March 30, 19 16] 



NATURE 



113 



into rigor mortis. In support of this hypothesis it 

 may be mentioned that Major Mott received through 

 Lord Sydenham information from the secretary ot the 

 War 'Irench Committee to the effect that imperfect 

 detonation of 50-100 lb. of trinitrotoluene would pro- 

 duce sufhcient carbon monoxide to cause poisoning. 



In support of the opinion that carbon monoxide 

 poisoning may account lor some of the symptoms and 

 the fatal termination of cases of "shell snock with 

 burial," and without visible external energy. Major 

 Mott showed photographs and photomicrographs of the 

 brains of cases of carbon monoxide poisoning, and 

 demonstrated the fact that the punctate multiple 

 haemorrhages found throughout the white matter of 

 the brain corresponded with the appearances presented 

 by the brain of a soldier who had been buried by the 

 explosion of a shell. How long he had been buried 

 was not known, as he was brought in comatose to the 

 field ambulance station and remained so until death 

 forty-eight hours later. Throughout this brain, 

 especially in the white matter (as the photographs and 

 photomicrographs demonstrated), there were multiple 

 punctate haemorrhages. There was no visible external 

 injury to account for this condition of the brain, but, 

 of course, it might have been the result of concussion 

 by a sandbag ; the lecturer adduced reasons against 

 this assumption, and said the question whether carbon 

 monoxide poisoning was a factor in the production 

 of severe symptoms and fatal termination in " shell 

 shock " could only be settled by examination of the 

 blood of these cases. The lecturer thought that this 

 would be worth doing, for he had seen numerous in- 

 stances of shell shock with burial showing no visible 

 injury, in which there was a complete loss of recollec- 

 tion and recognition, and from which the patients only 

 slowly recovered. He narrated similar cases of pro- 

 found loss of memory occurring as a result of carbon 

 monoxide poisoning previous to the war. 



Interesting photomicrographs of the spinal cord ol 

 a man who lived forty-eight hours after shell shock 

 with burial were shown. The man retained conscious- 

 ness to the end, but was paralysed in all four ex- 

 tremities ; the intercostal muscles were also paralysed. 

 The man w^as evacuated five minutes after the shell 

 burst ; therefore there was no time for him to be 

 poisoned by carbon monoxide. Examination of the 

 spinal column showed no visible sign of injury, but 

 there were most extraordinary changes in the fourth 

 and fifth segments of the spinal cord^ — notably 

 haemorrhage in the grey matter, sieve-like vacuolation 

 of the fibres of the posterior column, and of one 

 antero-lateral column; another striking feature was 

 enormous swelling of many of the axis cylinders. The 

 phrenic nucleus which innervates the diaphragm w^as 

 destroyed with the exception of some of the cells in 

 the third segment ; these exhibited chromatolvsis indi- 

 cative of exhaustion. Sudden death would have been 

 the result if the lesion had been half an inch higher, 

 as the whole "nucleus diaphragmaticus " would have 

 been destroyed by the spinal concussion, and respiration 

 would have instantly ceased. How the spinal 

 concussion was effected could not be ascer- 

 tained; It was most probablv due to a sandbag 

 hurled from the parapet, for this man was partially 

 buried. Still, it is dlflficult even then to account for 

 the limitation of the lesion to an Inch of the spinal 

 cord except by transmission of the force to the cerebro- 

 "^mnal fluid In which the spinal cord Is suspended. The 

 (hanges in the spinal cord were exactlv similar to 

 those described bv Col. Gordon Holmes '^ as a result of 

 concussion of the spinal cord caused by bullet wounds of 



lJ-o^^?Kf "J"^"*;'^",^ ^^'="'''="'^" P^«'"3 f^'' Goulstonian Lectures delivered 

 Holme. /j!^v-1VS°'I^''= of Physicians of I^ndon by Lt.-Col. Gordon 

 Holmes. Brtt.MtdJtuf^aJ, November 27, December 4 and 15, 1915. 



NO. 2422, VOL. 97I 



the spinal column without penetration of the enclosing 

 membranes. 



Regarding the sieve-like vacuolation of the myelin 

 fibres, and the enormously swollen axis cylinders, un- 

 like that produced by ordinary fracture dislocation, it 

 is of interest to note the opinion of Prof. Leonard 

 Hill, who, in a letter to the lecturer, suggested that 

 the shock may have been so great as to kill the axo- 

 plasm, for " a water pressure of between 300 and 400 

 atmospheres kills all protoplasm (excepting deep-sea 

 fishes). Water enters into the muscle and swells it 

 and turns it opaque. There are curious fractures pro- 

 duced in the muscle fibre. The myelin of nerve fibres 

 is broken up by the water entering Into these. la 

 the case of a high-velocity bullet striking the spine,, 

 it seems possible that the cerebro-spinal fluid beneath 

 the struck part ma}' be instantly compressed and act 

 as a solid body transrnittlng the blow to the. cord. 

 There cannot be time for the fluid to be displaced. 

 There is, anyway, a water-pressure limit beyond which 

 protoplasmic activity is destroyed, and I imagine 

 bullets must produce this pressure, but I very much 

 doubt whether air waves produced by shell bursts can 

 re.ach to such pressures as 300-400. atmospheres." 



It is quite possible, therefore, that a sandbag hurled 

 against the neck could cause spinal concussion similar 

 to that of a bullet wound, but without producing, 

 visible injury. 



Major Mott then directed attention to the fact that 

 while a large number of these patients were of a 

 neurotic or of a neuropathic disposition, vet the 

 strongest nervous system would eventually break down 

 under the stress of continuous exposure to shell fire 

 and trench warfare. 



The varying groups of signs and symptoms Indica- 

 tive of loss of function or disorder of functions of the 

 central nervous system arising from exposure to forces 

 generated by the detonation of high explosives are 

 classed under the term " shell shock." In a larger 

 number of cases, although exhibiting no visible injury, 

 shell shock is accompanied by "burial." The signs 

 and symptoms, with the exception of the profound 

 effects on consciousness and memory, accord in the 

 main with those of the two common types of func- 

 tional neurosis — neurasthenia and hysteria. 



From the point of view of compensation or pension 

 the War Office authorities ven,' properly regard " shell 

 shock " as a definite injury, although there mav be no 

 visible sign of it. This fact Is of considerable Import- 

 ance, for, as in the case of pension or comf>ensation 

 for traumatic neurasthenia under the Emploj-ers' 

 Liability Act, the notion of never recovering may be- 

 come a ^xed idea. The detection of conscious fraud is 

 not easy in many cases of " shell shock " in which 

 recovery might reasonably have been expected, for It 

 Is difficult in many cases to differentiate malingering 

 from a functional neurosis due to a fixed Idea. The 

 first point is to be sure of your diagnosis that the 

 disease is altogether functional, and being satisfiec^ 

 thereof to avoid all forms of suggestion of the possi- 

 bility of non-recovery. A very great difficultv in the 

 complete investigation of these cases arises from the 

 fact that few or no notes, as a general rule, accom- 

 pany the patient; one has therefore to relv upon the 

 statements made by the patient himself, or perchance 

 by a comrade, if he has no recollection of the events 

 that happened. Most of the cases of "shell shock." 

 however, are able to give satlsfactorv information of 

 the events that preceded the shock ; thev even tell you 

 thev can call to mind the sound of the shell coming 

 and see It In the mind's eye before it exoloded ; then 

 there is a blank in the memory of variable duration. 

 In some of the more severe cases, especlallv where 

 there has been burial or physical concussion bv a stone 



