“Contribution to the Study of Shell Shock”
As Big of Misnomer as Misdiagnosis
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As introduced in yesterday’s blog, Captain Charles Myers, a British Physician authored a significant case study of shell shock of three wounded soldiers in the Lancet, the publication of the British Medical Society. See C.S. Myers, “A Contribution to the Study of Shell Shock” The Lancet, on February 13, 1915 page 316-320.
Myers begins his case study of shell shock by calling them “remarkably similar.” All three soldiers were
• Injured by a by shells bursting near them;
• Had sleep problems before their injuries,
• Had memory disturbances after their injuries;
• Had vision affected;
• Had disturbances of smell and taste.
And quite significantly to Myers, despite the proximity of the blasts, none had any significant disruption in hearing.
Soldier # 1:
Myers describes the first soldiers case as follows:
“During the (retreat) from this trench at 1:30 p.m., they were “found” by the German artillery. Up to that time he had not been feeling afraid; he had rather ‘been enjoying it’ and was in the best of spirits until the shells burst about him… He was trying to creep under wire entanglements when two or three shells burst near him. As he was struggling to disentangle himself from the wire, three more shells burst behind and one in front of him. After the shells had burst he succeeded in getting back under the wire entanglements. … Immediately after the shell burst in front of him his sight became blurred. It hurt his eyes, and they burned when closed. At the same moment he was seized with the shivering, and the cold sweat broke out especially around the loins “like a punch on the head, without any pain of it’. The shell in front cut his haversack clean away, bruised his side, and apparently it burned his little finger. …
“When he got to treatment… he was crying the whole time and worrying as to whether he was going blind. … At the dressing table station he was crying and shivering; he was taken thence to a hospital by horse ambulance… He thinks he must have slept on the ambulance, as he remembers nothing. (Emphasis in original.)
Three months post injury ‘says he has lost the sense of taste and smell since the shell’s burst around him.’
Woke up last night and found himself crying: ‘not thinking of anything in particular’.
Past history: He had been for two months in the Aisne district on the lines of communication, sleeping badly all the time owing to lumbar pain… He had failed to pass a medical examination some time previously because of renal trouble.
Soldier # 2:
Myers says of the second soldiers combat experience:
“The patient says he was buried for 18 hours owing to a shell bursting and ‘blowing in’ the trench in which he lay.”
This soldier also has lost his sense of smell and much of his sense of taste. While some “memory” of the events around the time of his injury returned, comparison to his later description of events was not consistent with what other soldiers who survived the battle remembered. While Myers seemed troubled by the conflict in these stories, it can clearly be explained by the brain injury symptom of “confabulation”.
Soldier # 3:
Myers detailed the history as follows:
The patient says was blown off a heap of bricks, 15 feet high, owing to a shell bursting close to him. Thinks he must have fallen into a pool of water, as he next remembers finding himself, about 3 p.m., the same afternoon in a cellar near a church with his clothes drenched. He does not know how he got there or how he left the cellar, but he remembers being in another hospital before he was admitted here.”
Myers details this soldier’s symptoms as follows:
“A healthy-looking man, well-nourished, but obviously in extreme nervous condition. He complains that the slightest noise makes him start. His legs feel weak and he has pain in the precordial region. His sight has been very much impaired since the shock. …
He has slept very little the last two nights. Hands tremulous. Knee jerks normal, but the first attempts to evoke them provoked a spasm of the calf muscles and a few general convulsive movements as the patient lay in bed. His hands became very tremulous and his forehead sweated profusely. He appeared as if about to faint and says that he felt cold and dizzy, and experienced round and round movements of the stomach. … The slightest touch on the legs provoked well-marked spasm of the quadriceps muscles of the same thigh. Extensor muscles of the toes appeared to be in a state of clonic contraction.
Left nostril fails to detect smell of ether, peppermint, eucalyptus, ammonia, carbolic acid, or iodine tincture, all of which are at once recognized when placed beneath the right nostril. No signs of nasal obstruction. Taste: Only tastes very strong solutions of sugar, salt and acid…”
Conclusions. Myers, after discussing the three histories, ends his study of shell shock with this comment:
Comment on these cases seems superfluous. They appear to constitute a definite class among others arising from the effects of shell-shock. The shells in question appear to have burst with considerable noise, scattering much dust, but this was not attended by the production of odor. It is therefore difficult to understand why hearing should be (practically) unaffected and the dissociated “complex” be confined to the senses of sight, smell and taste (and to memory). The relation of these cases to those of “hysteria” appears fairly certain.
Thus, at a critical juncture in military medicine, with all the observational facts recorded to shift the focus to brain injury, the theory of hysterical illness raises its specter. That pattern gets repeated and becomes the cornerstone of far too much bad diagnosis – even to this day – at least in forensic neurological practice.
Myers’ choice of the word “hysteria” in his study of shell shock is now replaced by the words “conversion disorder”. Myers might have been a pioneer – a leader in the field of military medicine in 1915 – yet his ignorance relative to what we know today about brain anatomy, is significant. The two most predictable markers of brain injury are loss of memory for events around the time of the injury (amnesia) and the loss of smell. He dismissed these findings. Further, he clearly lacked any basic understanding of the biomechanical forces which result in brain injury. While his ignorance is understandable, the ongoing use of these ridiculous psychiatric excuses for clear-cut neurological phenomenon, are not.
In the next pages, we will look at the clues to a proper diagnosis in these three cases histories: amnesia, loss of smell and the biomechanical and neuropathological explanations for brain injury.