Neurasthenia and Shell Shock

[Old Tom]

Robert,

I have just been re-reading Martin Gilbert's 'First World War' in which, while dealing with the period Mons to the Marne he refers to the British official medical history of the war. I expect you are well aware of the publication, but just in case, Gilbert quotes:

During 1914 several men were evacuated from France to England owing to having been 'broken' by their experiences in the retreat from Mons. Within a month, at the base hospitals in France, Lt Col Gordon Holmes, an expert of nervous disorders, 'saw frequent examples of gross hysterical conditions which were associated with trivial bullet and shell wounds, or even with only slight contusions of the back, arms and legs'. By the end of the year more than a hundred British officers and eight hundred men had been treated for nervous diseases, mostly what the official history called ' a severe mental disability which rendered the individual affected temporarily, at any rate, incapable of further service. By the end of the war as many as 80,000 officers and men had been unable to continue in the trenches, and many had been invalided out of the army altogether for nervous disorders, including what came to be known as 'shell-shock'

Old Tom

[Robert Dunlop]

Old Tom, thank you very much for the quote! I haven't read the BO medical history. Gilbert's quote reminds me of Sir Archibald Murray's emotional reactions to the retreat. The estimated number, 80,000, gives a very clear sense of the scale of the subject under discussion.

Robert

[Robert Dunlop]

In April 1916, another paper appeared in the BMJ. The author, Dr Harwood, was an eye specialist. He commented that "...almost every patient [with neurasthenia] will be found to have more or less difficulty with reading.This is usually taken for granted and passed over as a mere incident. In reality it gives a clue to the most efficient treatment of such cases, from whatever cause arising." Harwood pressed for these men to have an eye examination and corrective glasses, if needed. This helped, in Harwood's opinion, with symptoms like headache, giddiness and even nausea. There was no clear evidence to support the recommendations.

Harwood's paper contained an interesting analogy for neurasthenia. He was making the point that the eye muscles that control the shape of the lens in the eye, and hence the ability to see things in focus, could also be weakened with general neurasthenia. The analogy is useful for understanding the concept of neurasthenia:

"The living body may be compared to an electrical system, which may break down owing to faults either in the circuit or in the battery. An organic [physical] nervous lesion may be compared to a break in the circuit, a functional nervous condition to a lowered efficiency of the battery, affecting the whole circuit, but usually showing its effects more markedly in some parts than in others.

Neurasthenia, in the widest possible sense of the term, corresponding to a lowered efficiency of the battery, is a general condition affecting every function, organ, and tissue of the body, though its effects are usually more marked upon some one function or organ or tissue than upon the rest, so that different names or labels become attached to different forms of the same underlying condition."

Robert

[Robert Dunlop]

It wasn't long after The Lancet editorial before the next major paper appeared. The author was Dr Harold Wiltshire, a physician from King's College Hospital in London. He had served as a captain in the RAMC, having been responsible for assessing functional psychiatric cases at the No 12 General Hospital in Rouen until August 1915. Wiltshire's paper was entitled 'A Contribution to the Etiology [cause] of Shell Shock', published in The Lancet in June 1916. He started out by noting:

"The functional nervous affections of modern warfare are essentially the same as the functional nervous affections of civil life, and in consequence should be of great value in helping to elucidate problems connected with the etiology of functional nervous disease in general."

Wiltshire then pointed out that the cause of 'shell shock' was "buried in confusion". He attributed this to three factors:

1. Bad terminology - where the term 'shell shock' was being used to describe any psychological problem, whether related to shell explosions or not.

2. Dubious clinical histories - particularly because affected soldiers had varying degrees of memory loss.

3. Rapid changes in clinical condition - which, compounded by the fact that medical notes rarely accompanied patients along the evacuation chain, meant that two doctors would have seen very different features in the same patient. This led, in Wiltshire's opinion, to more confusion about the diagnosis.

These issues were of such concern that Wiltshire began his paper with a footnote to the title:

"The term 'shell shock' is used unwillingly in this paper in order to avoid multiplication of names; but this use is limited to cases of secondary functional nervous disease resulting from fighting at the front, all organic cases, mental deficients, simple chronic epileptics, &c., being excluded."

