- from 'The War Budget' April 26th, 1917
- 'Shell Shock'
- by W. R. Houston, M.D.
War's Toll on the Nervous System of the Fighting Man
from a French book - 'Pyscholgie de Guerre'
Dr. W. R. Houston, Professor of Clinical Medicine in the University of Georgia, author of the striking article published below, is an eminent neurologist who spent several months working at the front in a French war hospital in order to make a special study of the effect on the nervous system of men struck by shells or suffering from shell shock.
The beautiful city of Lyons, lying at the confluence of the Rhone and Saone, has been made the "Hospital City of France." More than thirty-five thousand sick and wounded are cared for there. At the Neurological Centre, which finds a home in the handsome buildings of the Nouvelle Lycée, the new boys' college at the entrance to the park, opportunities are offered for the study of every injury to the nerves and to the brain. There are many illustrations of wounds to the several nerves of the extremities taken individually and in groups. There are instances of the isolated destruction of the small single nerves that control one muscle, as of the nerve controlling the muscle that supports the shoulder blade, or the one that activates the muscle which rotates the shoulder blade forward when the arm is raised above the head. There are wounds at all levels of the spine, and rents in the skull that have torn away those highly specialised areas of the brain substance that preside over speech or vision or hearing. In the accounts of the great bombardments we have all read of men who were found dead in the trenches, unwounded. Death had resulted from air concussion in the zone contiguous to the exploding shell. The concussion is more intense and the danger greater if the shell explodes in a closed space, as in the deep chambered trenches of the Western front."
Many men are killed outright, but most survive. The latter seldom regain memory of the beginning of their accidents. At most they recall the whistling sound that preceded the arrival of the shell.
The facial expression is typical — comparable to that seen in the cerebral type of infantile paralysis—the corners of the mouth drop, the tongue is paretic, the lids droop, and the eyelballs are without motion. In all cases is found irritation of the footsole, provoking an obvious and prompt elevation of the great toe and a fanlike spreading of the other toes — on unequivocal indication of damage to the motor pathways leading from the brain.
Ghosts That Pass in the Night
In severe oases, and sometimes from milder ones, there develop a series of most bizarre clinical pictures. It is the general nervous system that is most often and most strikingly affected. As the patient emerges from his clouding of consciousness, he seems to be in a state of confusion. His memory is weakened. He has lost in power of voluntary attention. He has hallucinations. These psychopathic states may persist for days or months, and are accompanied almost always by persistent nightmares of fire and battle that startle and disturb the rest.
There is often deafness associated with injury to the ears; again, deafness is present with ears apparently normal. Sometimes the deafness is associated with vertigo such as suggests damage to the inner ear.
As to the sight, we encounter every degree of disability, from slight cloudiness of vision and narrowing of the visual field to complete blindness. In a considerable number of cases these troubles are due to damage done the retina.
The vocal cords may be paralyzed and the tongue incapable of being protruded, so that the patient is entirely mote, unable to make the slightest sound, to whistle or to blow, or even to imitate the movements of the lip in speech. His breathing muscles are contracted so that he cannot draw a long breath. In milder cases there is a stammering to the degree of almost complete unintelligibility.
The Laughter of Profound Pity
A remarkable series of moving pictures was made of these patients at Lyons. Large groups illustrating each of the contractures and paralyses were marched past the camera, but the most striking groups were the tremblers and the bent backs, and when, as constantly happens, many physicians come to see the astonishing and almost incredible cases that are found in this neurological hospital, the profound pity that these patients excite is inevitably mixed with laughter at the sight of the poor fellows with wildly inco-ordinate movements, struggling to maintain their balance as they totter across the stage of the exhibition hall, or shuffle along with feet in constant motion, like a novice at skating, and the back bent forward from the hips, almost at right angles.
How Patients are Treated
The methods of treatment vary according to the nature and degree of the trouble. The treatment of one case, for instance, consisted in cold douches and showers for a general effect, but more particularly in twisting and manipulating the joints of the paralysed limbs until pain, and even very severe pain, was induced. If bending the finger joints produces no pain, the wrist is manipulated; if the wrist is without sensation, the shoulder is manipulated. Sensibility returns to the anaesthetic areas through the pathway of pain induced in neighbouring regions that are more sensitive.
In another case the treatment was to place the hands over the eyes, whereupon the patient would promptly fall into a hypnotic state and go through all the phases of the grand attack. As his struggles began to subside and he was sinking into a quiet sleep, he was ordered to wake up, to awaken his shoulders, awaken his back, awaken his limbs, awaken all over. He is regarded when apparently awake as a vigilambule, one who, while apparently awake, has large portions of his brain cortex asleep, and who for this reason is so easily and by such slight transition thrown into complete hypnotic slumber.
Drill as a Medicine
In addition to these treatments carried out by the attending physicians, and by trained masseurs working under their direction, an interesting and indeed most inspiring part of the work for the restoration of these men is the systematic motor re- education carried out by the men themselves. Every morning from 8 until 9 o'clock, and again of an afternoon from 2 until 3, in the quadrangle of the Lycee the men are gathered at the sound of the bugle for drill.
They are grouped in squads according to their several disabilities. The club-footed squad, the hemi-contractured squads, the contractures of the left arm, the contractures of the right aim, and so on. Each squad has its non-commissioned officer, who is himself convalescing from the same disorder, ami the whole battalion is under the command of a sergeant, who is partially recovered from severe organic and functional disturbances.
Encouragement by Example
The apparatus employed in the exercises is of the simplest — a manual of arms carried out with a wooden pole, some board platforms for the exercises to be taken lying down, a few weights and pulleys. The intention is to bring the defective muscles into play through the unconscious influence of limitation; to strengthen the muscles which oppose those that are contracted; to give tone to the physique as well as to the morale of the men.
A physician passes from group to group encouraging and instructing the leaders, calling attention to stragglers that may be failing of the efforts demanded of them. The cheerful atmosphere of this scene, the sharp cries of command making a not unpleasing discord of sound; the emulation of the soldiers to attain the progress that they see others have made — all gives one the feeling that these men are cordially enlisted in the effort to overcome the handicaps under which they lahour, and a large part of the success of the treatment in this institution is to be attributed to this community of effort.
Some Curious Cases
It was possible in this hospital to find the same clinical pictures resulting from causes of every degree of potency.
1. There were the highly neurotic subjects, who had never been near the front, but who on receiving the news from home of the death of a wife or being parted from a sweetheart had developed these terrible attacks and paralyses. These were few.
2. There was the somewhat larger group of cases similar to the first two cited cases of tougher-fibred but still imaginative men, whom the emotional shocks of the campaign, combined with fatigue and long strain, had been able to bring to a grand hysteria.
3. A third group more stable than the last could be made hysterical only if, after being weakened by hunger, sleeplessness, and overwork, they were subjected to the shock of a violent explosion, though the same shock might have previously left them untouched.
4. Last, there were men, stalwart, tranquil, robust men, who had never known nervousness, neither personally nor in their families — unimaginative, stolid men, who, being suddenly hurled through the air, torn and lacerated in the fine structures of their bodies by am explosion, buried alive perhaps by falling earth, were, when they ultimately regained consciousness, transformed instanter into disorganised neurotics, exhibiting all the characteristics typical of the grand-hysterics.
To see these strong men suddenly reduced from the flower and vigour of youth to doddering, palsied wrecks, quivering at a sound, dreading the visions of the night, mute or deaf, paralysed or shaken by violent agitations, rent from time to time by convulsive seisures as though tormented by many devils — this wreckage of men's souls seemed to me to mirror more vividly the horror of war than any picture drawn from the carnage of the battlefield.
