Myers – the Dawn of a New Era

For both military medicine and for psychiatry, this paper is very important and even today there are lessons that can be taken from this work. There are interesting facets to all aspects of this article.
To begin with, the title of the article is important. Myers describes his paper as “a contribution to the study of shell shock”; this implies that there was already a broader debate underway of which the readers of The Lancet were aware. Note that there is no attempt to define shell shock or to describe the term. Myers writes in a manner that presumes that the term is known by his audience. Thus, although this is apparently the first written mention of shell shock in the journals, it seems that this was taking place within a wider debate that was presumably occurring in places like grand rounds and medical meetings at that time, of which no extant record can now be found.
The next important aspect is the date – February 13th 1915. While the First World War broke out in early August 1914, it took some time for the armies to join in battle, and the first major battles did not occur until September. Less than four months later, Myers was describing cases which he viewed as “a definite class among others arising from the effects of shell-shock.” It is noteworthy that in such a small amount of time this new condition had been accepted as valid diagnostic entity, to the point that Myers could use it in The Lancet without explanation or caveat. While examining the date, it is interesting to note the last date on Case Three is February the 1st, and that under Case One he mentions that “now” is February 1st; 12 days later Myers was in print. This was at a time when the physical publication process would have consumed considerable time. They knew about accelerated publication in those days. Even with this very tight publication timeline Myers obtained approval from his commanding officer to publish this article. Apparently, even for a condition as controversial and novel as shell shock, medical professionals in the British Army were given great freedom to publish as they saw fit.
It is also interesting to note how advanced was Myers in understanding the essential nature of the condition. While he does discuss the cases in terms of the physical effects of the explosion of the shell, he concludes that “the close relation of these cases to those of ‘hysteria’ appears fairly certain”. Thus, he has grasped that the injury suffered by these soldiers is a wound to the mind, rather than an injury to the nervous system. It is apparent that Myers had this insight even earlier, as he records that he had attempted to use hypnosis to treat Case One as early November 10th 1914.
Also impressive is Myers’ concern about memory. It is now accepted that disorders of memory are a central feature of post-traumatic mental illness. Myers measured and followed the memory disturbance in these patients.
Even more impressive is the clear description of the disruption to olfaction that occurred in these patients. Disruption to olfaction in patients with conditions such as PTSD is a subject of intense current research interest. It is perhaps a sad reflection of all of us who have worked in this field to learn that the first case-histories of post-combat malaise clearly and accurately record disruption to olfaction as a feature of the condition. One might ask what we have all been doing in the intervening ninety years. There are, of course, interesting reasons why Myers was able to make these insightful observations concerning olfaction. He worked at a time when modern psychiatry was still emerging, and although he is remembered for his contributions to psychiatry, he would have had a sound knowledge of neurology. The lack of separation between mind and body in those days allowed him to make observations that we are only now rediscovering.
There are some aspects of the paper that will sit uncomfortably with modern readership. The references to bowel motions, and the suggestion that a return to more regular defaecation was associated with a decrease in symptoms in Case Three, would be something that we would probably not fit in a case history today.  The paper is almost as important for what it does not say as for what is said. There are no references; Myers seems to have thought that he was entering into a virgin field. There is no discussion of or reference to the work of da Costa in North America forty years previously, following the American Civil War. As Hyams and his co-workers have pointed out, post-deployment syndromes have been described after most wars. It is our repeated folly to forget the achievements of past generations, and to need to relearn what has been previously forgotten. Let us hope that we have at last learnt not to forget what has previously been discovered.
Author’s affiliation: Australian Institute of Health and Welfare Contact author: Australian Institute of Health and Welfare, GPO Box 570, Canberra, ACT, Australia 2601 Email: keith.horsley@aihw.gov.au