  CosÌ od’ is che solava la lancia d’Achille e del suo padre esser cagione prima di trista e poi di buona mancia. Thus I have heard that the lance of Achilles, and of his father, used to be occasion first of sad and then of healing gift. Inferno, Canto XXXI, 4-6. Terminology1. Shell-shock, a lay term, usually refers to the medical entity or disease-group: functional neurosis, or more briefly, neurosis. The history of the term Shell-shock will repeat that of Railway Spine in the last century; the term will fall into disuse when the cases subsumed thereunder get their exact medical diagnoses—which, statistically speaking, will prove to be as a rule psychoneuroses, either hysteria (pithiatism), neurasthenia (nervous exhaustion, “prostration”), or psychasthenia (obsessive neurosis). 2. But the laity cannot be got to use the term Shell-shock in this exact sense, because the laity cannot make exact diagnoses. In the post-bellum and reconstruction period the physician will need to guard against regarding all cases called Shell-shock as really neuroses, merely on the ground that Shell-shock is probably neurosis. Laymen will in the reconstruction period succumb to the lure of the 100 per cent and gossip about cures and failures in the same loose manner that is but too familiar in discussions of Lourdes, Christian Science, the Emmanuel Movement. It will be worth while to preserve a certain generality and comprehensiveness for the term Shell-shock, which will stand to medicine as the term weeds stands to botany. 3. In short, keep the connotation but try not for any denotation of this lay term Shell-shock in the lay mind! The dangerous history of the term dementia praecox may be recalled. Neither dementia nor praecox is an exact term 4. The term Shell-shock appears to be a perfect term for the ordinary man, as it means much and little, connotes enormously and denotes a minimum and casts the lay hearer back upon the expert. But confronted by the term Shell-shock, the ardent social worker or the ordinary man fails to get any incorrect notion about the nature, and especially about the prognosis, of the condition. If there is any suggestion of prognosis, it is the correct suggestion of curability possibly conveyed by the suddenness implied in the term shock; but I defy the ordinary man to get from the ordinary term Shell-shock very much that denotes anything in particular. All he gets is an enormous connotation. This connotation may run back for the race into tree stumps, savages brandishing spears, palatial decorations, the protrusion of animal spirits, the Leyden jar (sometimes familiarly known as the “shock bottle”), and the aspen shaking of the man in fear or its interior equivalent. But whether the slang runs back so far or no, and whether the shell is a shell of powder or a shell of fear, and whether the shock is of solid particles or in a moral sense, the problem is implicitly laid down in the slang (see historical discussion, Shattuck Lecture). 5. The terminological difficulties are clarified somewhat by the French distinction of États commotionnels and États Émotionnels in the Shell-shock group. The French very neatly distinguish what they term États commotionnels from États Émotionnels. They think of the États commotionnels or commotional states much as we think of commotio cerebri, that is, of a physico-chemical happening in the brain of an essentially curable (or reversible) nature; that is, of something that falls short of being, as they say, lÉsionnel, namely, as bringing about a structural lesion. That is, they distinguish a brain with a visible focal lesion from one which has sustained a physical jar or commotion, and they distinguish the effects of both of these from the États Émotionnels 6. Terminology, especially in the matter of explanations to laymen (Americans demand monosyllabic explanations as a preliminary to taking suggestions!), is not always assisted to clearness by physicians on account of the old ontological fallacy that Charcot insisted on. Would that the medical profession understood neuroses at their true value! Only too frequent is the impression on the part of the profession that imaginary symptoms are by the same token non-existent! I have even heard a physician well-trained in somatic lines say that Shell-shock did not exist because Shell-shock was nothing but neurosis, and neuroses were characterized by imaginary symptoms,—accordingly neuroses, being imaginary, do not exist! All of which reminds us that many of the profession were entirely skeptical when Charcot made his original observations. Some men here in America felt that, whereas hysteria might occur in Paris, it did not occur to any extent in America. The Shell-shock data of this war will abundantly prove to the profession the existence of the neuroses, and I feel that physicians will have to brush up their ontology to the extent of conceding that a symptom may be in a sense imaginary and yet not in any sense non-existent. 