Neurasthenia and Shell Shock

[Robert Dunlop]

The next respondent was another surgeon, Mr Buzzard. His comments brought out the link between cases of shell-shock and similar symptoms in men who had no history of being next to an exploding shell:

"There was no essential difference between these cases of amblyopia [loss of vision] following shell explosion and the various forms of hysterical deafness, mutism and paralysis which they were seeing so commonly in connexion with this war, and which they saw in somewhat smaller numbers during peace time in connexion with the Workmen's Compensation Act."

The Workmen's Compensation Act, along with the introduction of the railways and, more importantly, compensation for injuries sustained in railway accidents, saw a rise in the number of cases reported as 'malingering' before the war. In summary, people would present with bizarre symptoms that were, in the opinions of the medical examiners, blatant attempts to get money by conning the system.

Mr Buzzard disagreed with the notion of a specific physical cause that was somewhere else in the brain:

"Mr.Parsons had discussed the situation of a possible block in the visual paths in these cases of hysterical blindness, but Dr. Buzzard was unable to agree with him when he suggested some spot between the mid-brain and the occipital cortex as the site of such a block. It was impossible to give an anatomical localisation for a disturbance which was purely mental and belonged to the region of ideas."

Nevertheless, Mr Buzzard went on to note that:

"While it was true that all these cases demanded not only their interest but their sympathy, and that in the large majority the application of the term " malingering " was grossly unjust, from a scientific point of view there was no hard-and-fast line between cases of pure hysteria on the one hand and cases of malingering on the other, if they regarded the former as at one end of a scale and the latter at the other end, and realised that they met with cases showing all the intermediate stages between the two extremes. The only difference between pure hysteria and malingering was probably a matter of the degree to which the "wilfulness" to be blind or deaf or mute was buried in the depths or flourished on the surface of consciousness. They were all aware how difficult it was to discriminate between what they called "functional" and "malingering" sometimes, and their judgment and verdict was often biased by their personal feeling towards the patient. If his manner and bearing attracted one he was suffering from a functional disorder. If he was peculiarly unprepossessing [i.e. just plain and ordinary] he was almost sure to be a malingerer. They ought to recognise and to admit to themselves that the two things were very near akin, just as their treatment of the two conditions was practically identical."

Here we see an alternative view that considers many cases to be examples of 'malingering' but without the deliberate attempt to deceive. This is linked with the view that there could not be an identifiable place in the brain that was physically damaged, though it should be remembered that Mr Parsons felt that temporary physical damage was only likely to be a causative factor in the immediate aftermath of an explosion. Parsons linked this idea with the frequent occurrence of loss of consciousness, a clear sign that the brain was affected physically by an exploding shell.

More seriously, Mr Buzzard's comments show how some doctors attempted to distinguish between intentional and devious malingering versus unintentional and to-be-pitied 'hysteria' based on the general impression made by the person. A very dangerous way to categorise illness and causality.

"A patient suffering from mutism [unable to speak] after exposure to shell explosion at present under Dr. Buzzard's care was such a nice fellow that no one could call him anything but a case of functional or hysterical mutism. At the same time one had to admit that his only successful attempt to speak for some time after his admission to hospital was when he blurted out his conviction that he would rather be dumb for the rest of his life than return to the Front."

Robert

[Robert Dunlop]

Another surgical eye specialist, Mr Paton, picked up on the same theme:

"Mr. LESLIE PATON expressed his great indebtedness to Mr. Parsons for his lucid exposition of an extremely difficult subject. Few things were more important at the present time than a proper appreciation of the difficulty of distinguishing between malingering and a true disturbance of function, and there was grave danger of many cases being regarded with unjust suspicion or even being set down as definite malingerers."

Herein lay the heart of the issue. Leaving aside the possibility of any triggering damage, temporary or otherwise, the distinction was being drawn between a problem that was deliberately and consciously 'made up' to deceive versus a 'true' problem that was still psychological, not physical, in origin.

The discussion clearly shows that this group of doctors was trying to make sense of a complex set of clinical problems, where some of the issues could only be resolved by understanding psychological factors. Most, but not all, of the participants were surgeons and not specialists in psychological medicine. They were not a million miles from Myers, however, in their analyses of what was happening, given that it was Myers' cases in The Lancet that had triggered this meeting.

A Dr Feiling, who worked at the Hospital for Nervous Diseases in Maida Vale, recounted the use of hypnosis to unlock a case of prolonged post-traumatic amnesia. The soldier had been buried for many hours after a shell explosion.

The notes of the meeting make for interesting reading. They show varied opinions, experiences and interpretations. This is normal for any medical meeting . The process is somewhat akin to the process of evolution. It is a key part of the medical scientific discovery process, which generates new leads and new insights. Many prove to be wrong. Gradually the truth emerges. We must bear in mind that not every doctor would have access to, or an interest in reading, the minutes of this particular meeting. The mere fact that the meeting was held on this topic shows how Myers' original paper had had an impact. The narrow focus, traumatic amblyopia, might have led non eye specialists to skip over the report.

