikes the back of the skull, which is known as a contra-coup injury, i.e. on the opposite side to the original force (the coup if you will). It is not difficult to see (pardon the pun) how, given that the visual cortex is at the back of the brain, that a contra-coup injury would cause the visual cortex to malfunction badly.

Robert

[headgardener]

Myers' paper triggered a series of responses from other specialists in diseases of the eyes, ears, and other special senses. These articles are worth considering as they illustrate how doctors sought to understand the condition.

Within a month, the Neurological Section of the Royal Society of Medicine had organised a meeting to review the issue. The meeting featured a presentation by Mr Parsons, a surgeon. The talk was entitled "The Psychology of Traumatic Amblyopia following Explosion of Shells" (amblyopia refers to poor vision in one or both eyes). Parsons referred to Myers work when describing a 'typical case'

In respect of Myers' original paper; when considering the blindness that many of these men experienced it is absolutely correct to look for a recognizable physical injury that explains the symptom. But in many cases there isn't any obvious injury, or the injury may simply not match the scale of the symptoms. Hysteria is mentioned as a common feature. Myers position was that many of the more extreme symptoms of 'shell-shock' were an emotional reaction to a shocking event. His thinking on this subject is very much in line with some of the French and German schools of thought (neurologists such as Charcot and Janet, plus early psychotherapists such as Freud).

Myers is trying to explore the concept of the blindness experienced by a 'shell-shocked' man as actually being an 'hallucination', much in the way that a very traumatized individual will commonly describe having 'flashbacks' of the traumatic event that they experienced. They were certainly a feature of many men's post-war experience.

Essentially, you can think of a 'flashback' as being an hallucinatory episode of variable length in which an imagined scene, created within the brain's processes, temporarily over-rides the 'real' images transmitted to the brain by the patient's eyes (via the optic nerve to the visual cortex - a very real neuro-physiological process). This 'over-ride' is already a very difficult phenomenon to explain from a purely neurological perspective, yet we all recognize that it happens. In what would now be called 'psychogenic blindness', the patient may be over-riding the information coming from their eyes with something coming from their imagination; an 'hallucination' of blindness, as it were. I know that we tend to associate hallucinations with seeing things that aren't there rather than not being able to see things that are, but in this instance you have to think of the patient as 'seeing' literally a 'blank'. The degree of control that any individual has over this process is debatable.

Myers wasn't saying that trauma to the brain can't cause temporary blindness, or that these men weren't concussed or physically injured in some way. But their physical injuries can't easily explain the range and extent of their symptoms. Blindness, in this case, was the most obvious medical problem, so it's logical that this should be the symptom that the medics focused on in the hope that it would help them discover the root of 'shell-shock'. There was a danger of ignoring the greater context (namely, the individual patient and the circumstances in which the patient acquired the injury) by allowing the search for a cause to be focused solely on neurology.

And, in any case, not all men diagnosed with 'shell-shock' experienced trauma to the head. Equally, not all men who suffered trauma to the head were 'shell-shocked'.

[Robert Dunlop]

I am going to keep updating material in a chronological sequence. The aim is to give everyone a sense of how the understanding of shell-shock evolved as the war progressed. Thus far it has not been apparent that British doctors were picking up cases with the exact same symptoms who had not caught in a shell blast. We have seen how there were men who became psychologically debilitated, hence the reference to setting up a new convalescent facility in the south of England in one of my earlier posts.

As to Myers struggles, these cannot be deduced from his first publication in the Lancet. If anything, the opposite is the case. The Lancet was, and still is, a very prestigious medical journal. A paper that was deemed irresponsible or off the page would not have been published there. It wouldn't have even reached the peer review stage.

The Royal Society of Medicine meeting came shortly after Myers' paper. Parsons, having touched on the 'physical' basis for eye symptoms, went on to note:

"It is definitely stated by Dr. Myers that smell is partially lost in spite of the fact that there is no unpleasant odour noticeable when a shell explodes. This is probably to be explained by suggestion."

Here we see Parsons' attempt to link physical cause (a strong 'shock', in this case an unpleasant odour) with effect (partial loss of smell). Given that this is not possible, as there was 'no unpleasant odour noticeable', Parson appears comfortable in suggesting a 'pyschological' cause, namely suggestion.

He then writes:

"I do not, however, think that it is necessary for the explanation of loss of vision and hearing that the visual and auditory paths respectively should have been definitely stimulated. These paths-situated in such intimate relation with the higher levels-play such a prepotent part in cerebral processes.... that at any rate a partial visual block might be expected at times to persist beyond the recovery of consciousness. The duration of such persistence, however, is likely to be much greater if the primary shock has a powerful visual element, whether it be a blinding light or an awe-inspiring spectacle."

It must be remembered that Parsons was writing from the comfort of England. He had not attended men on the battlefield, or even close to it. Drawing on past experience again, he was suggesting that the brightness of an explosive flash might somehow prolong the disturbance in vision. At least some aspect of 'shell-shock' was, in his mind, related not to the blast effect but to associated physical phenomena - bright light, unpleasant odour, etc.

