Browse through our Journals...
Shell-shocked and confused:A reconsideration of Captain Charles Myers’ case reports of shell-shock in World War One
William Sheehan, M.D.
Richard J. Roberts, Ph.D.
Steven Thurber, Ph.D.
Mary Ann Roberts, Ph.D.
With the advent of high explosive artillery in World War I, came a heretofore unknown neuropsychiatric condition initially termed “shellshock.” A baffling aspect was that soldiers suffering emotional, cognitive and sensory dysfunctions after blast injuries did not have obvious physical head wounds. Thus, the problems were viewed as forms of cowardice or malingering and when evinced by ordinary soldiers, treated punitively. Two individuals with “shellshock” were described and treated by Captain Charles Myers who assumed, consistent with the paradigm of the time, bombardment-related problems to be hysterical in nature. In this study we revisit these cases from World War I and provide analyses based on what is now known about closed head blast injuries.
As half-hearted diplomatic efforts failed and Austria, confident of German support, declared war on Serbia at the end of July 1914, Winston Churchill wrote to his wife: “I wondered whether those stupid Kings and Emperors could not assemble together and revivify kingship by saving the nations from hell but we all drift on in a kind of dull cataleptic trance.” (Gilbert, 1994, p. 25). The stupid Kings and Emperors, however, failed to assemble or revivify kingship; by August 2, German military patrols, attempting to implement the Schlieffen plan, were crossing the French border for the first time since 1871, and—despite the comment of one member of Britain’s Liberal Government, “Why four great powers should fight over Serbia no fellow can understand” (Gilbert, 1994, p. 23}, by midnight on August 4 not four but five Empires were at war, and several million soldiers were mobilizing. Each of the armies expected that they would crush their opponents within months and that the war would be over by Christmas.
As always, the war broke out with many under the influence of that intoxicating infatuation which resembles nothing so much as the experience of first love. Many, “wild with joy,” were afraid of missing out. In this vein the British poet Rupert Brooke wrote: “Now God be thanked who has matched us with His Hour; and caught our youth, and wakened us from sleeping.”
The first glimpse of what the war would actually involve came as a shock to warriors nurtured on the lore of brilliant cavalry charges and the scads of glory to be won through individual acts of heroism. Since the Crimean and the Franco-Prussian war, high-explosive artillery had emerged. The first encounter with the new technology could be awe-inspiring—and terrifying. Thus, on the evening of August 20, a British Captain named Spears, attached to the French Fifth Army, was seated with a French officer on a hill enjoying a tranquil outlook on the fields, towns and villages of the Sambre valley south of Charleroi (Gilbert, 1994, pp. 51-52); “A dog was barking at some sheep,” he wrote:
“A girl was singing as she walked down the lane behind us…. Darkness grew in the far distance as the light began to fail. Then, without a moment’s warning, with a suddenness that made us start and strain our eyes to see what our minds could not realize, we saw the whole horizon burst into flame. A chill of horror came over us. War seemed suddenly to have assumed a merciless, ruthless aspect that we had not realized till then. Hitherto it had been war as we conceived it, hard blows, straight dealing, but now for the first time we felt as if some horrible Thing, utterly merciless, was advancing to grip us.”
That “horrible Thing” was modern artillery. No one had ever experienced anything like the tremendous thundering of these guns, thundering so great that it could be heard by civilians clear on the other side of the English Channel.
For the British, the first direct contact with the “horrible Thing” was experienced by the British Expeditionary Force at the battle of Mons, where the shelling was so terrific that thousands of shattered soldiers were sent staggering southward from the Front toward the French frontier; “the men stumbling along more like ghosts than living soldiers,” wrote one witness, “unconscious of everything about them, but still moving under the magic impulse of discipline and regimental pride.” (Gilbert, 1994, p. 59).