Wiltshire then set out his credentials, commenting that he had worked at the No 12 General Hospital for 6 months. This brought him closer to the front line, which meant that he had seen cases at an earlier stage than colleagues back in England. As a result, Wiltshire had drawn the following two conclusions:

"...namely, [a] that the condition of shell shock was of extraordinary rarity amongst the wounded ; and that the vast majority of these cases, if not all, were due to psychic shock, and not to physical shock."

He drew up a list of potential causal factors:

1. Wounds.

2. Possible physical causes, including:

a. physical exhaustion from exposure and hardship.

b. physical concussion.

3. Possible chemical causes : Absorption of toxic gases generated in shell explosions.

4. Possible 'psychic' [psychological] causes:

a. gradual psychic exhaustion as a pre-disposing cause and [ii] as a cause of neurosis per se.

b. sudden psychic shock from horrible sights, [ii] losses, [iii] being near an explosion and [iv] sounds.

5. Causes of relapse.

Wiltshire excluded the possibility of gas bubbles appearing in the blood from being near the high pressure of explosions. He quoted a paper by the Surgeon-General that opposed this theory, which I will review later.

The next paragraph is at the heart of Wiltshire's paper and is worthy of being quoted in full. His observations, supported by a colleague's letter, are very significant:

"In the 12 months during which I was attached to general hospitals in France many thousands of wounded, the majority being the subjects of shell wounds, passed through the surgical divisions of these hospitals ; yet I cannot now recall to mind a single instance in which I was called in to see a condition of shell shock complicating a wound. In fact, shell shock was not to be seen in the surgical wards. Mr. Beckwith Whitehouse confirms this observation in a letter as follows: 'From my experience of 12 months surgery at No. 8 General Hospital I should say that functional neuroses are amongst the rarest of the conditions found in the surgical cases admitted to a base hospital. ’Shell shock,’ as exemplified by monoplegias, paraplegias, mutism, somnambulism, fits, hysterical tics, and neurasthenia, is conspicuous by its absence. Amongst the large number of pure shell wounds I cannot recall a single instance of shell shock.'

Wounded soldiers remained "cheerful" unless they were severely ill from blood loss or infection "though some may show a slight degree of nervous exhaustion this is usually of late development, manifesting itself when the wound condition is such that return to the front becomes a factor to be reckoned with." Of the 150 cases of 'shell shock' that Wiltshire had identified, only 14 had any wounds "but in all of these, the wounds were trivial". In 2 of the 14, the wounds were sustained after the 'shell shock' came on; in 6 cases the wounds had healed completely before the episode.

"Consequently, not only may it be said that in no single case did a wound merit consideration as a physical cause of shell shock but, further, that the wounded appear to be comparatively immune to shell shock. In view of the fact that the wounded must have been exposed to the physical and chemical effects of shell explosions to a greater degree than the unwounded, this fact is most significant."

We must bear in mind that Wiltshire defined 'shell shock' as "cases of secondary functional nervous disease" [meaning that the signs and symptoms were psychological and were caused by something else but not necessarily shell fire]. Nevertheless, he was saying that men could be seriously wounded by shell explosions [sufficient to require evacuation to a general hospital] or they could be shell shocked but not both together. This was a very profound observation, which recurs throughout the rest of the paper.

Robert

[John-B-Rooks]

Hello.

Wiltshire's paper has to provide the most cogent explanation of the difference between the physical and psychological effects of shellfire so far, 'shock-of-shell' including its shrapnel flinging and concussive effects against 'shell-shock' arising from non-physical effects. This is truly wonderful research Robert.

Thank you

John

[John Gilinsky]

Dr. Wiltshire's assertions we now know are fundamentally incorrect from a clinical point of view. However even given the absolutely limited and extremely restricted access, distribution and exchange of medically and other "shellshock" related information during the war both in print through published medical journal articles and otherwise the small numbers and in many cases the non-scientific and anonymously anecdotally based formats of such published reports the vast majority of medical personnel both rightly and wrongly would barely have registered a professional medical knowledge of shellshock during the war based on such professional medical journal literature. One "expert's" "authoritatively" published opinion may hold sway even today for persons eager to find simple, direct and "informed expert opinion" on whatever ailment (real or otherwise) ails them or others. The inherent danger of indepth readings of such contemporary medical literature (a must however for the serious research)is being caught up in the seemingly professionally clothed but in fact or essence personal or one man's opinion evidence rather than professional, expert's assessments and the like. I cannot stress for us TODAY that the primary resources the actual medical records AND the long term medical histories of such "shellshock" victims, patients, subjects including pre-duration and post-war non-medical evidence such as police reports, legal judgements, etc...needs to be scientifically assessed.