Robert

[Robert Dunlop]

Later in 1915, another eye surgeon published a paper in the British Medical Journal. Evans' paper was entitled "Organic Lesions from Shell Concussion". It came out in the December 11th edition.

"A large number of cases of shell concussion have been reported since the beginning of the present war. As far as they concern the eyes, the main symptoms are impairment of sight [can't see very well], contraction of the visual fields [like looking down a tunnel], photophobia [bright light causes pain], and blepharospasm [constant blinking]."

Having described the symptoms and signs, Evans makes an interesting comment that shows how far Myers' and similar works had influenced thinking:

"When these symptoms are noted with little or no evidence of injury to the eyes or neighbouring cavities, it is usual to regard them as functional - a form of traumatic neurosis - and in the majority of cases this view is correct."

Evans then goes on to sound a warning:

"It must not, however, be assumed that they are all of this nature, and it is the object of this note to draw the attention of the profession in general and military surgeons in particular to the possibility of such symptoms arising from more or less gross organic lesions. The lesions may be present without any superficial sign of injury whatever, or very gross changes may follow such slight surface injuries that it is impossible to regard the latter as the true origin of the organic lesions, and we are compelled to admit that they are probably concussion effects."

Although not refuting that many patients developed 'functional' symptoms, Evans goes on to describe some cases where explosions caused problems with eye sight that had a physical cause. The signs of damage were minimal, so it was easy for a doctor to misdiagnose the problem as 'functional'. The case examples included a hole at the macula (which is the part of the back of the eyeball that picks up colour and enables us to read for example), bleeding into the eyeball, rupture of some of the delicate membranes inside the eye, etc.

The report ends with the same warning:

"The cases recorded will, I think, sufficiently indicate the necessity of investigating cases of "shell shock" very carefully in order to differentiate those that are functional from those that are due to organic lesions."

Sound advice, of course, but it illustrates two things. Firstly, it was always important to consider physical causes but it often took a specialist to recognise these. Therefore we must treat the observations of non-specialists with some caution (so Myers, for example, might have missed something in his cases as he wasn't an ophthalmologist.

Second, and more significant, is the clear notion in Evans' mind that 'shell shock' could be due to a functional problem (without any observable damage) or due to an organic problem, as a result of some damage.

Robert

[Robert Dunlop]

As if to reinforce Evans' point, the same edition of the BMJ published a second article following immediately after Evans' paper. The author of the second paper was also an eye surgeon, a Mr Bennett who worked at the Royal Eye Hospital. He described the case of a soldier who was wounded in the face by an exploding shell in the Battle of Neuve Chapelle. The shell went off about 4 feet away, blinding the soldier. There was no evidence of loss of consciousness or any immediate effects on hearing, smell or taste. The fact that Bennett explicitly noted these negative findings strongly suggests he was influenced by Myers' paper.

There were two striking findings in this case. Firstly, the iris (that part of the eye that surrounds the pupil as illustrated here) was torn in the same place in both eyes. In Bennett's opinion, this was clear evidence that the force of the blast on the eye balls had caused the eye balls to flatten, thereby tearing the delicate structure of the iris. Second, the visual fields were contracted down. In other words, the soldier could not see off to the sides when looking straight ahead (tunnel vision).

"The amblyopia [difficulty seeing], seemingly due to commotio retinae and functional disturbance, improved with rest and treatment..."

Commotio retinae is a very specific condition, which is also known as Berlin's oedema. The retina (plural - retinae) is the delicate membrane of cells at the back of the eyeball that picks up light and converts it to nerve signals. The cells are called photoreceptor cells (cells that receive and process light). When the eyeball is hit by an object (or the blast from an exploding shell) then the retina can become damaged by swelling, just like the swelling that happens when there is a sprain or injury to another part of the body. The word 'oedema', in Berlin's oedema, refers to swelling due to fluid build up. In the retina, this swelling will cause the photoreceptor cells to malfunction, which causes loss of vision in the affected area. If the problem is bad enough, then the area of the retina will die. This causes a hole in the retina (but not through the eyeball) - remember in the previous thread that Evans had reported a hole in the macula as one of the results of a concussion injury to the eye. There are some wonderful colour photographs that illustrate commotio retinae here. In each of the four photographs, the front of the eyeball (ie where the iris and pupil are located) would be above the top of the photo. The black area at the top of each photo is the fluid within the eyeball. The next all green layer is the retina, composed of the photoreceptor cells. Then there is a red layer, which is the fluid that has accumulated from the injury. Behind the red layer is another motley green layer, which is the tissues at the very back of the eyeball. The photographs have been taken using a very special imaging machine, which was not available in WW1. It should be noted that these effects are often not be visible if you look inside the eyeball, even with an ophthalmoscope - the special magnifying glass and bright light that doctors use to look through the pupil at the retina. So it is highly likely that non eye specialists did not pick up these changes when examining soldiers who were experiencing tunnel vision.