Not coincidentally, the Battle of Mons also saw the first reports of the notorious condition that would become known as “shellshock.” Several members of the British Expeditionary Force who had taken part in the retreat were described as having been “broken.” Though Lieutenant-Colonel Gordon Holmes, an expert on nervous disorders, characterized at least some of these as “gross hysterical conditions” (Gilbert, 1994, p. 61) the equally eminent Captain Charles Myers, a protégé of the celebrated W.H.R. Rivers at Cambridge, hypothesized that the condition might be related to prolonged bombardment from explosive shells. In fact, the soldiers were suffering from a confusing mélange of behavioral and neurological symptoms that were hard for even specialists to sort out, symptoms that would remain exceedingly difficult to fit into the dichotomized categories of structural and functional conditions that had first emerged with the differentiation of the Big-endian and Little-endian separation into neurology and psychiatry in the late nineteenth century.
Some of these soldiers no doubt experienced the shattered nerves of severe panic reactions—a predictable enough response to the danger and stress of battle that is a manifestation of the instinctual fear/flight response and has surely been the common lot of soldiers going back to at least the time of the Iliad. The classic treatment of this response to the danger of war is Stephen Crane’s Red Badge of Courage (1895) which begins with the running from battle of a panicked soldier who, filled with remorse and questioning his own manliness, regards even “the wounded soldiers in an envious way. He conceived persons with torn bodies to be peculiarly happy. He wished that he, too, had a wound, a red badge of courage.” Crane’s hero eventually faces his fears and returns to action, and thereby becomes that inestimable thing--a man.
There were certainly cases of hysteria in the war. Perhaps the following, described by Corporal Henry Gregory, is such a case: “The enemy opened fire about dinner time, as usual, with his big guns. As soon as the first shell came over, the shell-shock case nearly went mad. He screamed and raved, and it took eight men to hold him down on the stretcher.” On the other side were men who had “honest” wounds, with only too evident red badges of courage. Thus, at Gallipoli in 1915, one orderly wrote: “It was difficult to select the most urgent cases. Men had lost arms and legs, brains oozed out of shattered skulls, and lungs protruded from riven chests; many had lost their faces and were, I should think, unrecognizable to their friends…. One poor chap had lost his nose and most of his face, and we were obliged to take off an arm, the other hand, and extract two bullets like shark’s teeth from his thigh, besides minor operations. It was really a precious hour or more wasted, for I saw him next morning being carried to the mortuary” (Quoted in Gilbert, 1994, p. 150). Another case is described by the poet Robert Graves, who was stationed in a section of a trench lying only twenty yards from a German-occupied sap. He recalls: “I went along whistling ‘The Farmer’s Boy,’ to keep up my spirits, when suddenly I saw a group bending over a man lying at the bottom of the trench. He was making a snoring noise mixed with animal groans. At my feet lay the cap he had worn, splashed with his brains. I had never seen human brains before; I somehow regarded them as a poetical figment. One can joke with a badly-wounded man and congratulate him on being out of it. One can disregard a dead man. But even a miner can’t make a joke over a man who takes three hours to die, after the top part of his head has been taken off by a bullet fired at twenty yards’ range” (Gilbert, 1994, pp. 172-173).
Compared to the victims of these brutally obvious and catastrophic wounds, shell-shock was not always regarded as a real illness, and many of the soldiers who suffered from it were seen, at least early in the war, as either malingerers trying to get out of combat or as base cowards. Officers were, of course, regarded more sympathetically than ordinary soldiers; they were usually evacuated to England to recover, whereas ordinary soldiers were often sent to the Front. One “treatment”—known as Field Punishment No. 1--involved tying the offender to a fixed object within range of enemy shellfire for up to 2 hours a day for a period up to 3 mos. “ Many other soldiers were court-martialed and shot. Despite the ruthlessness of these methods, victims of shell-shock continued to present with relentless regularity; at the Battle of the Somme in July 1916, 40% of all the casualties—16,000 men—were diagnosed as suffering from shell-shock. By the end of the war, 80,000 officers and ordinary soldiers had been evacuated for what the official British Military History of the war called “a severe mental disability which rendered the individual temporarily, at any rate, incapable of further service”; many of those had been invalided out of the army altogether, and some never did recover. The alarming nature of this condition, despite the initial skepticism, was acknowledged by the end of the war. A vivid description of the typical case is given by journalist Philip Gibbs, assigned to cover the Western Front:
The shell-shock cases were the worst to see and the worst to cure. At first shell-shock was regarded as damn nonsense and sheer cowardice by Generals who had not themselves witnessed its effects. They had not seen, as I did, strong, sturdy, men shaking ague, mouthing like madmen, figure figures of dreadful terror, speechless and uncontrollable. It was a physical as well as a moral shock which had reduced them to this quivering state.