John

[Robert Dunlop]

Wiltshire then proceeded to analyse the other causes, starting with possible physical causes. He discussed the issue of 'exposure and hardship':

"We might presume that these [factors] would gradually exhaust physical and psychic tone and so lessen psychic resistance..."

In other words, prolonged cold and the difficulties of living in the trenches would wear down psychological reserves of energy. This would make men vulnerable to the effects of shell fire. Wiltshire noted, however, that only 3 men out of 142 felt that exposure and hardship were responsible. In one case, the soldier had been punished for deliberately injuring his trigger finger on his second day in the trenches. The other two men were described as having a past history of neurasthenia. Wiltshire concluded:

"..in respect of trench warfare, when the troops are well fed, exposure and hardship do not dispose to nervous breakdown."

Robert

[Robert Dunlop]

Dr. Wiltshire's assertions we now know are fundamentally incorrect from a clinical point of view.

The next section addressed this directly. The second possible physical cause was "physical concussion", which "...may be produced by alterations in atmospheric pressure resulting from a shell explosion, physical blows from sandbags, beams of wood, or earth when buried, or by a combination of these forces". This section, therefore, focuses on the logical association between exploding shells and 'shell shock', namely the effects of the force of an explosion.

Wiltshire put an insightful challenge to his audience:

"If true concussion were a common cause of shell shock it would not be unreasonable to expect [a] that shell shock would occur among the wounded at least as frequently as among the unwounded; that the neurosis caused by concussion would follow a broad type, with which we should by now have become acquainted, rather than copy every known type of functional nervous disease ; [c] that the concussion should be severe enough to cause unconsciousness at the time it occurred..."

He repeated the observation that shell shock was not seen in the physically wounded. He then went on to to day that "...in spite of18 months’ study of these cases we cannot indicate any type of neurosis, constant even within wide limits, as caused by physical concussion..." These two observations, Wiltshire contended, were sufficient to negate points [a] and above.

"With regard to expectation [c] difficulty is caused by dubious clinical histories, but in this connexion [sic.] I think that the general tendency is for these patients to exaggerate the degree and duration of unconsciousness."

Wiltshire then reviewed the 142 patients that he had studied for whom there were clear histories (i.e. for 8 patients there was no history of what happened). Only 52 men, just over a third, had a history of "being exposed to the physical effects of explosion..." This included being near an exploding shell, being knocked over by an explosion or being buried. The histories were detailed enough for Wiltshire to assert that most men were in trenches when shells exploded nearby, which meant that they were not exposed, in his analysis, to direct blast effects. In 9 cases, it was not clear that the men fully lost consciousness. Ten men were definitely rendered unconscious. The remaining 33 men "did not lose consciousness at all". The conclusion was "...that true concussion was neither frequent nor severe in these cases".

Further details were provided for the men who were exposed to shell explosions:

"Subsequent neurosis was almost certainly due to psychic shock" - 8 men

"Certainly partly psychic" cause of shock - 7 men

Significant delay in onset of symptoms, up to 3 weeks - 6 men

History of similar attacks before joining the army - 3 men

Neurosis came on before the explosion - 1 man

Similar symptoms recurred when soldier was about to return to the front - 1 man

Types of neurosis unlikely [in Wiltshire's opinion] to be caused by simple physical concussion - 10 men [2 hysterical tics, 2 typical hysterical weakness of a single limb, 5 deaf-mutes, and 1 hysterical sleepwalking]

Wiltshire presented two case histories to illustrate:

1. A 24 year old lieutenant who was caught in the vicinity of an exploding 15 cm German shell. He recalled one man was blown away and four others were 'done for'. The lieutenant was 'knocked out' very briefly. Subsequently he retreated to the dugout day and night, had trouble sleeping, and was continually thinking about high explosive shells. He was sent back to England with a diagnosis of neurasthenia, returning in early 1915. He could not return to active duty and when seen by Wiltshire was still "seeing the man blown up and the trench, as it was, like a butcher’s shop."

2. A 28 year old sergeant, who had seen continuous service from Mons onwards. Three weeks before meeting Wiltshire, he had been working with a ration party when German shells hit. He was knocked over and saw the other men in pieces. A second shell lifted him and blasted him about 10 yards. He did not lose consciousness. The sergeant continued in his duties but two days later was exposed to further shelling. He then began having nightmares "seeing people killed, shells dropping and all kinds of horrid dreams..." and became generally weak and depressed. After admission to the general hospital, he developed 'head shaking' and nervous tension, jumping at the slightest sound. There were spasmodic movements of the head and jaw, along with a fine tremor.