The case of the private, aged 37, in Bennett's article clearly showed, better than any other so far, that the blast of a shell could result in impaired vision. There were wounds on the face and the iris was torn in both eyes. Bennett showed the same visual field findings as Myers - the soldier could see straight ahead but could not see objects off to the side. Given that Bennett was an eye specialist, it is not surprising that he made the diagnosis of commotio retinae as the cause for the visual field defects. Very significantly, however, Bennett also noted that there was 'functional disturbance' too, ie he could not explain all of the symptoms from the probable damage to the retinae.

Robert

[Robert Dunlop]

I have traced a very specific aspect of shell shock, following on from Myers' paper. The focus has been on eye problems that could be related directly back to shell explosions. This has illustrated several things. It is clear that there were very definite physical effects caused by blast. Some were specific to the eyes, such as tunnel vision from commotio retinae (in effect, a contre-coup injury to the eyeballs). In many published cases, there were more general effects too. Loss of consciousness was the most significant. Then there were the other problems, which can be divided into two broad categories. One category was the related (in time) physical effects, such as the impact on hearing, smell, taste or other senses. Separately, there were problems that did not appear to have a physical cause. These were labelled as 'functional', 'hysterical' or similar. Even the most expert eye specialists, who were best placed to tease out every nuance of physical cause, recognised that there were some signs that could not be explained.

Before examining other papers, here are some points that we need to keep in mind based on what has been covered so far:

1. The physical effects of a shell explosion tended to improve with time. The rate of improvement or recovery was variable. Regaining consciousness usually happened before, for example, the recovery of tunnel vision. The latter could take several weeks. The tendency to recover means we have to interpret any mention of treatments, such as hypnosis, with healthy scepticism. To suggest, for example, that a person did not have a physical problem because he 'responded' to hypnosis must not be taken at face value.

2. Many specialists did not examine soldiers until some time after the event, up to many weeks later in cases that we have examined so far. This means that we have to rely on a range of observations, not just the views of doctors at one point in the evacuation chain, if we are to build up a more complete understanding.

3. Specialists in one area of medicine miss things that are not related to their specialities. We must constantly bear this in mind. The tendency is to label such findings as 'functional' or 'hysterical'.

4. By 1915, several causative physical factors had been hypothesised, including: blast and concussion; bright light or noise; and toxic fumes. Psychological factors were also being explored.

Robert

[James A Pratt III]

I think I have found the most prominate Neurasthenia/ cronic fatigue sysdrom/nervous breakdown sufferer of WW I Grand duchess Olga Nikolavna eldest daughter of Czar Nichols II and Czarina Alexandria. Her mother decided that she Olga and her sister Tatiana at the start of WW I were going to become nurses. Sadly, working in the operating room was too much for Olga who was only 18-19 years of age and had to be moved to less demanding duties. As part of her treatment she recieved arsenic injections!? for more information see: her wikipedia bio and Alexanderpalace.org

[Robert Dunlop]

Thank you for mentioning this. Professor Simon Wesseley reviewed the war pension records of nurses from WW1. There were 49 nurses who received a pension for the effects of neurasthenia and 24 for disordered action of the heart (DAH). A reminder of the tremendous work that was done in nursing the casualties of war, especially given that this was before antibiotics.

Robert

[Robert Dunlop]

While reading 'The Black Watch: a record in action', I came across the following quote. This anecdotal account illustrates one of the key problems in trying to understand shell shock:

"A shell did come my way. How close it came I will never know, because all of a sudden I felt as though my head were bursting. My ear drums rang and pained excruciatingly.

Then I found myself sitting up on the ground with a man from my patrol supporting my head.

Now, this is the strange thing. I was instantly and absolutely oblivious when the shell exploded. All the sensations I have described came when I was recovering consciousness.

Surgeons have told me since then that they were exactly what the shell caused when it exploded, but my brain did not register them until my senses returned. My clothes were scorched and even my hair was singed. I do not know why I was not killed, but in a few hours I was ready for duty once more."

The example illustrates how men could be temporarily incapacitated by a shell explosion. There was loss of consciousness followed by other symptoms. Then the soldier returned to duty. Medical officers serving near the front line knew this. Specialists back in England might not, although they would have talked with colleagues who served at the front when the latter were back in England on leave.