The sense conveyed by the term “shellshock” of a mixture of psychological effects and physiological damage produced by bombardment by exploding shells made enough sense both to soldiers themselves and to the general public that later attempts to introduce other, more specific terms such as “functional nervous disorder,” “traumatic war neurosis,” and even the tried-and-true “neurasthenia,” failed to take hold. Capt. Myers’ term remained in general currency for the duration of the war, arguably because it best reflected the irreducible ambiguity of a condition and an array of torments that seemed to lie uncertainly placed in the No-Man’s Land between the Mental and the Physical. What, for instance, would one make of the turning of a man to jello after the landing of one of the dreaded German minenwerfers, known to the British as a “Minnie” or “Moaning Minnie” as described by Lieutenant G. V. Carey at Hooge in July 1915:
This was the most alarming frightfulness that our fellows had as yet knocked up against. Apart from the number of people it had blown to bits the explosions were so terrific that anyone within a hundred yards’ radius was liable to lose his reason after a few hours, and the 7th battalion had to send down the line several men in a state of gibbering helplessness (Gilbert, 1994, p. 178).
Was this a neurological injury, a psychological condition? Or was it not clearly something of both?
Myers’s own report of several cases of shell-shock he had examined in France appeared in Lancet in February 1915, and makes clear the perplexing, overlapping, but at the same time fairly consistent nature of the symptoms:
Myers’s case 1 was a 20 year old private who had been “rather enjoying” the experience of war until, when retreating from a trench one afternoon, he was “found” by the German artillery. “He was … retiring over open ground,” writes Myers, “kneeling on both knees and 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… Immediately after the shell had burst in front of him his sight became blurred…. At the same moment he was seized with shivering, and cold sweat broke out… He thinks the shell behind him gave him the greater shock—‘like a punch on the head.’ The shell in front cut his haversack clean away… It was this shell, he says, which ‘caused his blindness’ (Myers, 1916).
He was transported by horse ambulance to a first hospital (where he was given brandy), then on to a second and finally to Myers’s unit at Le Touquet. (Notably, he remembered “absolutely nothing” of his transport.) Myers’s initial impression was of a “well-nourished man of nervous temperament, flushed complexion, and dark eyes.” His examination revealed contracted visual fields and a loss of both taste and smell that had begun when the shells burst around him. (Myers carefully tested the smell with substances such as peppermint, ether, iodine tincture and carbolic acid.)
Though this particular patient resisted Myers’ attempts to induce hypnosis, after being evacuated to England the patient continued to improve, and a month after being “shell-shocked,” was reported to be “not so nervy”; his taste and smell had partially returned, though his visual fields continued to be constricted. Presumably, after further treatment—which under someone like the much-loved and admired Rivers would have included talking about their fears rather than taking the traditional “stiff-upper lip approach”--he would have been deemed fit to return to the Front.
Case 2 was a soldier buried for eighteen hours owing to a shell bursting and “blowing in” the trench in which he lay. He had previously been involved in the two days’ retreat from Mons and had slept badly since, often when billeted taking “large doses of whiskey” to procure sleep. Perhaps because he came with a history of “leading a fast life” as well as “domestic worries,” his manner did not inspire Myers’ confidence as to his reliability. The patient claimed to suffer from pains in the abdomen, back, and limbs. He was also found to have constricted visual fields and a loss of color sensation (except, notably, for red) as well as a loss of smell and taste. The symptoms were all regarded as hysterical in nature; thus Myers assured himself of the “functional” character of the restricted fields by the fact that “the patient was never observed to collide with objects when walking, and that he was able to box here while convalescent.”