"To sum up these 52 cases which had possibly been exposed to the physical effects of explosion, there are only 5 (3.5 per cent of all cases of shell shock) in which the evidence, being negative in other respects, favours physical concussion as the cause of the subsequent neurosis. Even in these it is possible that psychic shock preceded loss of consciousness or that true loss of consciousness never occurred. We may conclude that physical concussion occurs in but a few cases of shell shock ; in these it is not severe in degree, and plays but a small part in the production of symptoms, being comparable to, and in most cases of no more importance than, the minor injury in cases of traumatic hysteria of civil life."

Robert

[seaJane]

I do apologise if this is by way of barging into an ongoing conversation, but, Robert, if you should come across any references to neurasthenia or shell-shock in a Royal Naval context during the Great War, I should be very glad to know. I have a couple of references from the Journal of the RN Medical Service but, otherwise, specifically-naval material is proving hard to track down.

Best wishes,

sJ

[Robert Dunlop]

Hi sJ. Will do. So far I have only come across the one article that was published before the war, which was quoted very early on in this thread. Please feel free to post excerpts from the articles that you have found. Thanks.

Robert

[Robert Dunlop]

Wiltshire then examined 'possible chemical causes' of shell shock. Once again he made the point that if toxic gases were involved in causing shell shock then the physically wounded should be affected as well. Three patients in the series complained of "shell gas" poisoning. Wiltshire provided case reports on all three men:

1. 24 year old rifleman who had been on the Western Front for 6 months before being involved in the fighting around Hill 60. When his unit moved forward to effect a relief of the front line, it came under heavy shell fire. Six shells 'pitched near together', knocking the soldier down and covering him with dust and debris. He felt 'gassed and dazed' but was not 'stunned'. After going down into a dug-out, he began shaking all over. Headache persisted for 48 hours and he felt depressed. Nightmares consisted of seeing 30-40 men with terrible injuries, crying out for help. The soldier did not report sick but was sent back because of the tremor.

2. 20 year old soldier who had to provide a written history because he had become mute. Shells had burst near him, and the fumes made breathing painful. At the same time, he was struck in the side by a stone or fragment. He had no memory for the subsequent transfer back to the dressing station. Afterwards, the soldier became mute, depressed and 'miserable', suffering from constant headaches. Sleep was disturbed by frequent nightmares: "...as if there was always someone trying to shoot at me, and always shells bursting near me, and it seems as if I cannot escape from the gas."

3. 27 year old soldier who had been at the front for 3 months. He was wounded but this healed and he returned to the front after one month. Soon afterwards the unit was caught be shellfire when moving through a railway cutting. The shells were most gas shells. Initially, the soldier was forced to lie down after about 15 minutes shelling because of temporary blindness and breathing difficulties from the gas. After another 10 minutes, he was struck on the head and knee. He had no memory from then until waking up in the hospital, at which point he was 'all of a shake'. The slightest sound caused a startle reaction and he became mute and depressed. Dreams were an occasional problem.

From the histories, the two men who lost consciousness appeared, to Wiltshire, to have been hit rather than gassed. There were no signs of physical injury to the head. His assumption was 'the psychic stimulus of terror was present in all three of these cases...' He felt that it was 'fair to infer that these men were in a condition of psychic tension in which they could each have been knocked down by the proverbial feather, and that the effect of the blows was psychic rather than physical'. There was no clear evidence, in his opinion, that toxic gases had played a role, especially given that the subsequent symptoms of shell shock were not seen in physically wounded soldiers.

Robert

[Robert Dunlop]

The next section in Wiltshire's paper reviewed 'psychic' (ie psychological) causes of shell shock symptoms. The first sub-category in this section was 'Gradual psychic exhaustion from continued psychic strain'. Wiltshire looked at chronic stress as a predisposing cause, ie a factor that made it more likely for a soldier to develop shell shock. He admitted, quite rightly, that it was difficult to determine the degree to which, or even whether, chronic stress was a predisposing factor. He noted that 'most' soldiers claimed they had been well until the 'shock' occurred (78 of 129 men who could give a history). "Some admitted that they had felt the strain on their nerves" (51 of 129). Wiltshire checked for a family history or a past history of psychological problems from chronic stress. Of the 78 men who denied any build up of stress, 32 had a previous or family history. In the remaining 51 men, who mentioned chronic stress in the build up to the 'shock', only 8 did not have a past or family history. Wiltshire concluded:

"It is certain that continued psychic strain is much more potent as a disposing cause in those of neuropathic predisposition [ie with a past or family history], and I think that it must also have exerted a similar influence in a large number of those who were unconscious of its action."