The Royal Society of Medicine meetings were one example where doctors got together. British Medical Association meetings were another. Informal communications were common in medical circles, with colleagues meeting privately or in the various clubs for example. As Wessely noted:

"...shell shock was not a phenomenon that had gone undetected until World War One. Indeed, Charles Myers, who wrote the first paper on shell shock in a recognised medical journal [as we have seen, he wrote the first article that used the words 'shell shock' in the title of the article but there were earlier articles], acknowledged that he had not invented the term (Myers, 1940). Drawing on pre-war experiences, it appears to have come into popular usage by word of mouth because it so effectively expressed both the disorder and nature of war (Winter, 2000)."

Robert

[Robert Dunlop]

In May 1915, the minutes of another Royal Society of Medicine meeting were published. The meeting involved the Laryngological Section, i.e. doctors involved in treating disorders of the throat. A case was presented where a soldier had lost the ability to speak (aphonia or mutism). The soldier had been shot in the throat but the injury did not seem to explain the loss of voice. Several doctors in the audience then talked about other cases. Aphonia was described after shell explosions causing 'shock, fright and concussion' but it also occurred in men 'most of whom were about to be sent to the Front, but others had experienced this after being in the trenches.' The participants all agreed that physical causes could still play a role in causing 'functional aphonia'. Several men had turned out to have pulmonary TB or other physical causes of loss of voice. Nevertheless, it was clear that the symptom could occur with or without exposure to a bursting shell, without any apparent physical damage to the voice box or the nerves that control the vocal cords.

Robert

[Guest]

Robert - I have been watching this great thread with interest. Are you going to write a book on this? I think you should....

MG

[John-B-Rooks]

Hello Robert.

This is indeed a fascinating thread that deserves the widest possible audience. My only observation is that the various types of shock, physical or psychological, need to be differentiated. Your Black Watch soldier in the above post seems to me to have been a candidate for a neuraesthenic episode in the weeks following the trauma of a physical 'shock' but, not paticularly for 'Shell-shock' as it was a single episode and he was back on the line after, presumably, a mug of hot, sweet tea. The psychological status of the soldier also needs to be examined. Was he, for instance, aware that an explosive concussion could have killed him or did he think of it more like being knocked down in the boxing ring? I only ask this in passing because it is obviously not answerable in this case at this distance. One wonders though whether a modern squaddy, brought up on Casualty/ER and the like, might have greater or lower expecatations about survivability in similar circumstances although cases seem to suggest that the margin between death and survival, albeit with horrendous and life changing injuries, can be very slim.

To save any potential for misrepresentation, my interest in medical history is general and certainly not limited to the Great War.

John

[John Gilinsky]

Hello Robert and everyone else including especially those who have posted in this particular thread: Anecdotal, journalistic, post-war/post-incident second hand accounts etc... are not the fundamentally critical primary sources. Regrettably until quite recently (arguably within the past 10 to 15 years or so) they constituted typically almost the ONLY source for anyone interested in shellshock and other mental or physical medical concerns of participants in the war. However there are now many graduate dissertations and especially access to definitely primary materials: medical records including all types such as corporate, medical service unit, individual case/clinical files, etc.... I am not posting this to detract from the interpertative efforts of anyone but only wish to point out that the literally though slowly growing numbers of researchers who use such primary sources should be encouraged as well. How accurate, valid or reliable in comparison with such medical records are such anecdotal accounts? I realize the HUGE tasks of dealing with just one unit, regiment or battalion alone but we do a disservice to history, to the memory of all veterans whether "shellshocked" or not and we generate a confusing web of spurious pathways for future historians if we superficially interpert accounts according to whatever criterion are preferable, accepted or popular at the time.

John

[Robert Dunlop]

Thank you everyone for the additional comments. Martin, I am not planning a book. For the moment at least, it is enough to make the information, and interpretations FWIIW, available online here.

The next major publication, IMHO, came from Dr William Aldren Turner. He was a distinguished neurologist, who worked at the famous National Hospital for the Paralysed and Epileptic, Queen Square, as well as King's College Hospital. Professor Wessely noted that Turner "was rushed to France in December 1914 as a temporary Lt Colonel [in the RAMC] when it became clear that psychiatric casualties were multiplying. Turner, who had wished to return to London, handed responsibility for psychological cases admitted to French hospitals to Charles Myers. In March 1915, Myers officially took over from Aldren Turner in Boulogne, touring medical units to offer a specialist opinion and gather data for a treatment policy." After returning to England, Turner published 'Remarks on Cases of Nervous and Mental Stress Observed in the Base Hospitals in France' in the BMJ (May 15, 1915). Turner's remarks were based on three months of observation, which included the aftermath of the First Battle of Ypres. Given the short period of time, Turner's review is extraordinary.

