Neurasthenia and Shell Shock

[Broznitsky]

it has been a pleasure reading and appraising Turner's paper.

Thanks again for doing it.

Carry on!

[Robert Dunlop]

Turner divided the manifestations of shell shock into neat groups, while pointing out that there could be some overlap. Anecdotal reports continued to be published, some of which emphasised just how complex this new clinical problem was. In 1915, the Neurological Section of the Royal Society of Medicine published its proceedings. Dr Arthur Hertz reported the case of a 29 year old soldier who was blown over by a high explosive shell. The incident occurred in December 1914, causing the soldier to be unconscious for two days.

"When he regained consciousness he found that he could not move his right arm or his left leg [this is a very unusual combination - loss of power in different limbs on different sides of the body]. Power in both limbs soon returned to some extent, but as soon as he tried to stand, violent involuntary movements occurred in his left leg."

Hertz first saw the man four months after the incident, in April 1915. At that time:

"His mental condition seemed to be impaired, he only answered questions after a considerable latent period [long pause], and his speech was slow. The whole of his right arm was weak, the grip being particularly feeble. When he clenched his left hand an associated movement occurred in the right hand, but on clenching the right hand no similar movement occurred in the left hand. The muscles of both arms were equally well developed. The tendon reflexes in both arms were brisk, but were no better marked on one side than the other."

If the weakness in the right arm was due to nerve damage, either in the arm itself, the spinal cord or in the movement controlling centres and pathways in the brain then there would have been muscle wasting on the right. In other words, the muscles in the right arm should have been less well developed than the left arm. Similarly, there should have been a difference in the reflexes (either decreased on the right if the lesion was outside the spinal cord or increased if the lesion was higher up in the nervous system).

"All movements of the left leg were somewhat weak. The muscles were equally well developed in both legs. Both knee-jerks were brisk, the left one being slightly brisker than the right. Well-marked ankle clonus [rhythmical contractions of the ankle when the foot is quickly flexed, usually a sign of damage in the higher nervous system] could sometimes but not invariably be obtained on the left side. The plantar reflex was constantly flexor on both sides [which is normal], but Babinski's second sign (combined flexion of the thigh and pelvis) was very well marked on the affected side. As soon as the patient attempted to walk, violent involuntary movements were set up in the left leg: the leg moved rapidly from side to side round the point where the toes were in contact with the ground. When a step forward was taken with the right leg, the left leg dragged behind and very irregular movements occurred. The gait seemed to be of so obviously hysterical a nature and the signs pointing to organic disease were so slight,that it was thought that al the symptoms would probably be cured by suggestion. The patient was kept in hospital for a month, but all efforts to cure him by means of suggestion entirely failed. He proved very easily hypnotisable, but even when deeply hypnotised the movements of the leg could not be controlled when he was told to walk. He is now in exactly the same condition as when he was first seen, except that his mental condition has improved to a slight extent."

This case illustrated the dilemmas that doctors were facing all the time, though not in significant numbers. This can be inferred from the fact that such cases featured in the likes of the RSM proceedings - doctors (and the RSM) would not publish common cases in this way.

"The associated movement of the paralysed hand when the normal hand contracts, the slight exaggeration of the left knee-jerk and the tendency to ankle clonus, and above all the presence of Babinski's second sign, indicate that some organic changes [actual and permanent damage to some nerves or nerve cells] have occurred in the brain as a result of the concussion. The complete failure of suggestion to produce any improvement raises the question whether al the symptoms, in spite of their unusual character, may not be organic in origin."

Thus Hertz has pointed to a small number of signs that suggested some nerve damage, along with the persistence in the symptoms. But he knew, as would his audience have known, that the signs could not explain why the muscles were not wasted and why the involuntary movements were so unusual. None of the experts in the audience could explain this either. One suggested a trial of anaesthetising the patient briefly with ether. The idea was that, under the influence of an anaesthetic, any conscious or sub-conscious attempts by the patient to produce the symptoms would be abolished. Therefore, during the recovery from the ether, when the patient was still muddled and not fully conscious, it would be possible to see what was real and what was 'put on'. The experiment had no such effect and "he is now (June 9) in exactly the same condition as he was when first seen on April 1".

Robert

[Robert Dunlop]

Other authors continued to grapple with the issues in the literature. At another meeting of the Laryngology Section (the throat specialists) of the Royal Society of Medicine, there was a detailed review of 'Warfare injuries [to the throat region] and neuroses'. Milligan and Westmacott, both surgeons and both majors in the RAMC, wrote an introductory paper. Most of the paper (4.5 of the 6 pages) related to pure physical injuries, such as bullet wounds to throat. Then came a series of paragraphs, starting with:

"Nerve injuries such as those [described earlier in the paper, which were related to bullets or shell fragments cutting or damaging nerves] present no particular dificulties, but when one comes to cases of loss of sight, of speech, hearing, smell, or memory, without any objective evidence of damage done, we are at once faced by problems of real moment. We speak constantly of concussion as the cause of such cases, but what is concussion? Is concussion always attended by definite organic changes, however minute, or are there certain molecular alterations in tissue fluids or tissue cells which so modify the transit of impulses from the higher nerve centres as to produce at times temporary, at times permanent, loss of function? Again, in certain of these cases is there an element of hysteria, or is it a subconscious manifestation of the effects of sheer fright? What has struck us very forcibly has been the rapidity with which many of these cases recover when the patient is nursed under favourable and quiet surroundings, 'far from the madding crowd's ignoble strife.'"

The latter point is very interesting. The throat region has a lot of very important nerves in it. Surgeons know where these are, and take great care to avoid damaging them whenever they operate on the neck. Inevitably, however, a nerve will get stretched or bruised during an operation. This will cause the nerve to malfunction for a while afterwards. Usually the effects last days or weeks. Hence the surprise that if physical blast effects were causing nerves to be 'bruised' then there should be such a rapid recovery. We cannot place too much weight on this observation - the two situations are not necessarily analogous. But the observation is important as it shows how different groups of doctors were approaching these problems in an effort to understand the cause.

Given that throat specialists are usually ear, nose and throat (ENT) specialists, the authors raised the issue of deafness:

"If we may be allowed to revert for one moment to the auditory nerve [the VIIIth Cranial Nerve mentioned earlier in this thread], we are satisfied that so-called concussion deafness. is in many cases merely a passing phase in the temporary abolition of sensory impulses in a brain already anaemic [in this case 'anaemic' is used in the sense of 'weakened'] as the result of physical fatigue and mental strain, the actual loss of hearing being induced by a sudden climax as it were- e.g., the bursting of a shell-accompanied as it is by a general atmospheric commotion ['commotion' as in 'concussion'], and the not infrequent burial of the soldier in the earth work of his trench. Nine or ten cases have been observed by us, of the deaf and dumb state, all recovered from within six weeks. The period of subconscious inertia following such injuries varies within wide limits, as also does the response of the special organ or organs involved. It is our belief that the abrogation of function is due not to an organic lesion, but to a temporary suspension of neurone [nerve] impulses from the higher cortical [brain] cells of the central nervous system to the periphery. Our view is that the hiatus [blockage or hold up in nerve signals] or synapse [junction between two nerves] interfering with the flow of nervous stimuli is a central and not a peripheral one, for the reason that in so many of the cases of sudden blindness and sudden deafness no trace of any peripheral organic lesion was demonstrable, and moreover, the rapid recovery of so many of the patients we have observed is a strong argument that none was ever present."