Wiltshire then examined whether chronic psychological stress could be the sole cause of 'shock'. He recorded two cases of men who developed symptoms of 'shock' upon reaching the trenches, before even facing a shot. One man had a history of 'previous nerve collapse' before joining the army. The other man had a life-long history of being 'timid'. Both men were described as 'simple examples of anticipatory

terror acting on men'. In total, 13 men appeared to have chronic stress as the only cause of their symptoms. All but 2 of these men had strong family and/or past histories. "In all these continued psychic strain cases the resultant neurosis was of asthenic type. Weakness, loss of energy, mental depression, and poor sleeping were prominent symptoms. Some were apprehensive and fearful, and most showed fine tremor and increase of knee-jerks [signs of heightened stress]." Wiltshire noted that men with past or family history took significantly shorter (2 months on average) to succumb, versus 6 months in the other two men. Given the small numbers, it would be unwise to attach too much significance to this difference.

Wiltshire's conclusion was that:

"This group of cases shows that continued psychic strain is not likely to produce a nervous breakdown per se, except in the case of individuals of neuropathic predisposition."

He went on to make a very interesting distinction between the (asthenic) symptoms of collapse from chronic stress versus men who gave a history of chronic stress followed by a sudden 'shock' from another 'special incident'. There were 6 men who fell into this latter category. They were more likely to manifest some of the other characteristics of 'shell shock', such as paraplegia, sleep walking, and hallucinations of smell.

Robert

[Robert Dunlop]

The next category of study was 'sudden psychic [psychological] shock'. Wiltshire opened this section with the following comment:

"In most cases of shell shock the immediate cause of the nerve collapse is to be found in some sudden psychic shock."

This statement is in stark contrast to the findings and conclusions of some other commentators.

There were four events, according to Wiltshire, that precipitated most instances of shell shock:

1. Horrible sights

2. Losses

3. Fright from an explosion

4. Sounds

I will provide more information on each of these 'causative' events in the next post/s.

Robert

[Robert Dunlop]

1. Horrible sights

Wiltshire found that 'horrible sights' were a "definite causative factor" in 51 of 142 cases. A further 13 men were probably affected. More significantly, Wiltshire noted that many men suppressed any memory of horrible sights. This meant, in his opinion, that it was a more common cause than the figures indicated, given that the estimated incidence was based on men's recollections.

"I became convinced that the more a memory was repressed the greater was its significance in respect of the cause of the nervous condition, and, as far as I could ascertain, this repressive tendency was mainly concerned with memory for sights, from which, indeed, it was rarely altogether absent. Almost without exception men confess that they hate and fear shell fire, and I think that the self-control which enables them to endure it is largely due to the fact that full realisation of its horrible possibilities is not acute or clear in their minds. This deficiency of realisation may be partly conscious, a refusal to think, and partly unconscious, a negative gift of nature. Throughout life nature disarms our most trying moments by withholding acuity of realisation, and thus preventing psychic strain from attaining sufficient strength to break our nervous resistance. It may be that horrible sights are potent to cause shell shock because they convert a poorly imagined blurred picture, into a real picture acutely focussed, a half realisation into a full realisation, the latter being too powerful for nerve resistance to withstand."

In other words, men could tolerate shelling to a degree by not thinking about the danger. This is a common defence mechanism that helps protect us, to some degree, when facing stressful and dangerous situations. As soon as men were exposed to horrible sights, however, their mental resistance was overcome.

Several case studies were then presented, starting with a 19 year old soldier. He had been with a company that was hit by shellfire. A single shell killed 20 men and wounded 20 more. When seen after the event, the soldier could remember the fall of the shot but nothing more until he 'awoke' 48 hours later. He complained of feeling 'swimmy in the head', could not sleep and was experiencing terrifying nightmares. So far, the story is consistent with a concussion from the shell explosion. The history of the event, however, cast a different light on what happened. The soldier was not knocked down or rendered unconscious by the explosion. "He worked well in assisting the wounded, and then proceeded to clear up the fragments of the killed. Whilst doing this, he suddenly lost his mental balance... [and did] not recognise his friends..." This is a powerful example of the complexity behind the label 'shell shock'.