The opening paragraph summarised Turner's findings:

"Cases of nervous and mental shock may be counted among the more interesting and uncommon clinical products of the present war. Cases of this character began to arrive in England shortly after the commencement of hostilities in which British troops were engaged, and have continued to be met with in our base hospitals at home with varying degrees of frequency up till the present time. It was soon recognized that one type of case was due to the explosion of big shells in the immediate vicinity of the patient, who did not himself receive any detectable physical injury or bodily wound. Intermingled with the cases of this nature, cases of a general neurasthenic character were found whose symptoms were attributable to exhaustion of the nervous system induced by physical strain, sleeplessness, and other stressful conditions associated with the campaign."

Turner distinguished between two major causes of 'nervous and mental shock': the effects of a major explosion; and 'exhaustion' due to the stresses of prolonged combat, which Turner also called 'the effects of "wear and tear"'. Turner made another important observation, which would not be confirmed until the 1980's:

"In a general way the frequency of these "shock" cases depends upon the intensity and character of the fighting at the front. The severe fighting in Flanders and around Ypres in the latter part of October resulted in a large number of such cases being sent down to the base. The numbers of the cases subsequently diminished, and during the earlier months of this year were relatively small, with occasional accessions, the outcome of such engagements as took place on January 25th and 26th and March 10th to 12th."

Turner identified four groups of cases:

1. "There is a definite type of mental shock in which the symptoms are essentially of a psychical character."

2. "A spinal type characterized by a limitation of the symptoms to the extremities, and usually to the lower limbs."

3. "Symptoms are referred more particularly to the special senses. In this class the remarkable cases of blindness or amblyopia, deafness and deaf-mutism have been included."

4. "More specialized symptoms, such as stammering or hesitation of speech, local palsies and tic-like movements, have been included in a fourth group."

More details to follow.

Robert

[Robert Dunlop]

The first group of cases were classified by Turner as:

"Psychical Shock: Mental Stupor.

From time to time cases are sent down from the Casualty Clearing Stations in a state of mental stupor [reduced consciousness]. Some of these cases are unaccompanied by any history or statement which would throw light upon the cause or method of onset of the symptoms. Other cases of a similar though less profound type of stupor, on recovery from the acuter phases, are able to give some account of the nature of the psychical shock through which they have passed.

The symptoms exhibited by these cases of stupor are interesting and create a clinical picture of a striking character. In the more severe class of case the patient is entirely unconscious of his surroundings. All the usual tests applied with the object of arresting attention - such as throwing a bright light on to the eyes, pinching the skin, or clapping the hanids close to the ears - fail to provoke a response. The deep reflexes, however, are normal or brisk, and the plantar response is of the flexor type. The pupillary light reflex is frequently impaired or lost. Urine is passed normally; swallowing is carried out usually without difficulty.

In some cases the patient would appear to be living again through an experience of the past, probably associated with the time of onset of the symptoms. Many of the cases present a scared or startled appearance. When approached they shrink and hide under the bedclothes. Others are dull, lethargic and apathetic, taking no interest in what is going on around them.

A closer examination reveals a marked degree of rigidity of the limbs in most of the cases. As a rule all of the extremities are affected.

In the milder type of case the stupor is less profound. These patients may carry out simple actions, such as putting out the tongue when requested to do so, but in a slow, apathetic and hesitating way. They present a dazed appearance, are readily startled when spoken to, and take little or no notice of what is going on around them. Even in the slightest cases some rigidity of the limbs may be detected, which gradually passes off as the mental condition improves.

When information has been obtained upon the possible cause or origin of the symptoms it has been found to be of a psychical character, such as seeing a friend or relative killed by his side.

On the other hand, there were cases of a severe type in which no history was obtained. It is permissible to assume that they may have resulted from shell explosion, or from repeated and continuous shelling. These symptoms are found mainly in young soldiers; in no case has the patient been over 28 years of age, the majority being about 22 or 23.

The duration of the stupor varies. The general outlook for recovery is decidedly favourable. Rest, quiet surroundings, and ample nourishment are the main points of treatment."

Robert

[Robert Dunlop]

Turner went on to describe a related clinical problem:

"Loss of Memory.

Comparable in many ways to the cases of stupor just described are those cases of loss of memory, or transitory amnesia, which are admitted to the base hospitals for further observation. Prolonged fatigue and exhaustion coupled with continuous shelling, seem to be the primary causes of these mental breakdowns. The history furnishes evidence that the patient had been found wandering, and was unable to give a satisfactory account of his movements. On inquiry of the patient himself as to what had happened to him, one is told that he had been under heavy shelling for a time just previous to his losing consciousness... One such patient said that in the stress of the engagement he had "lost his head" and became unconscious.

The loss of memory may extend over a period of several days.

In addition to the loss of memory, the patients complain of headache, and sometimes of a feeling of strangeness and discomfort in the head; the head, they say, is muddled. Sleep is disturbed at first. The reflexes are normal, altlhough the pupillary light reflex may be impaired. Recovery takes place satisfactorily with rest in bed and ample feeding."