ENT specialists are very good at examining the parts of the hearing process that lie outside the brain. What the authors are saying is that they recognise that the temporary hearing loss from a shell explosion is real. However, they could not explain the rapid recovery, and the association with mutism in some cases, with damage to the hearing system outside the brain. In other words, they were not finding that the inner ear or VIIIth Cranial Nerve was malfunctioning.

"What has struck us in many of the cases of so-called concussion deafness has been the presence of previous ear disease. This, we believe, has tended to throw the effects of the concussion more upon the sentient than upon the conducting segments of the organs of hearing. Illuminating evidence of the central origin of these functional disturbances is also obtained from an examination of soldiers who have suddenly lost the power of speech. Laryngeal examination demonstrates that these cases are not cases of hysterical aphonia, but that they are cases of neurotic or functional aphonia due to the sudden arrest of those volitional impulses which are necessary to produce speech. There is no paresis of the adductors as in true hysterical aphonia; there is a total inability to put the vocal cords in motion. Something has happened to prevent volitional impulses, a synapse somewhere, and probably in the cortical cells of the centres for speech, precluding that transmission of nerve energy which is requisite to start the machinery of speech. Such cases do well with rest, strychnine, and a judicious mixture of auto-suggestion and encouragement."

I haven't translated all of the specialist words used in the previous paragraph. In summary, mutism was not associated with any signs in the voice box or throat. This was unlike the signs in patients with 'hysterical' loss of speech. It was as if the brain could not send any signals to the voice box to work in any way at all. Put another way, in hysterical mutism the brain is signalling the voice box but the signals cause the voice box to malfunction. In post-concussion mutism, no signals were being sent to the voice box.

It should be recalled that ENT specialists would not have seen all soldiers with hearing and speech problems. Hence the preponderance of cases with previous ear disease.

The authors ended by noting:

"These thoughts and observations are but as pebbles on a rock-bound coast, a coast presenting dificulties to him who would explore inland; but to the man who succeeds in passing what at first sight appear impenetrable barriers, there is the reward of having added something to the sum total of human knowledge, of having done something for the benefit of mankind in general, and in particular for the welfare of those courageous men who at present so bravely and tenaciously defend our sea-girt home.

'On Fame's eternal camping ground

Their silent tents are spread,

And Glory guards with solemn arms

The bivouac of the dead.'"

Robert

[Robert Dunlop]

The British journals tracked publications in foreign journals as well. The BMJ reported the following on July 31, 1915:

"Emotional Shock following Shell Explosion.

FIESSINGER (Journ. des praticiens [a French journal], February 15th, 1915) gives an account of a number of cases of emotional shock following shell explosion. One case was that of a noncommissioned officer of heavy artillery, who had received a severe bruise - but no more serious damage - on the left thigh. The patient had been a bright and cheerful man with no antecedent nervous manifestations, family or personal. To any inquiries he replied in monosyllables, and after a few questions his expression and manner indicated profound fatigue. His memory appeared normal, but there was a marked alteration of intelligence. He preserved absolute silence, appeared to be extremely melancholy, and suffered from insomnia, intense headache, and distaste for food. The reflexes were normal, and muscular power was retained. Subcutaneous injections of strychnine resulted in some improvement.

A similar case was that of a lieutenant of artillery. There was no trace of a wound in this case. The patient appeared to be in a state of stupor ; he refused all nourishment and preserved a fixed stare. After two days there was a phase of nervous excitement, followed by one of melancholy and intense depression. The author points out that the explosion of heavy shells provokes a terrifying impression on nervous subjects, and that this shock is less marked on those who have been seriously wounded otherwise. With regard to the nature of the attack, the author states emphatically that in none of the cases referred to was there any evidence of simulation [faking], and that the condition was to be regarded as a traumatic neurosis, only occurring in those of susceptible nervous system. Rest treatment and suggestion were beneficial, and there were few ultimate ill effects."

Two brief comments are needed:

1. Any mention of response to treatments, such as injections of strychnine, must be treated with great caution. The natural history, in many cases, was for the symptoms to improve with time and rest, even in the absence of any other treatments.

2. Note the view that the symptoms were likely in men with a 'susceptible nervous system'. This assumption led to a prolonged phase, covering WW2, Korean and Vietnamese wars, of trying to identify men with 'susceptible nervous systems' before they went to war. Screening tests were used but these failed to prevent the same problems appearing in men who had passed the screening tests. But that is another story.

Robert

[Robert Dunlop]

Another mention of mutism, this time in a brief report on a lecture entitled 'Music, Emotion, and Mutism', which was published in the BMJ on Dec 11, 1915.

"Incidentally, Dr. Mott dealt at some length with the subject of mutism produced by shock, and discussed the problem in the light of some remarkable cases he had observed among men suffering from shell shock, who, though they had no visible signs of injury, had lost their speech while yet quite able to write a lucid account of their experiences. Dr. Ormerod expressed the opinion that the condition thus produced by violent emotion in men presumably healthy corresponded exactly with that which lesser emotions could produce in neurotic patients, which we are wont to call hysterical mutism. Why such emotion should particularly affect the function of speech was, he thought, hard to explain. But the fact had long been known. Virgil described the condition of terror in the well-known line;

Obstupui, steteruntque comae, et vox faucibus haesit. "

In the Jan 1 1916 edition of the BMJ, the following review was published:

"Treatment of Mutism following Injuries of War.

Marage has studied more than a hundred cases of mutism following directly on injuries in warfare (Compt. rend. de l'Acd. des Sciences No. 20, November 15th, 1915). As a sequel of a cerebral concussion, without apparent lesion, caused by the explosion of a large shell, the patient, after a loss of consciousness varying in duration from a few minutes to many days, fails to recover his speech. In 64 out of 100 cases this mutism disappeared spontaneously at the end of some weeks, but in the remainder all kinds of treatment completely failed. The mutism was often accompanied by vertigo [a sensation of spinning] and distressing tinnitus [ringing noise in the ear/s - vertigo and tinnitus suggest damage to the balance organ (vestibular apparatus) and to the hearing organ (cochlea) within the inner ear respectively), and all of the patients complained of very violent frontal headache. Insomnia is the rule, and often for two or three months there may be only an hour or two's sleep at night. There is more or less marked defect of memory; not only are all events following the battle forgotten, but the patients cannot write a letter, owing to their defect of memory. Auditory hyperaesthesia [increased sensitivity to sound] is so great that sounds which are barely perceptible to a normal ear are described as intolerably loud."

Robert

[Robert Dunlop]

A small aside. The following obituary appeared in the BMJ, illustrating that the term 'shell shock' had come into use:

"Casualties in the Medical Services Feb 26 1916

Lieutenant-Colonel John Wilfred Stokes, R.A.M.C. (T.F.), died suddenly in a military hospital at Lachmere, Ham, on February 10th, aged 43. He... had twice been invalided home suffering from shell shock, and had been under treatment at Ham since December."

Robert

[Robert Dunlop]

Returning to Turner's paper again, he made a clear distinction between the effects of shell explosions and the concept of neurasthenia. Shell shock was not the same as neurasthenia, though the latter could be caused by the former. Before looking at the literature from 1916 and 1917, I would like to backtrack slightly. Just to reinforce our understanding of neurasthenia, I would like to review Rankin's paper from 1903, which was entitled 'Neurasthenia: The Wear and Tear of Life'. It reiterates material that has been published earlier in this thread but this will be no bad thing IMHO.