The second case was a 29 year old sapper. He arrived at the base hospital in a semi-conscious, semi-confused state. There was a generalised tremor but no other neurological signs. After sleeping heavily, the sapper began to recover a better sense of where he was, recognising the staff and beginning to talk in a more coherent way. He complained that everything was a 'blur' but during the clinical interview things began to open up. While talking, he would suddenly interrupt with brief emotionally-charged phrases, followed by brief trance-like reactions: "Joe, don’t go - Give me my rifle - Joe - Ten killed - Poor old Taffy - Dreamt last night - Saw Harry Edmunds with all his ribs broken - When we had the explosion - 5000 bombs, or two and a half tons of explosives, blew up - Joe - Clay said he’d never live three weeks - Glasses blown in - Taffy killed by shell in stomach - Horrible sights - S - L - all privates blown off him - Just after leaving workshop." Afterwards, he felt better but, when questioned about the men's names, he remembered that they were in his company but "did not remember anything connected with them in France. When asked where these men were he said that he did not know, but he was not in the least anxious or bothered about them". Wiltshire again noted that "the case would have been included as a possible physical concussion case by anyone who had not seen or received notes about the patient in the first phase [ie immediately after the explosion]."

This case, and others, reveals how powerful the psychological defence of repression (suppressing extremely powerful and emotive memories) can be. It is one of the reasons why veterans did not discuss their experiences. Repression comes with a price, however. It requires a lot of energy to keep things repressed. This causes other problems, including the feeling of weakness that is often mentioned. Memories will often slip to the surface, during sleep for example.

Robert

[truthergw]

I'd like to thank you, Robert for this thread, the quotes, and your informed and insightful commentary on them. I'd like to put in a plea for the harassed MO, subaltern and nco here. With the lack of a clear cut diagnosis from the foremost medical authorities on the subject, is it any wonder that the men at the sharp and muddy end saw the borderline cases as malingerers? Swinging the lead was a fine art in the pre war army and was seen as the soldier's prerogative. Much ingenuity was expended on new wheezes to evade duties. The knowledge that malingerers were dealt with very severely was one of the main safeguards against it happening. The army system was one of deterrence rather than punishment. That is why sick parade was a form of borderline punishment in itself.

[Robert Dunlop]

Thanks Tom. A timely reminder of the flipside of this story. You touch on one of the difficulties in interpreting the medical information. The men who made it through to studies, such as Wiltshire's 150, would have been the men who were deemed not to be malingerers. This introduces the problem of selection bias. The results, and therefore the interpretations, are distorted because, perhaps, some men who had 'shell shock' were filtered out before being seen by Wiltshire.

Your point, of course, is quite different. But very important nonetheless! I understand what you are saying, especially from the NCO perspective. How much more difficult, as you say, when there was no clear understanding of what 'shell shock' was about.

Robert

[Robert Dunlop]

The section on losses is very brief. Wiltshire noted that the death of a relative or close friend was similar to the effect of horrible sights. It was the significance of the personal loss, rather than just the number of men killed, that seemed to be more relevant.

Fright from an explosion could be 'simple' from just being 'near a shell or bomb explosion'. However, the fright of being buried as well, or some other frightening factor, was usually added to the fright of the explosion. A case of 'simple' fright was presented. It related to a 19 year old sapper. His mother had a history of being 'nervous'. He had had a nervous breakdown before the war, related to overwork 'in no way connected with accident or fright'. While sheltering in a dugout, two shells landed nearby in quick succession. There was a 'slight falling in' but no significant collapse of the dugout. The sapper carried on with his normal duties during the night but then presented sick next day. He had no memory of the previous hours, felt 'very queer', and was experiencing headaches and bad dreams. On examination, there was 'constant tremor of both arms and slight tremor of the head and tongue, and jerky movements of the eyes. There was some spasm of the right leg, and both legs reacted to examination by violent tremor.' Significantly, the symptoms were the same as he experienced in the previous breakdown. With the presenting history of memory loss, it would have been easy to ascribe the symptoms and signs to physical concussion from the shell explosions.