Robert

[Robert Dunlop]

The next section in Turner's paper was on 'deafness and deaf-mutism'. He commented that deafness was 'not... uncommon'. Physical causes had to be excluded, including rupture of the ear drum/s by the pressure of a shell blast. Pre-existing ear disease also had to be considered as a contributing factor. "In addition to the deafness the effects of the explosion are a stunning or dazing of the mental faculties and sometimes temporary loss of consciousness." Turner described the results of testing the hearing loss, which typically revealed that the VIIIth Cranial Nerves were affected. These nerves, one for each ear, carry the signals from the inner ear to the brain. "This form of deafness is not of long duration. It may pass away in a few hours, or at most in a few days. The general symptoms of neurasthenia may persist for a longer period."

Turner then went on to describe the cases where soldiers lost the ability to speak as well as the ability to hear. "Deaf-mutism is another effect of the explosion of big shells, and provides one of the clinical surprises of the war." As mentioned above, the hearing loss appeared to be associated with malfunction of the cranial nerves. Interestingly, Turner never came across the symptom of tinnitus [ringing in the ears], which commonly occurs with damage to the inner ear from loud noises. Nor were there any other findings related to damage of the part of the ear that controls balance, such as staggering gait or flickering of the eyes (nystagmus). The description of mutism is worth quoting directly, given that it was such a 'clinical surprise':

"The mutism may be complete, though in less profound cases the patient may speak in a whispered voice. Attempts at phonation [i.e. trying to speak] may be accompanied by movements of the lips and facial muscles. In the early stages deaf-mutism may be accompanied by general symptoms of shock, such as headache ,tremors, twitching movements of the limbs, and insomnia. In the later stages it is the only symptom present, the patients being frequently bright and very sensitive of their disabilities. The cases of deaf-mutism would appear to be more persistent than those of simple deafness. One case which was examined three weeks after the onset was still completely deaf and dumb."

Robert

[Robert Dunlop]

'Blindness and impairment of vision' was next on the list. Turner noted that, compared to deafness, problems with eyesight were 'relatively infrequent'. He distinguished between two types of eyesight problems:

1. "In tle first class quite a number of soldiers suffering from the symptoms of a general mild neurasthenia following prolonged fatigue complain of being blind. An examination of these cases shows that they are not really blind, but are suffering from photophobia [bright lights are painful] and tonic spasm of the eyelids (blepharospasm). Further investigation into the origin of the symptoms reveals that at the time of the explosions, dust or mud was blown into the eyes, and had given rise to conjunctivitis, hyper-sensitiveness to light, and spasm of the eyelids. Recovery takes place quickly under suitable local applications and rest."

2. "In the second class the patients suffer from a temporary blindness or impairment of vision. In the cases of this character which were examined, consciousness was stated to have been abolished temporarily at the outset. In addition to the loss of vision, the eyeballs are tender to pressure in the early stages [this would fit with earlier paper describing pressure effects on the eyeballs from the blast]. The pupillary light reflex [reaction to light being shone into each eye] is normal. An ophthalmoscopic examination [looking into the eye with a magnifying lens and bright light] shows no structural change in the media, retina, or optic discs [though this may have missed findings that would be detectable today with more sensitive methods]. In one case in which the blindness was unilateral, an associated partial ptosis of the upper lid on the same side [a sign of damage to the cranial nerve that helps keep the eyelid open, so that the eyelid droops on one side - ptosis] was present. In another case the examination revealed a large patch of opaque nerve fibres [a sign that the nerve fibres in the back of the eye had been damaged]. In a third case Colonel Lister found a slight peripheral contraction of the visual fields. Most cases show some error of refraction [blurring of vision due to long- or short-sightedness]. Recovery is said to be complete eventually, although I have myself not been able to observe a case sufficiently long to ascertain the duration of visual impairment."

Robert

[Broznitsky]

I am not planning a book. For the moment at least, it is enough to make the information, and interpretations FWIIW, available online here.

Thank you very much indeed Robert (and others who have contributed) to this excellent thread.

[Robert Dunlop]

It is my pleasure. I am really enjoying the chance to re-examine the original papers in some detail. The challenge has been to suspend any preconceived notions about causality - or at least to try and make these notions explicit whenever possible. Much more to come

Robert

PS: the emoticon is not an example of unilateral blepharospasm

[Robert Dunlop]

Next is "Stammering":

"Hesitation of speech has been observed in several cases in consequence of shell explosions. As in the previous cases of shock, the impediment may or may not be preceded by a temporary loss of consciousness. The onset of the symptoms is favoured by previous conditions of fatigue, sleeplessness, and exposure. Most of the patients were suffering from an associated neurasthenia. The symptom itself corresponds in every way with that seen in civil life. The organs and muscles of articulation are of normal character and development, but co-ordination in their movements is defective. The outlook for recovery is good, although the symptom may persist for several weeks."