"The term 'neurasthenia' was first given in 1879 by Beard, of New York [hence the 'American' spelling of neurasthenia], to a group of symptoms which, though sometimes ill-defined and always capable of infinite variation, yet retain a general relationship which serves for the groundwork of a disease entity, little understood and never described before Beard's time, but through his investigations and those of many successors nowadays universally recognized as a formidable enemy of mankind. Speaking generally, neurasthenia may be regarded as a derangement of function resulting from exhaustion of nervous energy."

Rankin went on to observe:

"The causes upon which it depends are varied and often obscure, but, despite the testimony of contrary opinion, it can scarcely be denied that the increasing wear and tear of life at the present day probably plays the most important part in its etiology.

...it is one of the disorders which in its prevalence has become fashionable enough to be designated 'the disease of the century'; and, most noteworthy of all, that its victims are to be found in far greater abundance among the restless inhabitants of busy communities and large centres of industry than in country districts where life is passed under conditions of uneventful monotony, and of prosaic, unexciting occupation and duty." [apologies in advance to all GWF members who live in country districts )

"The disease is widely distributed, and, though specially prevalent in America, is met with in all the civilized countries of both hemispheres. "It is," says Proust, "equally spread amongst all civilized peoples in whom the struggle for existence keeps up an incessant and exaggerated exaltation of the functions of the nervous system. To-day everyone endeavours to raise himself higher than his ancestors; competition has increased; conflicts of interests and persons have multiplied in all conditions of life; free course is given to ambitions that are often litle justified; a crowd of individuals impose on their brains a work beyond their strength; then come cares and reverses of fortune, and the nervous system, under the wear and tear of incessant excitation at last becomes exhausted.

In its incidence, neurasthenia is most frequently met with between [ages] 20 and 40, though it may set in at almost any age. It attacks men more frequently than women, and is specially apt to affect those of neurotic inheritance, or those individuals who live under conditions of mental or physical tension. All forms of excess predispose to its occurrence.

In the great majority of cases neurasthenia is a disease of gradual development, but occasionally it sets in acutely and can generally be referred either to some form of serious mental shock or to an accident which subjects the nervous system to severe physical jarring. Its symptoms are so varied that it is well-nigh impossible to give a comprehensive description of it, but the leading feature of every case is a constant sense of weariness which prevents the comfortable accomplishment of any act demanding sustained effort."

Robert

[Robert Dunlop]

Mention has been made of the difficulty that doctors had in deciding how shell explosions caused their effects. In September 1915, the following letter was submitted to The Lancet:

SHELL SHOCK. To the Editor of THE LANCET.

SIR,-I notice there is a good deal of correspondence in the papers about "shell shock." Permit me to mention an incident with reference to the belief that the wind of a round shot was often fatal to show that it was in former days compression of the air, and doubtless is so now, which kills. In July, 1882, I was a service officer of Admiral Sir Beauchamp Seymour on the Invincible, when we were attacking the Mex Forts at Alexandria, distant 1500 yards. I happened to be in the main top giving the ranges over the smoke of our guns. Several heavy round shot from the great smooth bore guns came pretty close. They did not trouble me, but one heavy projectile came so close, and with a rush like a railway train passing me, that I staggered back. It was so close that it cut the signal haulyards, and therefore must have been within a few feet. I at once came to the conclusion that it must have been a shell from one of the two 18-ton rifled guns which I knew were in the battery, and that I did not feel the wind of it because, being a rifled projectile, it, so to say, bored its way through the air instead of compressing it as round shot were believed to do, with fatal effect to anyone close to.

I have had a good deal of experience of round shot and shellfire, which began in the Crimea and ended near Soissons. I had a special pass then to get information if possible of a nephew wounded and missing; but the only projectile in which I ever took special interest was the big shell in 1882. One of my sons is an invalid from concussion of the brain from a shell bursting just as it cleared his head; but that is another matter.

I am, Sir, yours faithfully,

ALEX. B. TULLOCH, Major-General, retired."

Robert

[Robert Dunlop]

Early in 1916 (January 8), Charles Myers published the second of his series 'Contributions to the Study of Shell Shock' in The Lancet. This paper was subtitled 'Being an Account of Several Cases Treated by Hypnosis'. Interestingly, Myers mentioned that he had selected various cases of "shell shock", with the term in double quotes. The reason for this became apparent with the first case in this paper, labelled 'Case 4' as the numbering appeared to continue from his first paper. 'Case 4' was a man with total amnesia. He was found wandering behind the lines, wearing only a shirt and socks. He had no recollection of the events or even his name. On examination, the soldier had some numbness over the back of the head and increased sensitivity to pain down the left side of his body, as well as mild trembling in various limbs Under hypnosis, Myers gradually got the man to reveal his regiment and number. There was a brief history of being under attack from German grenades. After 'waking' from the hypnosis, the man was still struggling to recall his number again. Myers immediately re-hypnotised him. The details of the event became much clearer.

"Finally, he was persuaded to describe what happened after the bomb-throwing [when a German grenade hit him on the back of head but did not explode] (for his dream turned out to be an actual event), "I must have gone off my head and run away. . . . . . . I must have taken off my clothes in a field ....... I spent the first night under a hedge....... I spent the next two nights in a wood. I ate nothing....... The next night I was walking along a road on the outskirts of a village, and I was taken to a house by two men." These data, like the preceding, were only extracted with great difficulty and after much persuasion."

After "a much more powerful suggestion" made under hypnosis by Myers, "his entire expression changed..." The symptoms resolved immediately and memory was restored. The soldier subsequently rejoined his unit.

Robert

[Tim P]

I was surprised in the Netley film, kindly posted, to see how many of the cases were directly attributable to burial. A torment endured by my grandfather for three days. His honourable discharge followed this and I am quite profoundly affected by that film, fearful that he was in a similar state to the poor men in that film.

That his discharge for 'neuralgia' in feb 17 followed his evacuation from France in dec 16 leaves me in little doubt that he must have been a bad case.

[Robert Dunlop]

'Neuralgia' is not the same as 'neurasthenia'. It is pain arising from nerve damage. The most common non-traumatic example is the pain of shingles. Actually, 'pins and needles' is a form of neuralgia, albeit temporary. In war, neuralgia would be caused by a direct wound, by an accident, amputation, or indirectly, for example when a neighbouring bone was fractured.

Robert

[Robert Dunlop]

Early in 1916 (January 8), Charles Myers published the second of his series 'Contributions to the Study of Shell Shock' in The Lancet.

Myer's second case was a 23 year old private who had 'rhythmic spasmodic movements' of the legs.

"Three days ago, he said, the Germans sent over 'whizz-bangs and coal-boxes' in reply to our shelling, and he had been told that he 'got pitched up in the air.' The last thing he remembered of the occasion was digging himself out of the fallen sandbags. He remembered running then to the shell trench, but he 'found this too hot and returned to the firing trench, going to his dug-out, when he noticed that his eyesight was defective. He lay in the dug-out, flinching each time a shell came, and 'trying to get into the smallest possible corner'. At night he came out to endeavour to 'do guard,' but someone noticed that he was making involuntary spasmodic movements which had begun a short while previously.

He had also got 'shook up a bit' four months ago, when five or six bombs threw dirt in his face. His hands and his handwriting then became shaky but he did not report sick."

On examination, the soldier 'seemed depressed'. He was complaining of headache. There were unusual problems with sensation down one side of the body but the striking finding was the constant rhythmic movements of both legs.