The next paragraph is very interesting:

"Though in the cases under special consideration there can be little doubt that the early loss of vision has a definite neural basis [ie something is physically wrong with the nerves], it must, I think, be conceded that in the later stages the neural basis is of that undefined nature which we associate with so-called 'functional' conditions. In other words it is neurotic; but it is not 'shamming,' difficult though it be to draw the line between them."

Parsons was saying that the initial effects were physical, due in part to a bright light affecting the eyes, but that the subsequent eyesight problems did not have a direct physical cause. He explores this theme further:

"It has already been mentioned that in the earliest stage of recovered consciousness volitional control is almost, or quite, abrogated [i.e. as the soldier regains consciousness, he has trouble knowing or understanding what he is doing or what to do]. The man is merely an emotional animal, or rather worse, for he is deprived of that intelligent control which plays such an important part in animal life. His behaviour is hysterical, but it is a passive hysteria, unlike the commoner active hysteria in which the partially emancipated emotions are often guided by some preponderant ideational impulse. There can be litle doubt that in this stage the most potent of the primeval instincts-fear-holds almost undisputed sway, irrespective of the normal character of the individual, for the loss of volitional control implies the loss of the co-ordination of all those complex factors which make up the character of the man. As recovery progresses the outward manifestations of fear are more and more masked or suppressed, for the self-regarding sentiment gradually again becomes restored."

Thus there is a fugue-like state in which self-control is overtaken by profound fear. As full mental control is restored, the fear is gradually repressed (but does not go away).

"There are rare characters in which the emotion of physical fear appears to be non-existent, but in the vast majority of cases it is present, and however cleverly it is masked, or however nobly it is suppressed, it has to be reckoned with. If merely masked, it will prove a very powerful incentive to the avoidance of renewed exposure to danger, and a temporary disability may give place to deliberate fraud. If suppressed, it may yet require all the help which can be derived from the highest sentiments, reinforced by suggestion and by the active sympathy of discreet friends and advisers. These may all fail, but if so it is a case for pity and encouragement rather than contempt and obloquy."

Parsons has described a combination of physical and psychological responses. His exhortation to show 'pity and encouragement' reveals a mixture of paternalistic condescension and altruism, rather than condemnation.

"It appears to me that these are the principles which should guide the medical adviser in his investigation and treatment of the case. We are accustomed to take the past histories and present conditions of our cases. In these "wounds of consciousness" the past history involves a difficult investigation of the innate dispositions and propensities of the individual, the environment to which he has been subjected in his home life, his school life, and his further career, and last, but not least, in the special cases under consideration, the motives which led him to join the Colours. For every man who enlists is not necessarily a ready-made hero. Many have enlisted merely because they are ashamed of

not following the example of their friends. All honour to them, but they are not equipped with the sterling qualities of the man who is impelled by a noble ideal. The latter may recover completely from the shock, reinforced indeed by the sense of a moral victory won. The former may remain partial wrecks, too fearful of a renewal of their terrifying experience to be of any use in the fighting line. By injudicious forcing they may be wrecked entirely. On the other hand, by carefully studying their habits and tastes, they may be switched off into other paths which will lead to the restoration of self-esteem and make them again useful members of society."

Robert

[Robert Dunlop]

Then, as now, the Royal Society of Medicine meetings featured a key note speaker followed by discussion. Members of the audience shared similar cases and/or commented on Parsons' presentation. First up was Mr Herbert Fisher, a surgeon. He:

"...had recently seen the case of a man who had some two or three weeks earlier been rendered unconscious by the detonation of a high-explosive shell, and who on recovering consciousness found the sight of the right eye [typically the dominant eye and the one that is used to aim a rifle] quite dark. He was removed to a Base hospital, and it was not until some days had elapsed that he began to recognise some signs of returning sight in the eye complained of. When he (Mr. Fisher) first tested him the patient alleged that the right eye could do no better than count fingers at very short range [which is a usually a sign of very significant impairment of vision]. The left eye had the full acuteness of sight. There was no inequality in the response of the two pupils to light, and ophthalmoscopic examination revealed no change whatever in the eye complained of. By manipulating lenses before the left eye while the right eye was uncovered and, without the knowledge of the patient, using a convex lens before the left eye of sufficient strength to exclude its distant vision, the right eye read. He then demonstrated to the patient that he had been seeing the bottom line on the test board with the right eye; he was struck by the undoubted surprise of the patient and was quite convinced that he was not a malingerer. The patient was certainly surprised, if not pleased, to discover that he could see so well with the eye which he had considered was so defective."

In this case, the eye specialist was able to set up a situation where he seemed to be testing the sight in the left eye. In reality, however, the test was rigged so that the left eye could not see the chart and the patient was reading the letters using his right eye. There is no information about the signs immediately after the man recovered consciousness. Several weeks later, it is clear that the residual disabling symptom was not due to any physical damage of the eye itself or the pathways within the brain that enable the person to see.

Mr Fisher concluded that:

"He entirely agreed with Mr. Parsons that these cases should be treated sympathetically and the patients not upbraided, if a good result was to be obtained."

Robert