7. Babinski points out a case of hysterical paralysis of a leg which led the patient to lean so heavily upon his arm as to produce an organic crutch paralysis. It would be to no point to argue that the hysterical paralysis was here non-existent. Of course we shall have to meet the false analogies drawn from methods of cure. If a paralysis can be cured in a 8. Is it too much to ask the profession not ever to say that this rapid and seemingly miraculous cure was brought about because the disease was non-existent? Diagnostic Delimitation Problem9. The delimitation problem, taken up in Section A, is not identical with the differentiation problem, taken up especially in Section C but passim in Sections B and D; by delimitation we may refer to the process of localizing the diagnostic battle through exclusion of the other great groups of mental diseases that À priori ought not to come in question, but do come in question sometimes, before we slice down to the question. 10. Is there or is there not evidence of destructive lesion in the nervous system of this so-called Shell-shocker? Is this man a victim of organic or of functional neurosis? This latter is what may be termed the differentiation problem. Confining ourselves now to the delimitation problem, what are the major groups of mental diseases that might come in question? I shall enumerate these. We think of mental diseases as I, syphilitic; II, hypophrenic (that is, feeble-minded in some of its phases, including even slight degrees of subnormality not entitled to be called feeble-minded in the ordinary sense); III, epileptic; IV, alcoholic (or due perhaps to some drug or poison); V, encephalopathic (in the sense of some focal brain disease); VI, symptomatic (in the sense of some somatic disease); VII, senile (or presenile). The seven groups so far enumerated, I believe, the general profession is pretty well equipped to consider, at least roughly to diagnosticate and to handle with due respect to the interests of the patient and of the community. I am bound to say that some of my colleagues would not go so far as to the competence of physicians in general in these fields, and one is aware that a plenty of mistakes have occurred even in these groups through the bad judgment of practitioners. Nevertheless, I hold to the conception that our profession is reasonably well equipped to 11. Now a study of the literature of the belligerents having Shell-shock in mind as its special topic and aim proves to require a study of war literature in all of these groups. There are cases of so-called Shell-shock which even well-prepared medical men have placed in the neurosis group, when they should have been placed in one or other of the groups mentioned. 12. In short, whereas the Shell-shock delimitation problem deals with groups, I, II, III, IV, VI, VIII, IX and (as our compilation shows) especially with groups I, III and VI, on the other hand the shell-shock differentiation problem deals primarily with groups V and X. To clear the decks for action re the differentiation problem, let us dismiss the major troubles of the delimitation problem as shown in groups I (syphilitic), III (epileptic), VI (somatic) and thereafter very briefly refer to the residue of the delimitation
13. The neuropsychiatric side of syphilis in the war is presented in 34 cases (Cases 1 to 34). The syphilitic basis of sundry military difficulties, quite unsuspected by the laity and probably not too well understood by service men, is suggested by Case 1, a case of desertion by a French officer of high rank. Nor is Case 2, in which visions of submarines proved syphilitic, without its warning. Such cases point only too obvious a moral: 14. Neurosyphilitics have no place in the army or navy. Eight cases (Cases 3-10) follow in which the aggravation or acceleration or liberation of neurosyphilis has come about under the conditions of war. Some of these cases suggest the gravity of the problems of compensation, allowance and pension that may arise. We might ask, 15. Should not a government which enlists a syphilitic pay full allowances to him when under war conditions he becomes a neurosyphilitic? For the government was theoretically able to learn at the start (within a small margin of error by means of the serum test) whether the man was syphilitic. If a one-eyed man loses his remaining eye in an industrial accident in civil life, his damages are often fixed at damages for total blindness; for the industrial firm should not have employed a one-eyed man in an industry dangerous to eyes. The principle cannot differ with a man hired in a spirochete-bearing state: The company has hired a man who may under traumatic conditions become an incompetent neurosyphilitic, and should pay damages accordingly when the aggravation begins. 