Then a section entitled: "Local Palsies and Spasms. [Palsy is weakness of a muscle or muscle group due to nerve damage, which can be associated with some loss of sensation and with tremors or shaking).

These cases are not common, and the svmptoms are confined to the eyelids. Those examined have been ptosis [drooping of the eyelid] and spasm of the orbicularis palpebrarum [the muscle around the eye that controls blinking].The ptosis may be unilateral or bilateral [on one or both sides], and present all the features of a functional palsy [where the nerves are malfunctioning but there is no evidence of physical damage].The spasm is associated usually with local irritation and conjunctivitis.There was one "blinking tic [a repetitive twitching of a muscle or muscle group, in this case the muscle controlling blinking]" seen in consultation with Colonel Lister. The case was not a true one of nervous shock, as the symptoms had commenced when the patient was at his work- before joining the army. The onset was attributed to some chips of iron being forced into his eyes. A fall upon his forehead when on service had greatly increased the blinking."

Robert

[Old Tom]

May I add my appreciation. But for the benefit of a one time nuts and bolts engineer what is a 'blepharospasm 'It looks as if the emoticon has recieved a low blow.

Old Tom

[Robert Dunlop]

Ouch. Blepharospasm is what happens to the eyelid when you get soap in your eye. The muscle around the eye contracts, which automatically closes the eyelids. If you try to open the eyelids then there will be rapid blinking, with a tendency for the eyelids to close again. In this context, various doctors reported blepharospasm after blast wounds to the face. In some cases, there were clear signs of dust and other particles having been blown into the eyes, causing the delicate surface of the eye (the conjunctiva) to become inflamed - red and very sore (hence the term conjunctivitis). Just like the analogy with soap in the eye, the inflammation triggered blepharospasm. Does this make sense?

Robert

[Robert Dunlop]

The next section, which is relatively long, is entitled "Spinal Shock: Paraplegia". This section explicitly refers to Elliott's paper on transient paraplegia following shell blasts, which has been referred to earlier in this thread.

"The outstanding symptom of spinal shock is loss of power in the legs.This is brought about by shell or mine explosion in the immediate vicinity of the patient,with or without an accompanying burial of the patient in the trench or resulting debris. It has been found also as a result of a fall, the patient being knocked over and striking his back against the wall or parapet of the trench and injuring his back indirectly in this way.

In a characteristic case the symptoms and signs are somewhat as follows: The paralysis comes on suddenly, the onset being accompanied by a temporary stunning or dazing of the mental faculties. In other cases temporary loss of consciousness follows the shock, and on recovery from this the patient finds that he is unable to move his legs. In those cases which have been buried with or without an associated loss of consciousness, the paraplegia is discovered as soon as the patient is dug out."

Turner then goes on to describe two major variants. The first is where the soldier has minimal loss of sensation, very temporary loss of bladder function (not more that a day or so), back pain and tenderness, and a rapid recovery of strength in the legs. The second is more severe, with complete loss of power and sensation to the legs along with loss of bladder control. Of note, Turner felt compelled to write:

"Taking into consideration the fact that the cause and method of onset are similar in both types of case, the relatively slight clinical differences scarcely warrant the assumption that the first type of paraplegia is 'functional' and the second 'organic'."

My guess, FWIIW, is that some doctors may have been labelling the more temporary variant as 'functional' and, perhaps, dismissing the symptoms as being due to some weakness of character. Just a guess though.

Turner concludes the section with:

"Although the legs bear the brunt of the shock, paralysis is not invariably confined to the lower extremities. Cases were observed in which one or both arms may be similarly affected, although to a less degree, and others have been seen in which deafness or even impairment of vision have been accompaniments of the paraplegia."

This is a reminder that Turner's process of classification is a way of trying bring some order to the myriad of symptoms and signs that followed shell explosions. Combinations and permutations of these symptoms and signs could occur. Thanks to Turner's analytical approach, it is possible to see how someone with several symptoms, perhaps affecting eyes, hearing, leg weakness and stammering, could have had several areas affected by a blast.

The final section in Turner's paper is very interesting. Thus, juxtaposed to the description of various physical signs and symptoms is the section entitled 'Neurasthenia'.