"Under hypnosis he was able to recall all the period of his previous amnesia. He remembered the direction from which the shell came, how he was lifted up, how he fell on his back, &c. As he passed into a deeper state of hypnosis the contractions of the sartorius muscles [in the legs] became very much diminished, but did not absolutely disappear. Before rousing him from hypnosis, I suggested that he would remember all that that now and on waking he would lose his headache and his involuntary movements, and that he would recover his memory. The movements at once ceased and he awoke able to stand, absolutely free from his headache and further, with recovery of memory and, other observers spontaneously remarked, 'looking another man'. The previous unilateral disturbances of sensibility were found to have disappeared. He was transferred to a base hospital."

Robert

[Robert Dunlop]

The third case was a man who became mute. Myers saw him:

"...the day after admission to a base hospital, completely mute, but able to read and write. He wrote: 'I was buried alive on -- and again on- (5 months and 4 months respectively before admission), and then had the misfortune to have two shells burst over me on - (four days before admission). There was shelling for about 20 minutes and then two bursted over my head. I did not remember any more until you came to see me, but I am still liveing in hopes to regain my speech back.' In reference to his first burial he also wrote that he afterwards wandered with Lance-Corporal - for two days, but that his memory for these two days was completely gone ; his comrade and he finally came across men of the French artillery, who enabled them to rejoin their regiment. He could not recall how he got his food during those two days. He said that this time, although he found a piece of shell in his tunic, he was unhurt, but that on the first occasion he fell and hurt his back, and suffered for some time from pains in the back and head and from insomnia, which had recurred now.

Sixteen days after admission his speech was improving, but he showed me a report he had written out for me of his condition, and in so doing burst into tears. Apparently he had overheard a sister expressing the opinion that he was a malingerer."

During hypnosis sessions, the man regained his ability to speak and his memory of the events.

"Three days later (three weeks after admission) he appeared a normal man save for slight deafness and the complaint of 'coming all over of a shake' when he heard a gun fired. He moved and spoke naturally and his spirits were excellent. He had no recollection of telling me his forgotten experiences under hypnosis, but he could now recall all that he had told me and more.

He was transferred to-day to a hospital in England."

Robert

[Robert Dunlop]

The final case in Myers' series was a soldier with stupor (decreased consciousness with confusion) who was:

"...aged 29, admitted into a base hospital and seen by me on the following day. He was in a condition of pronounced stupor and had to be repeatedly roused from his apparently dazed condition in order to obtain his attention. He could not recall his name, regiment, or age. He could neither write nor read words ; he could name a few letters in very large type, but was liable to confusion. Twice he said 'water', 'comrade', and then made a gesticulation of falling. He was not deaf. He agreed that a shell came. He complained by gesture that he had pains in the forehead. His gait was normal, but he could not hold his hands out for many seconds without dropping them."

During the next few days, the soldier appeared to recover from his dazed state but he was left almost mute and without any memory of recent events. After a week, Myers decided to use hypnosis.

"...after much persuasion, I induced him to talk about the events that had preceded the onset of his disorder. He became very excited, breathed rapidly, and made gestures showing the positions of the various items in the scenes he began to describe, evidently visualising them vividly. Hoarsely and breathlessly he explained in broken sentences how he was in the trenches and was sent to draw water at a pump when two or three shells burst over him, knocking him down."

Although there was some improvement in speech after the first session, memory was not fully restored. Myers undertook a second session of hypnosis:

"...he described to me how, after being shelled, he lay on the ground in a dazed condition for some minutes, and how he rose, picked up the bottles, and returned to the trenches, after which he 'lost all sense and reason'. He said, 'I remember my mates telling me I was silly. It was time for us to be relieved at the trenches, but I don’t know how I went back with the boys ; it was only a short distance to the village. After that I remember nothing until you tried to make me speak'. By further persuasion I elicited from him full details of the still forgotten interval, how he got back to his billet, took off his equipment, then lay down, and was wrapped in a blanket by one of his comrades. 'I remember going to the doctors, complaining of a bad headache....... I remember a jolting ride, and then I lay on a blanket in a big room full of men'. By now he recalled the whole of his forgotten experiences, including the train journey down to the base."

A third session of hypnosis restored fully both speech and writing.

"He was discharged two days later to a hospital in England, and has since been passed for foreign service, occasional severe headache preventing him from active service in the field."

Robert

[Robert Dunlop]

The rest of Myers' paper was taken up with 'General Remarks'. He started with a short section on 'Malingering':

"After nine months of special work order in France and Belgium upon these disorders I have not the slightest hesitation in maintaining the genuineness of the cases above described."

Myers cited the different unusual symptoms as the reason why the men could not have been malingering.

He then went on to make some observations about the process of hypnosis. Before hypnosis, he noted that:

"...in all these cases whenever the memories dissociated from the normal personality were revived they were accompanied by an outburst of emotion, sometimes of frenzy, but generally of fear. But in the cases described in this communication it was impossible without the help of hypnosis to obtain any revival of the lost memory. Not even in dreams did it return. When such patients endeavoured to think of their forgotten experiences their headache became so severe as to prevent them from further direct effort. When, if mute, they endeavoured to talk they complained generally of a pain in the throat, as if someone were gripping their thyroid (Cases 4 and 5). cartilage [the Adam's apple area of the throat].

These pains appear to constitute the guardians of the condition of amnesia; any effort on the patient’s part to break down the latter generally resulted in increased severity of the former. It is, therefore, not surprising that pains frequently caused the patient to wake from hypnosis as soon as his attention was directed to his forgotten memories or when attempts were made to get him to speak. Experience soon taught me that before I could induce free speech during hypnosis I must first dispel, by suggestion, all pain, soreness, or discomfort in the throat, and that before I could hope to revive lost memories during hypnosis I must first suggest the disappearance of headache and prevent the recurrence of any trace of it. Even then there was frequently a strong disinclination to talk of the forgotten periods, as if they were being actively inhibited or 'suppressed' rather than passively 'dissociated'. When at length this reluctance was overcome the attitude of the patient often changed from depression to excitement, especially when the former condition had been well marked. His pulse and respiration increased in frequency, he sweated profusely, and not infrequently showed clear evidence of living again through the scenes which were coming vividly to his mind.

[After hypnosis] there usually followed a distinct change in the attitude of the patient. His previous despondency vanished; he was delighted at having recovered his speech and memory. Sometimes the change was so marked as to appear like an alteration of personality."

Myers summarised the results of hypnosis:

"(1) Apparently complete cures . . . . . . 26 per cent.

(2) Distinct improvement ........ 26 per cent.

(3) Failure to hypnotise ......... 35 per cent.

(4) No improvement after hypnosis . . . 13 per cent."

Hypnosis had an effect in about 50% of cases. Myers concluded:

"Thus the minimal value that can be claimed for hypnosis in the treatment of shock cases consists in the preparation and facilitation of the path towards a complete recovery."

Robert

[Robert Dunlop]

Early in 1916 (January 8), Charles Myers published the second of his series...

At around the same time (December 1915), Frederick Mott published a paper entitled 'The Psychic Mechanism of the Voice in Relation to the Emotions' in the BMJ. At the time of publication, Mott was the Pathologist to the London County Asylums. In the paper, he discussed 'mutism':

"In my experience at the military hospitals a number of remarkable cases have come under my care illustrating several points in connexion with the psychic mechanism of the voice in relation to the emotions. A large number of men suffering with shell-shock, and having no visible signs of injury have lost their speech, and yet are quite able to write a lucid account of their experiences. This mutism is really an exaggerated form of hysterical aphonia. A woman owing to an emotional shock may lose her voice; she can, however, as a rule whisper. These men cannot whisper or produce any audible sound. They occasionally show bodily signs of extreme terror, and in a very few severe cases one is reminded of the lines in Spencer's 'Faërie Queen':

'He answered nought at all, but adding new fear to his first amazement,

Staring wide with stony eyes and heartless hollow hue

Astonished stood, as one who had espy'd

Infernal furies with their chains untied'.