16. What are the responsibilities of government if the neurosyphilis is due to a syphilis acquired during the war? Often such infection may be due to a tragical form of “negligence.” But, as pointed out in a work on Neurosyphilis, 1917, I believe that any form of licensing system, official or virtual, which would permit the purchase of syphilis in or near military zones, abolishes the argument of “negligence.” A man acquiring syphilis under the connivance of government ought to stand as well as a syphilitic hired by the government, when it shall come to the question of compensation for incapacity. Yet, it may be argued, the man might have remained continent after all. The point is left to the mercy of jurists. 17. The share of neurosyphilis in the “crimes” and disciplinary problems of the army is intimated in three cases (Cases 11 to 13). 18. The latter part of the series (Cases 14 to 31) embraces problems of a more medical nature, touching traumatic paresis and “Shell-shock paresis.” Unusual, these cases may be readily conceded to be; but their infrequency is not such as to put them out of the field of consideration in the “Shell-shock” group. Very intriguing to the diagnostician would be the cases of pseudotabes and pseudoparesis (Cases 23 and 26 of Pitres and Marchand), were such cases at all frequent. Case 28, in which shell-shock (the physical event) apparently caused recurrence of a syphilitic (!) hemiplegia, is particularly instructive and might better belong with the Case 29 stands out as a warning example not to crowd the hypothesis and try to make syphilis sponsor for everything, even when it plainly is at work. Cases 32-34 are cases in which syphilis played a part, though possibly a minor part, in certain peculiar mental reactions. To sum up the part played by syphilopsychoses and syphiloneuroses in the war, we find, that 19. Syphilis may have occasionally a serious military effect, as in the case of desertion by a French officer of high rank. 20. Important problems of pension, retirement, and compensation are brought out, and as no previous war has had the benefit of the Wassermann reaction and other exact tests bearing upon the nature, progress, and curability of neurosyphilis, we may hope for a far more scientific determination of these questions by review boards during and after the war. 21. We find a few instances in which neurosyphilis has played a part in the discipline of troops. According to one author (Thibierge, 1917), syphilis has become a genuine epidemic among French soldiers and mobilized munition workers. In Germany, also, it may be remembered that Hecht has claimed that no less than an equivalent of sixty army divisions has been temporarily withdrawn from fighting on the Teutonic side for venereal diseases. In this connection, Neisser had recommended the giving of salvarsan and mercury in the trenches. According to Hecht, the appearance of syphilis should be a signal for sending a man to the front. Hecht also made the somewhat bizarre suggestion that special companies of syphilitics should be formed, for convenience of treatment, on the firing line. 22. A more solid foundation is laid for the theory that general paresis may be evoked by trauma—a conclusion already fairly well established by civilian cases, notably those of industrial accident. 23. The question whether shell-shock (the physical event) can produce general paresis is probably to be settled in the affirmative, for it may always prove difficult to show that the physical shell-shock did not actually produce mechanical molar lesions of the brain, permitting the rapid advance of spirochetes. It is perhaps easier to prove that shell explosion may precipitate neurosyphilis in the form of tabes dorsalis (take, for example, Cases 21 and 22). The cases of most importance in the question of traumatic neurosyphilis and traumatic paresis are cases 20, 21, 22, 24 and 25. 24. The picking out of preËxistent weak spots by Shell-shock is given clear illustration, as in the case of Shell-shock recurrence of an old syphilitic hemiplegia (Case 28). Only on such a basis could the syphilitic ocular palsy of Case 19 be satisfactorily explained. 25. The coexistence of functional phenomena with organic syphilitic phenomena is demonstrated by Cases 29 and 30; perhaps also in Case 16. 