As before, the treatment prescribed involved hypnosis. Again, over a period of weeks, the patient experienced a substantial, if not complete, improvement of his symptoms, which Myers attributed to the effectiveness of the treatment.
What was new in World War I—and led to the stalemate of the Western Front—were the advances in the technology of warfare that had occurred chiefly after the Franco-Prussian War of 1870-71. Diabolical weapons, seeming like something out of H. G. Wells’s War of the Worlds, that made their appearance in World War I included the machine gun, which essentially rendered futile the frontal attack, mustard gas, and flame throwers. In addition, dramatic improvements in artillery, with the development of rifled cannons, improved propellants using nitrocellulose (a.k.a. cordite), high-explosive fillings for shells (picric acid compounds such as lyddite) , which detonated rather than deflagrated and thus much more rapidly attained their maximum pressure (a quality that is technically referred to as “brisance”), and timed fuses which could burst a shrapnel shell over or behind ground forces at a particular point in the shell’s trajectory, were used on an unprecedented scale between 1914 and 1918. Artillery fire on a scale never before experienced indeed rendered it worthy of Captain Spears’s reference to “this horrible Thing, utterly merciless … advancing to grip us, their shells blowing to bits any thing of flesh and blood and bone immediately in its path, and scarring the landscapes of France and Flanders with such numerous deep craters that—a few years later—the mechanics of such processes would first disclose to astronomers the true nature of the craters of the Moon (See Sheehan & Dobbins, 2001, pp. 295-299).
Wilfred Owen wrote of his soul “looking down from a vague height, with Death,” and seeing
… a sad land, weak with sweats of dearth,
Gray, cratered like the moon with hollow woe,
And pitted with great pocks and scabs of plagues.
Across its beard, that horror of harsh wire,
There moved thin caterpillars, slowly uncoiled.
It seemed they pushed themselves to be as plugs
Of ditchers, where they writhed and shriveled, killed.
Whereas the victims of shelling in previous wars had mostly sustained devastating open head wounds from musket balls packed around black powder or pieces of shrapnel from exploding cannonballs, the high-explosives used in World War I shells could produce concussions and serious closed head injuries even at a considerable distance through blast-related pressure waves coursing through the visco-elastic (but non-homogeneous) vulnerable brain tissue harbored within the protective helmet of the skull.
In World War I, the physics had not yet been worked out—and indeed, has only begun to be understood in the last decade or so, with the emergence of “blast injuries” as the “signature wound” of the Afghanistan and Iraq Wars. According to an excellent recent review:
During an explosion … a solid or liquid is almost instantaneously converted into gases. These gases temporarily occupy the same volume as the solid or liquid and are thus under extremely high pressure. The gases then expand, compressing the surrounding air and forming a pulse of pressure called blast overpressure. As the gases continue to spread out behind the high-pressure region, they create a huge pressure drop.
Brain tissue itself has the consistency of firm custard—but custard of differing densities. As the shock wave reaches a soldier, the high- and then low-pressure air accelerates body tissues of differing densities at different rates. Inside the brain, the varied accelerations could shear and stretch axons just as blunt-force trauma does (Roberts, 2008).
Because soldiers reporting psychiatric symptoms as well as sensory and cognitive impairments in World War I presented after explosions causing no external visible injury, most physicians ascribed them to psychic trauma or emotional distress. In this respect, Myers was typical for his era.