We may ask, why should these men whose silent thoughts are perfect, for they comprehend all that is said to them, and are able to express their thoughts and judgements in writing, be unable to speak? The cause of the mutism is clearly not due to an intellectual defect,nor is it due to volitional inhibition of language in silent thought. Hearing, the primary incitation to vocalization and speech, may be unaffected, yet they are unable to speak. They cannot even whisper, cough, whistle, or laugh aloud. Many of these poor fellows, who are unable to speak voluntarily, yet call out in their dreams expressions they have used in battle and trench warfare. Sometimes this is followed by return of speech, but more often not. There has been a severe emotional shock. Is the fear effect still operating on the mind, full as it is of the recollection of terrifying experiences of the trench warfare they have been engaged in ? The frequency with which these cases of shell-shock suffer with terrifying dreams at night and occasionally even during the day in the half-waking state, points to the conclusion that the emotional shock is exercising an effect on the mind by thoughts continually reverting to terrifying experiences they have gone through at the front; and probably their continuous influence on the subconscious mind accounts partially, if not entirely, for the terrified or vacant look of depression on the face, the cold, blue hands, feeble pulse and respiration, and the sweats and tremors which the severer cases manifest. As these dreams cease to disturb sleep, so these visible physical manifestations of fear pass off and give place to the sweet unconscious quiet of the mind of normal sleep.

I believe this mutism is due primarily to an inhibitory functional paralysis of the voluntary cerebral nervous centres which control the management of the breath and direct its mode of escape through the glottis, mouth and nostrils, for I have many cases where they have involuntarily and unconsciously in their dreams talked and uttered cries and swears, but in their conscious state were unable, not only to talk and sing, but to whisper, whistle, utter a cry, cough, or laugh."

In other words, Mott is suggesting that mutism was not caused by physical damage to the brain (otherwise the effects would have been consistent night and day). He postulated that part of the brain was switched off, the part that controlled how the voice box worked. The switch was, however, only turned to off when the person was awake.

Mott went on to discuss the issue of terrifying dreams:

"The terror sometimes observed in soldiers suffering from 'shell-shock' is contemplative fear; it is fear made more or less permanent by the imagination fixing in the memory past terrifying experiences, repressed in great measure by conscious activity of the mind during the waking state, but evident in the dreams which afflict nearly all these soldiers suffering from 'shell shock' and trench warfare. Shakespeare has not only in his characters shown how a passion steals into the soul, so that it becomes the sole tyrant of the desires, but he has clearly indicated how dreams influence the minds of men, and how they are based upon past experiences. Thus Mercutio in the description of Queen Mab refers to the soldiers' dreams in the following lines, which are as true today as when Shakespeare wrote them:

Sometimes she driveth o'er a soldier's neck,

And then dreams he of cutting foreign throats,

Of breaches, ambuscadoes, Spanish blades,

Of healths five fathom deep; and then anon

Drums in his ear: at which he starts and wakes;

And, being thus frighted, swears a prayer or two,

And sleeps again."

Robert

[Robert Dunlop]

The debate about cause continued into 1916. Following Mott's paper, a surgeon in Cardiff was prompted to publish a brief paper entitled 'Peripheral Shock and its Central Effects'.

"The paper... by Dr. F.W. Mott... reminds me of a remarkable case of deaf-mutism which came under my observation some years ago. This condition existed in a collier for about seven years, consequent upon receiving a 'shock' in an underground colliery explosion. He was eventually cured by another shock during a second colliery explosion underground.

He was one of the few survivors in a big colliery explosion. He remembered nothing of the accident, but on recovering consciousness found that he could neither hear a sound nor articulate a word. After remaining, in

this condition for a considerable time he went to a school for the deaf and dumb, and eventually married a congenital deaf-mute. He lived happily in this state for some years, and resumed work until the occurrence of a second underground explosion, which was followed by his recovery from deaf-mutism; he stated that he distinctly remembered 'hearing the ground tremble' before lapsing into unconsciousness which lasted a few days. When he regained consciousness he got very excited upon discovering that his powers of speech and hearing had returned.

The present war has added to our knowledge of the causation of symptoms which are clinically so well known, and are described in the textbooks in chapters on concussion of the brain. It is no longer necessary to assume that 'commotio cerebri' must have taken place due either to a direct force - a 'whack' or 'crack' on the head - or to indirect force transmitted through the atlantoid articulations with the occiput producing a jarring of the skull [whiplash injury] and its contents. It can now be easily realized by those who have seen and studied the effect of high explosive shells upon the buildings of a town or village in the vicinity of which explosions have taken place. The damage which atmospheric disturbances alone can do to buildings, even at great distances from the site of the explosion, has strikingly illustrated the effects air currents must have upon human beings, whether standing or lying down, awake or asleep.

I have had the opportunity of seeing the effect of air disturbances caused by colliery explosions, and these are in some aspects as powerful as those of 'shell concussion.'"

Robert

[Robert Dunlop]

The next major contribution to understanding the cause/s of 'shell shock' came from Frederick Mott again. This time he delivered a series of lectures to the Medical Society of London. The series went by the name 'The Lettsomian Lectures on the Effects of High Explosives Upon the Central Nervous System'. A single lecture would have been significant. That were several (three in all) is a mark of how this topic had been a major issue, reinforced by the fact that the lectures were published very quickly in The Lancet. Each lecture was long and detailed. I don't propose to reproduce all of the content. Hopefully, I can do justice to Mott's work in this and subsequent posts.

Mott set the context with the following paragraph:

"The employment of high explosives combined with trench warfare has produced a new epoch in military medical science. This war was recently described at a Labour Congress as a barbarous, unromantic, machine war. Yet in no war of the past has individual courage and self-sacrifice shone with greater lustre; for the contemptible little army in the retreat from Mons fought against overwhelming odds and covered itself with glory. Again, in the terribly anxious times when the enemy tried to break through to Calais, what could have surpassed the courage and self-sacrifice of our men in the trenches on the Yser, or the gallant stand of the Canadians when the Germans sprang the gas upon us? Lastly, the landing of the Anzacs is one of the finest and most romantic deeds in the history of war."

Mott then went on to define three categories of effects of HE shells:

1. Immediate death, either from shrapnel, shell fragments, flying debris or cases where 'no visible injury has been found to account for it'.

2. Wounds or injuries, including physical damage to the nervous damage.

3. Effects on the nervous system, with no evidence of physical injury. Mott noted that this was to be the main focus of his lectures. Into this category, Mott included 'the functional neuroses and psychoses'. He went on to comment that:

"...so complex is the structure of the human central nervous system, and so subtile [sic.] the chemical and physical changes underlying its functions, that because our gross methods of investigating dead material do not enable us to say that the living matter is altered, yet admitting that every effect owns a cause, a refractory phase in systems or communities of functionally correlated neurons must imply a physical or chemical change and a break in the links of the chain of neurons which subserve a particular function."

From this comment, we can see that Mott considered that physical effects might still be at play in men who had symptoms but no detectable injuries. He was suggesting that, just because damage could not be picked up on post-mortem, the possibility of nerve damage could not be excluded. Mott recognised that there were unusual features, such as the sudden onset of mutism and then the sudden 'cure' when "...attention is for a moment taken off its guard".