The effect of sounds was limited to a very small number of men. In one case, a 36 year old NCO, had been exposed to an episode of shell fire. "He was not hurt in any way, but after this he suffered from anorexia, insomnia, and depression". The symptoms were similar to an episode of 'nerve debility' from 'overstudy of music' about five years earlier. Twelve days after the shell fire incident, the NCO was billeted near British artillery. The guns were very active and 'the noise properly finished me off'. The symptoms were severe neurasthenia and insomnia, which proved difficult to treat.

In summary, Wiltshire wrote:

"These cases show that the psychic trauma of acute fright will cause shell shock. Sounds exert but a feeble action in the production of fright, and simple nearness to an explosion is not often sufficient by itself; but when an explosion causes burial of the individual, or mutilation of others, the intensity of terror or summation of terror and horror produced is often sufficient to break through the bounds of psychic resistance and lead to nervous collapse."

Robert

[Robert Dunlop]

The final section in Wiltshire's article dealt with a new issue, from this thread's perspective. By mid 1916 there had been enough time for relapses to become evident. Just over 25% of the 150 cases (41 men) presented with a relapse of symptoms, having 'recovered' from a previous episode of shell shock. Most of the men had not even reached the front lines again. They were referred from the base camps, after being released from convalescence. Detailed history-taking demonstrated that none of the men had actually lost their symptoms completely before being released. Furthermore, 72.2% of the men had had a past history of psychological problems before the war. It was clear to Wiltshire that the relapses were due to the psychological trauma of having to return to the front. This reinforced his view that psychological trauma was the key cause of shell shock:

"This percentage of relapsed cases is greater than could be expected if the cause were an original finite physical trauma, but it is no more than we ought to expect in the case of an original trauma of psychic nature, and so still capable of conscious, or unconscious, action and reinforcement.

The general evidence shows that physical and chemical events can have exerted a causative influence in few, if any, cases of shell shock, the vast majority being certainly due to psychic trauma."

Wiltshire's summary section to follow.

Robert

[Robert Dunlop]

The summary is worthy of quoting in full:

"1. The [physically] wounded are practically immune from shell shock, presumably because a wound neutralises the action of the psychic causes of shell shock [though not entirely, as Wiltshire had also noted earlier that psychic factors were not entirely destroyed and 'may manifest its presence later in promoting late nerve exhaustion or by predisposing to subsequent neuroses from other stimuli'.

2. Exposure and hardship do not predispose to shell shock in troops that are well fed.

3. While it is theoretically possible that physical concussion resulting from a shell explosion might cause shell shock, it is certain that this must be regarded as an extremely rare and unusual cause. [This conclusion follows from point 1. If the physical effects of shell concussion were responsible then at least some physically wounded men should have manifested shell shock, in Wiltshire's opinion.]

4. Chemical intoxication by gases generated in shell explosions cannot be more than a very exceptional cause of shell shock.

5. Gradual psychic exhaustion from continued fear is an important disposing cause of shell shock, particularly in men of neuropathic predisposition. In such subjects it may suffice to cause shell shock per se.

6. In the vast majority of cases of shell shock the exciting cause is some special psychic shock. Horrible sights are the most frequent and potent factor in the production of this shock. Losses and the fright of being buried alive are also important in this respect. Sounds are comparatively unimportant.

7. A consideration of the causes and frequency of relapses favours an original cause of psychic nature.

8. Any psychic shock or strain may cause a functional neurosis, provided it be of sufficient intensity relative to the nerve resistance of the individual."

Robert

[Robert Dunlop]

Wiltshire started his article with an admonition about 'bad terminology'. He was concerned about the indiscriminate use, in his opinion, of the term 'shell shock'. This caused me to reflect back on the two different directions of study that authors used. In one instance, clinicians worked forwards in time from the starting point of a shell explosion. This meant it was possible to create lists of clinical features associated with shell explosions. Some of these lists have been presented in earlier posts. Wiltshire came at the issue from a different direction. He was working backwards in a group of men who had a list of related clinical features. Some of these men had been exposed to shell fire and even nearby explosions. Wiltshire demonstrated, however, that the clinical features were not always related directly to shell explosions. What we can't be sure about is whether Wiltshire was truly comparing like with like. But it is important to consider the implications of these two approaches. At least some of Wiltshire's cases seemed to be due to the direct effects of shell explosions, and would have been labelled as such by some clinicians. Yet the past histories and/or the timings of the symptoms suggested that more was at play.