However, the recent experience of blast injuries in Iraq and Afghanistan makes it clear, in retrospect, that many of these soldiers did indeed experience actual brain injuries. True, they often experienced emotional and psychological symptoms—for instance, regarding Myers’ case 1, we read: “One night the patient woke up and found himself crying, while not thinking of anything in particular; he at once pulled himself together.” But they also had physical symptoms including visual field cuts, loss of color sensation, and loss of smell and taste. Notably, the patients’ symptoms (which Myers thought hysterical) improved over the course of several weeks; an improvement that Myers apparently attributed to the effects of hypnosis.
We know now, as Myers did not, that in a patient sustaining an acute brain injury, the first phase is associated with brain oedema, due to ruptured tissue and the collection of fluid around the brain cells, and with temporary imbalances of biochemical substances (Luria’s “neural shock”). According to neuropsychologist David Andrewes:
These and other acute effects may, depending on the severity, be reduced over the days and weeks following the event and lead to a recovery of cognitive functions that were being suppressed by these mechanisms. This type of recovery is sometimes referred to “artefact recovery,” because in one sense it is not recovery at all since the functions were merely in suspension and were nota actually lost in the first place (Andrewes, 2001).
The artifact recovery seems to have been what Myers was observing. The improvement likely corresponds to the resolution of a large area of perfusion deficits—what we might call a “penumbra”—around a focus of possibly irreversible tissue injury that is now observed in serial perfusion, brain imaging studies (e.g., SPECT). The patients described by Myers were not followed very far into the classical recovery curve seen in TBI patients; therefore the long-term effects of their injuries are not known. Some may have been sent back to the Front; others may have remained dysfunctional and been discharged from the military and become chronic sufferers of shell-shock.
What is most interesting about Myers’ patients is the loss or partial loss of sense of smell (i.e., anosmia) in all three cases. We now know that post-traumatic anosmia due to blunt-force head trauma is a clinical sign associated with damage to the orbital-frontal cortex and other anterior regions of the brain. This is because the olfactory nerve (cranial nerve I) is subject to injury by being sheared across the boney cribiform plate of the skull. If blunt-force trauma is severe enough to produce post-traumatic anosmia, there is usually associated damage to other portions of the prefrontal region, particularly orbital-frontal cortex. Unfortunately, orbital-frontal cortex is called the “executive” portion of the brain because it is crucially involved in forming and executing sensible plans, making social judgments, adapting to new situations, self-monitoring, and matching one’s behavior to the demands of complex social/vocational/educational circumstances. Brain-injured patients with prefrontal damage are often noted to manifest “executive dysfunction.” Within the last 15 years, seven functional neuro-imaging studies of the brain using either PET or SPECT scanning have confirmed that patients with post-traumatic anosmia due to traumatic brain injury manifest a relative lack of activity in the frontal regions of their brains when compared to control subjects.
Loss of sense of smell and reduced sense of smell are relatively “silent” neurological deficits. It is rare that a patient’s primary complaint involves reduced sense of smell, a defect that typically needs to be revealed by actual testing of cranial nerve I (as Captain Myers did in 1915). This state of affairs makes it much less likely that the changes in olfaction Captain Myers noted on testing were “hysterical” or intended to avoid further military duty.
We now move forward some 80 years to the current Global War on Terror. Although the explosives used in World War I were substantially more potent than those employed in earlier wars, the High Order Explosives used in Iraq and Afghanistan have become even more lethal, according to experts like Dr. Charles Stewart (Stewart, 2009). Substances like C4 and Semtax, used in Improvised Explosive Devices (IEDs) and Explosively Form Penetrators (EFP), are capable of generating extreme blast-waves of over-pressure following by under-pressure as described above. Insurgents have gotten more effective at remotely detonating such devices when our troops are nearby and detonating secondary devices when additional military personnel arrive to deal with the aftermath of the initial blast. Newer body armor protects soldiers from what would once have been lethal body wounds, but is ineffective against blast-concussions. This means that more troops survive today, but with survival comes risk for longer-term brain-related effects of traumatic brain injury.
What findings would the inquisitive Captain Myers have to report if he were still alive today?