As to cause, Mott listed: "physical trauma - concussion or 'commotio-cerebri[/i'] by direct aerial compression or by the force of the aerial compression blowing the person into the air or against the side of the trench or dug-out; or by blowing down the parapet or roof onto him causing concussion, or a sandbag hitting him on the head or spine might easily cause concussion without producing any visible injury. Again, he might be buried and partly asphyxiated or suffer from deoxygenation of his blood by CO [carbon monoxide poisoning] as I shall prove..."

Mott then dealt with the physical structure of the brain and spinal cord, with both being suspended in the cerebro-spinal fluid [the clear fluid that surrounds the brain and spinal cord within the tough membranes called the meninges]. "Now this fluid is incompressible, and under ordinary conditions pressure from without it serves as a perfect protective mechanism, but when large quantities of high explosives are detonated an enormous neurons of the first type and in the cerebral aerial compression is instantly generated, and it is quite possible that this may be transmitted to the fluid about the base of the brain and cause shock to the vital centres of the floor of the fourth ventricle, causing instantaneous arrest of the functions of the cardiac and respiratory centres." Mott is referring to the part of the brain that lies below the back of the skull, just above the neck. This area controls consciousness and breathing. This area is targeted when someone is executed by a shot in the 'back of the head' because death is instantaneous. The results of an American study were quoted, revealing that a heavy shell could generate up to 10 tons of pressure per square yard. This was, in Mott's opinion, sufficient to cause death directly.

Mott turned his attention to the effects of high pressure and concussion on living nerves. He quoted from a study in which the nerve cells of the spinal cord were shown to become grossly swollen from physical shock. Several diagrams were included, illustrating the microscopic changes that took place in individual nerve cells.

The first lecture concluded with a lengthy discussion on the possible causes of the sudden death of groups of men in the vicinity of a large explosion. Mott cited Ashmead Bartlett's description of a group of Turkish soldiers at Gallipoli. They were found sitting in a circle, with the same expressions as, presumably, they had before the shell exploded. Mott quoted from other work, postulating that the huge increase in air pressure might cause nitrogen and other gases to form bubbles within the blood stream, which would prevent oxygen getting to the brain. He also noted that an explosion might use up all of the oxygen in the vicinity or there might be toxic fumes that poisoned the men. These ideas were juxtaposed with the possibility of direct physical compression of the brain stem, as noted above.

Robert

[Robert Dunlop]

In the second of the three lecture series, Mott started by examining the similarities between carbon monoxide poisoning and 'shell shock'. He related the anecdotal account of a British submariner 'who had been gassed in a submarine'. The officer had been rendered mute but suddenly regained his voice when Mott was talking to his mother. There was, however, a very fundamental difference with other cases of mutism from 'shell shock'. The officer had suffered severe and irreversible damage to his short-term memory. Prior to the war, the officer had been a mathematician. After the poisoning, he could not perform even simple calculations '- in fact there was a profound dementia'. This would be consistent with severe brain damage affecting the memory centres of the brain, which are very sensitive to a lack of oxygen.

Mott then reviewed the 'Crarae disaster' of 1885. There was a 'monster blast of gunpowder' in a quarry near Glasgow. Within 20 minutes, 100 onlookers had gathered to review the effects of the explosion. Forty people became unconscious. Several others fell down with 'giddiness'. There were 6 deaths. Some people who recovered became severely confused and many experienced severe weakness that lasted for some time.

Mott postulated that carbon monoxide would not be detected by soldiers on the battlefield because it has no smell. The final anecdote was about a sapper who lost consciousness after a German mine exploded. He and one other colleague were the only two of seven who survived. None of those who died had any visible injuries. When the sapper recovered, he had severe headache, vomiting, breathlessness and palpitations. He was left with weakness and tremors of the legs. "His symptoms entirely agree with many of the cases of shell shock." Unlike shell shock, however, the sapper noted that one of his dead colleagues looked "alive; the cheeks and lips were pink." These changes are characteristic of carbon monoxide poisoning but have not featured in any previous descriptions of shell shock cases in this thread.

The symptoms of carbon monoxide poisoning were listed, based on a textbook written by Glaister and Logan ('Gas Poisoning in Mining and Other Industries'):

"These authors point out that the commonest of all symptoms are headache, which may take the form of distension of the head without pain, ringing in the ears, interference with vision, which may become indistinct and blurred, hallucination of sight and even blindness, giddiness especially on exertion, powerlessness, yawning and often vomiting, shivering and feeling of cold, palpitation of the heart, and a feeling of oppression in the chest. The action of CO is most monster blast of gunpowder in a quarry attracted a marked upon the central nervous system. When men affected regain consciousness they appear dazed and stupid, and generally have no recollection of what happened. There is mental confusion, and they seem to have no power of concentration of thought, and they are unable to answer questions properly. Glaister and Logan also call attention to disturbances of speech. In some survivors speech is affected. The power of speech may be lost for some time or it may come back after many days. Tremors frequently occur. These symptoms so accord with those functional disorders of the central nervous system which have into lso frequently been found to occur in shell shock that one naturally thinks it possible that while lying unconscious at the bottom of a trench or dug-out sufficient CO is inspired to cause these severe effects on the mind which some of these cases exhibit."

Mott went on to present slides and images of post-mortem findings from the brains of patients who died of carbon monoxide poisoning. He then showed that these findings matched the post-mortem findings of a man who was admitted unconscious after a shell explosion. The shell had blown in the parapet, burying the soldier. It was not known how long he had been buried before being dug out. The brain showed multiple tiny points of bleeding into the substance of the brain.

Mott also gave details of case that Charles Myers saw. The soldier was buried for 5 minutes. Although he did not lose consciousness, the man was paralysed from the neck down when he was freed. His condition deteriorated subsequently and he died. This time, Mott commented that the nerve cells in the spinal cord looked swollen, as if from trauma. There was no sign of spinal fracture or dislocation, so the changes were ascribed to the force of the 'blow' from the explosion.

This part of the lecture was concluded with another non-military case of gas poisoning, where Mott gave details of pathology findings. He concluded with the comment:

"...this case suggests the desirability of examining the blood during life for CO in severe cases of shell shock without visible injury and where burial has occurred, and especially if some time has elapsed before excavation. This is all the more desirable seeing that the possibility of CO being produced in sufficient quantities by the imperfect detonation of high-explosive shells to cause poisonous effects is admitted by those competent to judge."

Robert

[Robert Dunlop]

At this point in the second lecture, Mott shifted focus to the "Mental and Bodily Condition of the Individual at the Time of Receiving the Shock". He was thus moving away from the external causes to examine susceptibilities in the soldiers who became 'shell shocked'. Mott listed several 'mental and bodily condition...':

1. 'Inborn' [ie something that the person was born with]

a. A timorous disposition and anxious temperament;

b. A neuropathic or psychopathic inheritance [ie someone predisposed to develop neuroses and psychoses].

2. Acquired

a. The result of alcoholism, syphilis, or previous head injury;

b. A lowered neuro-potential, the result of a post-febrile neurasthenia [ie being run down from previous infection];

c. Nervous exhaustion the result of mental stress, anxiety, insomnia, and terrifying dreams;

d. Physical exhaustion from fatigue, cold, wet, and hunger.

Mott "...prepared the following table from notes made by Dr. Cicely May Peake on cases admitted to Grove Lane Schools during six months :-

I. History reported on in 156 cases (shock), of which:

a. History predisposing to shock in 111 cases.

b. No history predisposing to shock in 45 cases.