26. It must be said that presumably there will be, unless our authorities are more successful than in the past, a considerable increase in venereal disease as the result of army life in wartime. There will be a certain number of cases of neurosyphilis a number of years after discharge from the army caused by infection acquired during service. (Germany is said to have got its crop of neurosyphilis after the War of 1870, in the early eighties of the last century.) The names of all soldiers acquiring syphilis and not considered cured at the time of discharge should, under ideal conditions, be given to health organizations in their home states so that they may be accorded proper care and treatment. 27. Shell-shock and epilepsy. The authorities have been somewhat surprised by the number of epileptics that have gotten by the draft boards. The statistics are not yet ripe, but certainly the enlistment of an epileptic is not a rarity. There are some singular instances in the war literature showing how hard it sometimes is to bring out epilepsy. There is the English case, for example, of a man, an epileptic’s son, who had himself been epileptic from 11-18, who entered the Expeditionary Force at the outbreak of hostilities, went Another man who had never been epileptic (though his sisters had been) was wounded four times, was never worried by shell fire, got somewhat depressed after the death of his father and five brothers in the service, but did not become epileptic until finally he was blown up and buried three times in one day, and it was a whole month later when he became epileptic, although treatment by rest and bromides apparently resolved the affair. Other cases seem to show that war experiences can bring out epilepsy, although in most instances it would appear that there was an epileptic or otherwise neuropathic heredity in these cases. 28. There is one author, Ballard, who has actually propounded a theory of Shell-shock as epileptic, pointing out the occurrence of epilepsy long after the early symptoms of Shell-shock have disappeared. 29. As in all other instances of mental or nervous disease, when an epileptic returns from the war, whether or not he was potentially or actually an epileptic before the war, his relatives are bound to term him a case of Shell-shock. I am familiar with a case in a hospital in a certain Atlantic port, a case of pronounced and obvious epilepsy. In the wards he is treated as the hero of every occasion. Not only the nurses and attendants, but the other patients and often the physicians can hardly resist thinking of him as somehow a case of Shell-shock. It is a comment upon the status of mental hygiene in general that this self-same epileptic, had there been no war, would have been, as it were, a common or garden epileptic, mute and inglorious on some sunny hillside. 30. In passing I may note how many instances in the medicolegal part of the war literature there are of epileptics who come up for courtmartial or for medical examination pending courtmartial. We may suspect that many a case of epileptic fugue has been regarded as a case of desertion. There is the case of an epileptic who left camp one morning and got drunk. Investigation showed that he left camp before anything epileptoid had happened. He developed in his drunkenness a pretty clearly epileptic crisis with great violence, for which he had a complete loss of memory. The French Council condemned him to five years of labor, not admitting in this instance that responsibility was diminished by reason of the man’s being epileptic. In short, from the military point of view, he should, so to say, have known enough not to have gotten drunk, and so have avoided getting his epileptic crisis. Of course the decision was here very close, and a like decision would not always be rendered. To add to the complication of this particular case, the very first epileptoid crisis which caused it to be known that the man fell into the epileptic group was due to Shell-shock, or at least developed immediately after the bursting of a shell 31. The question of epilepsy in the war is considered in a series of 33 cases (Cases 53-85). The considerations range from banal cases developing quite incidentally, up to cases regarded by one author (Ballard) as illustrating a theory of Shell-shock as epileptic (Cases 82-84). First are considered two cases actually syphilitic. In the first (Case 53), the diagnosis had to be revised from epilepsy to neurosyphilis (the convulsions of this neurosyphilitic were brought out by alcohol, and the reporter, Hewat, remarks that the serum of any patient developing epileptiform seizures between 35 and 50 years of age should be subject to test). In Case 54, the soldier got his syphilis in wartime and the syphilis acted