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Armistice Day, the Great War, and Brains: A Tale of Woe

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MEMORIAL

What do we remember? Veteran's Day--November 11th--was once called Armistice Day, the day the mangled soldiers started coming home in 1918.

The problem with war is that the men who declare and manage a war usually don't go to war. Had the politicians of various countries been obligated to live in combat on the front lines, it's doubtful that the ferocious carnage of the First World war, the so-called Great War, would have occurred. The casualties of that war are truly staggering, an estimated total of 16 million deaths and 21 million wounded. The Central Powers had the death of 4 million soldiers, the British 3.5 million, the French about 2 million, and the Americans 326,000 dead. The war turned parts of the European continent into a butcher shop, a huge industrial machine to produce human blood and meat, with an insidious ancillary embellishment: the most important battles were fought on soil contaminated by centuries of agriculture fertilized by human and animal waste. Trench warfare constantly exposed soldiers to contaminated soil. In a time without antibiotics and only primitive microbiology, even a minor wound could be a fatal outcome of infection.

Two facts about head injuries during the First World War are salient. First, because of the nature of trench warfare, the heads of soldiers were usually more exposed than the rest of their bodies, so that 25 percent of all cases of penetrating wounds were brain injuries or injuries to the cerebellum or cranial nerves. Second, the higher muzzle velocity of smaller bullets with a pointed shape allowed easy penetration of the helmet and skull, but the muzzle velocity was not high enough (as it was in the Second World War) to destroy large areas of the brain with shock waves and cavitation. The result was that brain injuries due to bullets (and most shrapnel) were usually discrete, and if the soldier recovered, the neurological deficits were usually focal. The trenches, in effect, provided a massive observational field to relate specific brain injuries to specific neurological and behavioral deficits.

During the Great War, most psychiatrists believed that war does not create any special kind of psychosis, or at least any long-lasting mental disorder. This was consistent with the prevailing notion that all madness involves hereditary tissue damage.

So what did military psychiatrists and neurologists do with their cases of battlefield psychological trauma--so-called "shell shock"? The answer is an ugly interlude in the history of medicine--the "treatment" of shell shock by punishment with electric shock. The physician usually associated with this interlude is the British psychiatrist Lewis Yealland, but the reality is that the famous British neurophysiologist Edgar Adrian, a later Nobel Laureate, was also involved.

In 1917, Adrian and Yealland (Adrian the senior author) published an extensive report in the British medical journal The Lancet on their treatment of common war neuroses. Adrian was a temporary captain in military service as a neurologist at the Connaught Hospital in Aldershot, and Yealland was a resident medical officer at the National Hospital for the Paralyzed and Epileptic, Queen Square, London.

The authors considered shell-shocked soldiers to be afflicted with hysteria. They stated that:

The chief phenomena underlying the hysterical type of mind are weakness of the will and of the intellect, hypersuggestibility, and negativism. The majority of patients are below the average normal intelligence as judged by the Binet-Simon intelligence scale, and others who are more highly equipped prove to have an unstable history either personally or in the family.

The authors stated explicitly that one is born an hysteric and does not become one.

The treatment method reported by the authors was the use of electric current applied to relevant parts of the body coupled with manipulating suggestion. In difficult cases, the intensity of electric current was increased to the point of pain.

Both combat effects--shell shock and physical brain damage--changed neurology and neuroscience. War has always been a most excellent way to spur medical progress, and the gruesome First World War was the most excellent way that had yet happened. Everything changed, all of neurology, psychiatry, neuroscience, and psychology.

The hell of the First World War ended on the 11th hour of the 11th day of the 11th month of 1918. Brain science, and especially neuropsychiatry, would never be the same.