II. No history reported on in 80 cases (shock).

III. No history of shock in 40 cases"

Further analysis revealed:

"a. Nervous predisposition (previous nervous breakdown, timid disposition, neuropathic temperament as family history, etc - 52 cases.

b. Epilepsy (pre-war 20, since war 5) - 25 cases.

c. Shock or accident (pre war) - 11; traumatic shock (pre-war) - 9.

d. History of insanity (patient 2, family 7) - 9.

e. Mental defectives - 9.

It will be observed that a large majority of the cases of so-called shell shock admitted with functional neurosis in some form or other occurred in individuals who either had a nervous temperament or were the subjects of an acquired or inherited neuropathy. In a certain number of cases the cumulative effect of active service, often combined with with repeated and prolonged exposure to shell fire and projectiles containing high explosives, had produced a neurasthenic or hysteric condition in a potentially sound individual."

Mott went on to note that some of these individuals had come through the South African War without any difficulty:

"Such men have not, as a rule, succumbed from a single 'shell shock', unless it was one of the big 'Jack Johnsons', but only after a third or fourth, and when they have been run down with the stress and anxiety of continuous apprehension and dread of the enemy surprising them.

On the other hand, there are 'the more or less rapid breakdowns' who give usually a history of either previous head injury, or of a nervous breakdown in ordinary life, or after some special stress indicative of a nervous temperament or a neuropathic disposition. Among the large number of officers I have seen sent back on account of neurasthenia, a considerable number associated with shell shock, I have not observed a single case of functional paralysis or mutism.

It will be observed that out of 156 cases in which a previous history is reported in the notes, 52 gave a history of either a previous nervous breakdown or a timid disposition, easily frightened, emotional, or afraid of the sight of blood ; in a few the fact was elicited that they had had a fright in early childhood and that this recurred in dreams. Some gave a history of a neuropathic tendency or inheritance. So that all the evidence goes to prove that an acquired or inborn tendency to neurosis in a majority of the cases."

Today, such a conclusion would be called into question for several reasons, not least the issue of ascertainment bias. This refers to the fact that, while the results may have been true for the sample examined by Dr Peake, the sample may not be representative of all cases of 'shell shock'. Those soldiers who ended up in Dr Peake's care may have been very different from other soldiers who were not seen by her.

Robert

[Robert Dunlop]

The third lecture in the series dealt with symptoms of shell shock. This review will only touch on significant differences from previous posts in this thread. Mott started with the following:

"From the point of view of compensation or pension the War Office authorities very properly regard 'shell shock' as a definite injury, although there may be no visible sign of it. This fact is of considerable importance, for as in the case of pension or compensation for traumatic neurasthenia under the Employer’s Liability Act, the notion of never recovering may become a fixed idea."

The mention of compensation and pension illustrates another reason why the lectures will have been important. Note Mott's concern that long-term compensation could reinforce the notion that 'shell shock' was a long-term condition. He then went on to discuss the problem of malingering, ie deliberate deception:

"The detection of conscious fraud is not easy in many cases of 'shell shock' in which recovery might reasonably have been expected, for it is difficult in many cases to differentiate malingering from a functional neurosis due to a fixed idea. The first point is to be sure of your diagnosis that the disease is functional, and being satisfied thereof to avoid all forms of suggestion and of the possibility of non-recovery. A very great difficulty in the complete investigation of these cases arises from the fact that few or no notes, as a general rule, accompany the patients; one has therefore to rely upon the statements made by the patient himself, or perchance of a comrade if he had no recollection of the events that happened. Most of the cases of shell shock, however, are able to give satisfactory information of the events that preceded the shock; they even tell you they can call to mind the sound of the shell coming and see it, in the mind’s eye, before it exploded; then there is a blank in the memory of variable duration.

All degrees of effects on consciousness may be met with, from a slight temporary disturbance to complete unconsciousness, with stertorous breathing [heavy snoring-like breathing that occurs when someone is deeply unconscious] continuing till death. Occasionally cases have been admitted under my care at the 4th London General Hospital who had not yet recovered 'shell shock'. Usually these cases came at a time when large convoys were sent from the front owing to a recent engagement [bearing in mind that this was published before the battle of the Somme]. The histories of cases sometimes.. absented themselves and wandering away from the trenches... is not unlike a fugue or automatic wandering of an epileptic..."

Mott then listed the various other symptoms, with additional explanatory material:

1. Amnesia - as with other writers, he noted that some men could recall what happened. Other men, however, found it difficult to recall anything, in part due to the effects of headache and extreme weakness. Mott noted that "...irresolution and indecision is a result of shell shock, [which] is a serious disability in officers and non-commissioned officers placed in positions of responsibility."

2. Psychic trauma and the effects produced by terrifying dreams - Mott describes the terror and signs of fear that accompany the nightmares suffered by many men. He also noted "Occasionally during the waking state contemplation of the horrors seen provokes hallucinations or illusions which may lead to motor delirium [severe confusion with thrashing around and other extreme behaviours] or insane conduct." Not surprisingly, Mott reproduces the quote from Shakespeare that is in a previous post. He pointed out that many men experienced a sinking or falling feeling in the dreams, hence the comment "it is [possibly] to this that Shakespeare refers in the lines 'of healths five fathom deep'."

3. Speech defects - including "mutism, aphonia [unable to make speak but able to whisper], stammering, stuttering, and verbal repetition." Mott estimated that 1 in 20 (5%) men were affected in this way. He noted, as we have seen before, that the ability to write was not affected. He embarked on a very detailed discussion of way that speech is controlled by the nervous system, which I won't recount. The conclusion was that "...we must suppose that mutism is caused by fear producing an emotional shock depressing the activities of the whole of the [brain] structures connected with [speaking] and production of audible sounds.

4. Headache - "The commonest situation for the maximum pain is the occipital region and the back of the neck; it is often described as a tight compression like a helmet - the helmet of Minerva. It seems to be correlated with thoughts of terrifying scenes and is increased when the mind dwells upon these, and it is increased by the mind trying to thrust them aside."

5. Disturbances of the cardiovascular system - basically the symptoms of what was called Disordered Action of the Heart (DAH - later changed to Effort Syndrome in an attempt to avoid any association with heart disease):- palpitations, breathlessness, central chest pain, and fatigue on effort.

6. Hearing and vision [problems] - including: loss of hearing, auditory hallucinations [hearing things that are not real], noises causing pain, a drumming noise in the ears or a persistent clicking/ticking sound. The visual problems have been listed before, including: loss or blurring of vision, light causing pain, and reduction in the visual fields. Mott mentioned one case of a soldier who, after a shell exploded, was able to move his wounded colleague to safety and then lost his sight.

7. Sensory disturbances - including: heightened sensation, decreased sensation or loss of sensation in various parts of the body.

8. Tremors - "...are extremely common and constitute a serious disability... A true functional tremor as distinguished from the malingerer’s tremor is not exaggerated and altered in its rhythm by taking the individual’s attention away - e.g., by making him count slowly and quickly."

9. Functional paralyses - gait [walking] - "functional paralyses are not at all uncommon, the most common being paraplegia [weakness in both legs],but hemiplegia [weakness in an arm and leg on the same side of the body] and monoplegia [weakness of one limb] are also frequently met with." Mott discussed some of the different gait problems he has seen, concluding with "I am instituting a museum of crutches, sticks, and other supports of patients admitted from hospitals where they have been many weeks and months, only waiting to be assured that there was nothing the matter with them."

The final section of Mott's last lecture related to generating "an atmosphere of cure". He emphasised that soldiers should always be given the expectation that their symptoms would improve.

Robert

[truthergw]

Robert, may I just say how much I am enjoying your contributions to this thread. They certainly throw a great deal of light on a very much misunderstood subject.