Robert

[Robert Dunlop]

"The cases of neurasthenia which are met with in the base hospitals resemble in essential features those seen civil practice. A common history as given by the patient is that after he has been abroad for several weeks or months he begins to sleep badly, loses appetite, and feels run down. Often the breakdown goes no further, and a short rest relieves the symptoms, and the patient is able to return to duty. On the other hand, to these symptom may be added feelings that he is incapable of doing his duty properly, he loses confidence in himself, and begins to worry about his health. In more severe cases the patient loses weight and complains of flatulence, constipation, and dyspeptic symptoms. [Dyspeptic symptoms relate to stomach and include symptoms like heartburn, indigestion, discomfort in the left upper side of the abdomen after eating, etc]

In many instances he may persevere with his work until a severe psychical shock, such as seeing one of his friends killed beside him, severe shelling, an upsetting experience, or bad news from home unsteadies him, and precipitates a definite attack of neurasthenia, requiring rest and treatment at home. An enquiry into the history of the cases will reveal usually either a previous attack of neurasthenia or occasional sleeplessness."

Turner described a pattern of increasing stress, over a period of time. In some cases, a shell explosion proved to be the last straw. In other words, the shell blast was not the cause but just another factor in a longer process. By way of contrast and:

"On the other hand, there is observed a form of temporary 'nervous breakdown' scarcely justifying the name of neurasthenia, which would seem to be characteristic of the present war. This occurs in those who have been strong and well, and is ascribed to a sudden or alarming psychical [ie psychological] cause, such as witnessing a ghastly sight or undergoing a harassing experience. As the result of such a shock the patient becomes 'nervy', unduly emotional and shaky, and most typical of all his sleep is disturbed by bad dreams. The dreams are of experiences through which he has passed, of shells bursting, of duels between aeroplanes, or of the many harassing sights of the war in the trenches. Even the waking hours may be distressful from the acute recollection of these events revolving in his memory. Headache, slight mental depression, and fine tremor may be accompaniments of these symptoms. There is usually an entire absence of objective signs; the deep reflexes are normal, the pupils respond to light, the tongue is clean, and the pulse of normal frequency. Recovery is satisfactory, especially if the patient is sent home for a complete rest."

This is a description of an acute stress reaction, in which recollections of shell explosions may figure. Turner recognised that it was not really typical of neurasthenia in the classical sense, although it did fit with what was termed 'traumatic neurasthenia'.

Robert

[Robert Dunlop]

The analysis of 'typical' neurasthenia, where the symptoms came on more gradually, was extended to include some specific groups of other symptoms and signs that would predominate in some soldiers:

1. Anxiety - "as the main feature. This may take the form of fear or apprehension as to his ability to do his duty, or fear of being left alone, or of having made a serious mistake in his work. In one case the patient conceived the idea that he was unable to hold his rifle. Should the anxiety be concentrated upon his health the patient develops symptoms of a definitely hypochondriacal character."

2. Excessive motor agitation ['motor' refers to movement of the muscles] - "in which tremulousness of the face, tongue, and limbs is associated with a nervous and agitated manner." In lay terms, this could be described as 'trembling with fear'.

3. Insomnia - "This symptom would seem to be more common in those whose duty confines them to an office especially where responsibility weighs heavily upon the individual. It has also been found as a consequence of prolonged strain or continuous shelling."

4. Depression

5. Other - "aggravated forms have the features of exhaustion psychoses and develop the symptoms of mental confusion and maniacal excitement." 'Maniacal' is derived from 'mania', which can be translated loosely as 'really hyped up in an uncontrollable way'.

Turner concluded with the following:

"...it may be stated that a form of neurasthenic breakdown may be found in cases admitted for medical disorder, especially of the gastro-intestinal tract, such as gastritis, enteritis, and colitis [inflammation of the stomach, small intestine and large intestine respectively]. It happens occasionally also that patients suffering from surgical wounds of the head show acute neurasthenia or psychical [psychological] symptoms, which may persist after the wound has healed;- these cases do not come within the scope of this paper."

Turner's paper is far more wide-ranging that Myers'. Not only in terms of breadth but also by virtue of the depth of Turner's analyses and insights. His skill as a neurologist is clearly evident but, above all, Turner was brilliant at piecing together and interweaving the psychological elements. The distinction between the effects of blasts and the psychological effects of campaigning are clearly brought home. As I mentioned earlier, Turner's astute observation that a rise in cases was associated with battles would not be proven until about 30 years ago. Although Myers is credited with the word 'shell shock', Turner deserves far more recognition. It must be emphasised, however, that Turner only saw the effects of the first few months of the war. Given that some problems could develop over time, and that the war would last a lot longer, there was still room for new insights to emerge. Furthermore, although First Ypres was a major battle, it wasn't on the same scale as the likes of the Somme. For the British army, these huge and prolonged campaigns were still to come. Nevertheless, Turner's observations were an excellent foundation, based on a meticulous and seemingly unbiased analytical approach to a new set of phenomena. He epitomises the detective-like skills of an excellent doctor who is faced with something that is unknown. As someone trained in the art and science of general internal medicine, it has been a pleasure reading and appraising Turner's paper.

Robert