The most significant observation, however, is the seeming absence of shell shock symptoms in soldiers who had been clearly wounded physically, to the extent that these wounds required admission to hospital. To date, I have not seen any other evidence to confirm or refute this observation. Finding such evidence, from contemporaneous sources, is top of my to-do list now. The implications of this observation are very important, indeed they are absolutely crucial, to understanding 'shell shock'.

One other minor point. Typically a paper of this nature will trigger a series of letters to the editor. There is nothing in the subsequent volumes of The Lancet in 1916, nor in the BMJ. The flood of wounded from the Somme may have had something to do with this. It was a very busy time for the medical services. One thing was for sure - the number of shell shock cases (however these were defined) was going to increase significantly.

Robert

[truthergw]

Wiltshire started his article with an admonition about 'bad terminology'.

edit...............

One other minor point. Typically a paper of this nature will trigger a series of letters to the editor. There is nothing in the subsequent volumes of The Lancet in 1916, nor in the BMJ. The flood of wounded from the Somme may have had something to do with this. It was a very busy time for the medical services. One thing was for sure - the number of shell shock cases (however these were defined) was going to increase significantly.

Robert

It seems strange that no one chose to follow up this paper. Could it be that there was pressure put on the editors ? I know that the press generally was carefully vetted.

[Robert Dunlop]

Then, as now, there were informal ways that pressure could be put onto editors. There are some indirect examples that relate to accounts of the numbers of wounded from the Somme. These have a more positive spin than we would feel comfortable with today. Several articles appeared to be addressing explicitly criticisms of the evacuation system, saying that these criticisms were unwarranted. The original criticisms are not published in either the BMJ or The Lancet, which suggests the authors were responding to letters to the Times or some equivalent.

The issue with Wiltshire's paper is different, however. Essentially there is nothing in the immediate aftermath of its publication. This could relate to the editor's previous editorial, which had already set the scene for a different opinion (probably unknowingly with respect to Wiltshire's paper, though it is possible that the lead time for publication was long enough that the editor had Wiltshire's paper in mind, or at least a first draft). But I suspect there was more going on. This suspicion is based, however, on more recent reviews that touch on the way that medical services were evolving to handle 'shell shock' cases and the like. More on this anon.

Robert

[Old Tom]

Robert,

Martin Gilbert, has more on the subject. Writing about the later stages of the Somme campaign of 1916 in his First World War, remarks that thousands of men left the battle field with their nerves shattered. Reporting sick and being asked what had happened, most would answer, ‘shell shock’ With some this was clearly the case, but for the medical authorities it was not necessarily so. The official medical history writes, he quotes : ‘To explain to a man that his symptoms were the result of disordered emotional conditions due to his rough experience in the line, and not, as he imagined, to some serious disturbance of his nervous system produced by bursting shells, became the most frequent and successful form of psychotherapy. The simplicity of its character in no way detracted from its value, and it not infrequently ended in the man coming forward voluntarily for duty, having been given a much needed fortnight’s rest in hospital’ Gilbert goes on to say the genuine cases of shell shock were also growing reaching more than50,000 by the end of the war. It was during the battle of the Somme that, because of the intensification of nervous breakdowns and shell shock, special centres were opened in each army area for diagnosis and treatment. The view of the military authorities, as the official medical history emphasises, was that the subject of mental collapse, he again quotes, was ‘so bound up with the maintenance of morale in the army that every soldier who is non-effective owing to nervous breakdown must be made the subject of careful inquiry. In no case is he to be evacuated to base unless his condition warrants such a procedure.’

Old Tom

[Old Tom]

A little further on Martin Gilbert comments, but without citing a source:

In the British sector in 1917 special centres were set up 12 to 15 miles behind the line to deal with the increase in mental disorders.

These were called NYDN centres - Not Yet Diagnosed (Nervous)

As many as a third of casualities recovered and returned to the trenches.

6 hospitals for officers and 13 for other ranks were set up in 1917 and 1918 in Britain for those that had been sent home for ever.

Old Tom

[Robert Dunlop]

Thank you, Old Tom. Martin Gilbert's comments about the Somme are borne out by the recent book called 'Pozieres - The Anzac Story' (which was recently reviewed in this thread here. As part of the demolition of the 'Anzac Myth', the author related several examples of men who were badly affected by the incessant shelling around Pozieres and Mouquet Farm.

Robert