[John Gilinsky]

While I also do appreciate very much your synopses of various major British senior medical practitioners' published accounts of what they refer to as "shell-shock" another grossly neglected and thus distorted area of investigation is the social cultural/anthropoligical aspects of military medical diagnoses (as it is indeed with all medical practice). Thus what may appear to be deviant, socially unacceptable, abusive, criminal, atypical, eccentric, or pathological conduct in one culture may be tolerated, ignored and seen as perfectly normal in another. Trench culture(s) depending on what sector/region and front a soldier (especially other ranks) were physically located in at any give time and for any given period of set time clearly materially influenced the overall health including mental of ALL soldiers. This could be for the better or for worse and of course would fluctuate depending on the individual concerned. The sheer numbers, isolation, grossly limited medical attendance for most of the military personnel involved overall would though also clearly tend to suppress what we know to be fundamental environmental or external considerations to the health of such personnel. I point this out to not detract Robert from your literary contributions and comments which are substantial but to place them in proper context of fullsome historical investigation.

John

Toronto

[Robert Dunlop]

Thanks. I won't be touching on the broader aspects, John, though having studied social anthropology I recognise what you say. Interestingly, however, the next step in my analysis touches on this. It comes from an editorial that was written in The Lancet just one week after the last of Mott's lectures was published, ie March 18, 1916. The editorial is entitled 'Neurasthenia and Shell Shock'. The author is not identified. The opening line is consistent with what we have read before:

"From the early days of the war attention has been directed to the probable dire results which were to be expected from the use of high explosives and from the awful experiences which must inevitably ensue."

The author then goes on to indict the 'medical authorities' for their initial attitudes towards the 'awful experiences', although the author's caveat should be noted:

"Based upon a very imperfect acquaintance with the procedure adopted by the military authorities, there was at one time quite a formidable campaign of invective directed against the inhumanity of treating men with nervous symptoms though they were either insane or malingerers. It was too hastily assumed that no middle course would be recognised, and that these unfortunates would be either certified as lunatics or else returned to duty or discharged from military service with an inadequate pension."

This is the first instance that I have come across in the medical literature where the socio-political dimension of shell shock was explicitly addressed. The author goes on:

"These views, which are entirely erroneous, caused much needless anxiety to many public officials. Questions asked in Parliament and letters addressed to the press served only to distract those who hastily took sides for or against the authorities. The delight of a supposed grievance, within the comprehension of every intelligent thinker, stimulated much ignorant invective. To the non-medical mind there is always something attractive in the contemplation of strong contrasts, hence it was argued that the soldiers in question must be either sane or insane, and that they must be dealt with accordingly. In the heat of controversy no count was taken of the difficulty so often experienced by alienists in dealing with borderline cases."

There is a brief excursion into the analogy of the borders between countries. On a map, the separation between two countries is clear. In practice, however, "these demarcations may mean very little" to the people who live near the borders. So it is in medicine, proclaimed the editor. Medical conditions are rarely so clear cut, particularly as to separate men into categories of sane and insane. A middle ground was needed. I will explore this in the next post/s.

Robert

[Robert Dunlop]

It is a shame that the whole editorial cannot be published verbatim. The style is typical of an astute and gifted editor. Drawing on the war, the article continued the theme of finding a middle ground:

"In medicine there is a neutral zone, a no-man’s land..., which really defies definition. This nebulous zone shelters many among the sad examples of nervous trouble sent home from the front..."

There was a need to gather more information, in order "that we can hope for new definitions of permanent value". In support of this, the author drew attention to importance of the existing term ‘neurasthenia’. It was noted that this diagnosis "applied to many of these cases has been of great service in allaying public anxiety". This was because neurasthenia "is commonly associated [according to the author] with an idea of a tedious, troublesome malady in which there is fair ground for hope of recovery under favourable conditions. It does not denote any permanent structural change in the nervous system.." In addition, neurasthenia was associated with the concept of cure, or at least remediation with various treatments.

It was noted that the pre-war diagnosis of 'neurasthenia' could encompass a wide range of symptoms, including: problems with memory, eyesight, smell and taste, along with disorders of sensation. There was a major problem, however, with the "sudden appearance of all or some of these symptoms in healthy young males", which "gave an impetus to fresh research and to the introduction of a new term 'shell shock'." The difficulty with 'shell shock', however, is that, while it indicated the likely cause, it did not provide "further explanation".

At this point, the editor drew the reader's attention to the recently published works of Mott and Myers. Specifically, Mott's lectures and the three series of papers that Myers had now published in The Lancet. These two authors had presented "the latest phases of scientific investigation and speculation concerning this subject [of shell shock]". High praise indeed, but there was more to come:

"Both writers are well equipped by previous study and training, have done first-class and as original work in other but cognate spheres, and have had unusual opportunities of making a large number of observations. Their contributions therefore merit the respectful consideration of all who desire assistance in lifting the veil of obscurity, which still bewilders many who have to deal with isolated examples of this condition."

Before going into the details of Mott's and Myer's work, the editor was at pains to point out, again, that "there has been a tendency to consider that the cases might be divisible into two classes". The first category was that shell shock caused pre-existing "mental deficiency" to be made worse. In other words, some doctors felt that soldiers who developed shell shock had some sort of mental problem which was exacerbated by a shell explosion. The second category held that shell shock was like hysteria, which could "to some extent be due to imitation, more or less under the control of the individual". In other words, some soldiers were making it up and deliberately triggering hysterical behaviour. The editorial concluded, however, that "the number of cases now investigated appears to afford conclusive evidence that the subject of shell shock is not lightly to be disposed of on either hypothesis".

Here we have one of the most esteemed medical journals in the world stating that the latest research did not support the ideas that shell shocked soldiers were mad or bad. But there was still a major problem. "It is not so clear, however, that the keenest investigation has yet supplied a satisfactory answer to all the doubts which have been expressed." In other words, Mott and Myers had not solved what shell shock was. These researchers had reached different conclusions. They both agreed that shell shocked soldiers had suffered terrible experiences. Myers had shown, in his latest series of cases, that soldiers sometimes reproduced symptoms of pain problems they had experience in the past, such as the pain of pleurisy. Mott, on the other hand, did not appear to hold with psychological causes. According to The Lancet editorial, Mott sought answers in some sort of problem with the central nervous system. Even in the absence of visible physical damage, Mott was emphasising the possibility of nerves malfunctioning as a result of physical shaking or pressure, lack of oxygen due to carbon monoxide poisoning or lack of blood supply due to nitrogen bubbles in the blood stream. Basically, Mott and Myers were being placed at opposite ends of the physical - psychological (body - mind) dichotomy of causality. The two leading investigators had reached diametrically opposed conclusions. In fact, this wasn't strictly true, as the author went on to elucidate. Mott had mentioned the similarities between some cases of mutism and hysteria, as we have noted in a previous thread. Nevertheless, the editorial was reinforcing the impression built up so far in this series of reviews - there wasn't a single coherent understanding of 'shell shock' except, perhaps, the link to exploding shells.

The final paragraph is worthy of quoting in full:

"Medical men, while grateful for these interesting lectures and papers, may feel in entire agreement with Major Mott’s concluding remark: ‘We shall want a brand-new Dictionary.’ There are numerous new terms as well as old terms employing ‘a newly earned meaning’ by both Major Mott and Colonel Myers; whether they will remain as permanent acquisitions will probably depend on the general recognition of their utility, of which the future must be the judge."

Much had been learned. Much more learning was needed. The exigencies of war, coupled with the medical and socio-political imperatives, meant that more research and debate would be forthcoming.

Robert