A partial answer to this query comes from an investigation by Dr. Robert Ruff and his colleagues at the Louis Stokes DVA Medical Center in Cleveland. (Ruff, 2008). These researchers carefully studied 126 combat veterans who reported mild TBI caused by exposure to an explosion during deployment, with both neurological exams and neuropsychological testing. Ruff and associates reported that “…the most sensitive tools for detecting residual brain damage on neurological examination was olfactory testing.” (p. 948) Just over half of the 126 combat veterans studied (52%) showed long-term evidence of impaired sense of smell on formal testing. Impaired balance was observed in 40 percent of the sample; and roughly 40 percent had impaired eye movements. Combatants who had the most persistent neuro-cognitive deficits reported experiencing exposure to more explosions that produced changes in consciousness. The 80 veterans with persisting neuro-cognitive deficits were also more like to manifest sleep disturbance and symptoms of PTSD.
The findings from the Ruff study are timely in that they temper the doubts expressed by some experts regarding that mild traumatic brain injury contributes to serious post-deployment difficulties. In the United States, Colonel Charles Hoge has been a critic of the proposition that mild traumatic brain injury due to blast exposure is a major health issue for combat veterans, citing survey data which suggested that the effects PTSD were more problematic than the effects of mild TBI. While across the Atlantic, Professor Simon Wessely and his colleagues reviewed the evidence on “shell shock” from both World Wars and cautioned: “…it will remain the case that the symptoms many soldiers suffer are themselves both common and nonspecific.” (p. 1644)
Recently, prominent psychiatrists Murray Stein and Thomas McAllister (2009) reviewed the research literature on the co-occurrence of traumatic brain injury and PTSD, presumed to be the two major components of the current wave of “shell shock” among our OIF/OEF troops. Their conclusion was one that Captain Myers and his medical peers might well appreciate:
“The frequent confluence of PTSD and persistent postconcussive symptoms in military personnel strains the bounds of these constructs. New studies are needed to improve our understanding of how emotional and biomechanical stressors can yield these adverse outcomes and how such outcomes can be prevented and treated.”
Blast-waves of military ordnance and psychological horrors of large-scale warfare still combine to plague modern combatants much as they altered the lives of the trench-warriors of World War I. There appears to be plenty left to figure out regarding the contributions of brain trauma and emotional trauma to the post-deployment adjustment difficulties.
In the words of Dr. Louis French (French, 2009) neuropsychologist at Walter Reed Army Medical Center, “No one returns from war unaffected.”
William Sheehan, M.D.
Richard J. Roberts, Ph.D.
DVA Medical Center and
Department of Psychology
University of Iowa
Iowa City, Iowa
Steven Thurber, Ph.D.
Mary Ann Roberts, Ph.D.
Department of Pediatrics
Roy and Lucille Carver School of Medicine
University of Iowa
Iowa City, Iowa
Andrewes, D. (2001). Neuropsychology: from theory to practice. New York: Psychology Press. (p. 451).
Crane, S. Red Badge of Courage (1895). New York: Appleton.
French, L. M. (2009). TBI in the military. Journal of Head Trauma Rehabilitation, 24, 1-3.
Roberts, R. J. (2008). Impact on the Brain. Scientific American Mind, 19, 51-57.
Ruff, R. L., & Wang, X. F. (2008). Headaches among Operation Iraqi Freedom /Operation Enduring Freedom veterans with mild traumatic brain injury associated with exposure to explosions. Journal of Rehabilitation Research & Development, 45, 941-952.
Sheehan, W. P. & Dobbins, T. A. (2001). Epic Moon. Richmond, Virginia: Willmann-Bell. (pp. 295-299. }
Stein, M. & AcAllister, T. (2009). Exploring the convergence of posttraumatic stress disorder and mild traumatic brain injury. The American Journal of Psychiatry, 166, 768-776.
Stewart, C. (2009) Blast Injuries: True Weapons of Mass Destruction. Tulsa, OK: Charles Stewart and Associates.
First Published August 2009
Copyright © Priory Lodge Education Limited 2009