to bring out an epilepsy with which the patient was hereditarily tainted (epilepsy syphilogenic, i.e., reactive to syphilis). Case 55 might perhaps better have been considered in the group of hypophrenoses, as he was epileptic and imbecile. He was at first condemned by court martial to five years’ imprisonment for leaving his post in the presence of the enemy. Another mixed case is Case 57, in which another feeble-minded subject showed seizures of a psychogenic nature, which he was able eventually to stop by clenching his teeth. Seven cases (Cases 58-64) are cases of a disciplinary nature, amongst which attention may be called to Case 62, the “specialist in escapes.” The medicolegal questions of responsibility in the drunken epileptic (Case 58) are particularly perplexing. 32. Case 64 is one of epilepsy following antityphoid inoculation one-half hour. There were five attacks during a fortnight and then no others. The antityphoid inoculation came eight weeks after a shell wound of the thigh, which had not served to bring out the epilepsy in this patient. Bonhoeffer had three other instances of the sort: one in a severely tainted subject, and the others in alcoholics. 33. The next group of cases, 66-77, yields a series of the most interesting medical problems, some of which scarcely 34. The cure by studied neglect (in Case 67) is one of hystero-epileptic convulsions occurring in series. Case 68 demonstrates the superposition of hysterica phenomena over a genuine epilepsy, a case therefore with two diagnoses: not hystero-epilepsy, but epilepsy and hysteria. 35. The theoretical implications of Case 69 are striking: The case was one of musculo-cutaneous neuritis (gross enlargement), in association with which Brown-SÉquard’s epilepsy developed, waxing and waning with the disease of the nerve. Another case of possible reactive epilepsy is Case 70, and a case of epilepsia tarda brings up the same issue (Case 71). Cases 72-74 are cases with strong psychogenic components, of which Case 74 is particularly instructive on account of the gradual building up of a remarkable visual aura of an approaching fire-wheel, this aura developing after scotoma from looking at the sun. Cases 75 and 76 are cases of somewhat doubtful epilepsy, one of fugue and the other of a solitary epileptic episode following 38 artillery battles in two months. 36. Friedmann discusses narcoleptic seizures, regarded as due to the brain fag of trench life (Case 77). Sham fits and epileptoid attacks controllable by will appear in Cases 78 and 79 respectively. Case 80 is a striking case of a man with epileptic taint, which two years’ service, four wounds, the death of a father and five brothers, and eventually Shell-shock and burial thrice in one day, served at last to bring out. 37. Shell-shock and bodily disease. In civilian psychopathic hospital practice, if a case is not syphilitic, not feeble-minded, not epileptic, not alcoholic, and without signs of intracranial pressure or disorder of reflexes, then we, as specialists, must consider whether the disease in question is not due to some form of bodily disorder outside the nervous system; for example, we think in practice of infectious psychoses, of exhaustive states such as the puerperium, of toxic states Under the war conditions, it might be thought that these somatic disorders yielding the so-called symptomatic mental diseases would be frequently found. Aside from these rarities in puzzling diagnosis, we find more commonly in the literature evidence of 38. The soldier’s heart, the so-called “D.A.H.,” or disordered action of the heart, of the English army reports. This soldier’s heart is sometimes associated with hyperthyroidism, and sometimes hyperthyroidism is found alone, with symptoms suggesting those of a sort of diffuse Shell-shock. One author claims rapid cures of hyperthyroidism by the relatively simple process of hypnosis. Perhaps this is not too unlikely in view of the still obscure relations between mind and hormones. A little more surprising, perhaps, is the assertion met with that psoriasis is sometimes a Shell-shock phenomenon. The literature clearly shows, however, that, as in most special problems, the internist is still in demand. I recall how one internist was misled on the witness stand into stating that he was a “general specialist.” This is what we would all need to be, were we to solve the problems of Shell-shock in the time allotted to us by the war. 39. Following are special cases to show how near the somatic (“symptomatic”) may be to Shell-shock. The somatic group of psychoses, sometimes termed symptomatic, is illustrated in 29 cases (Cases 118-146), and comprises cases ranging all the way from rabic phenomena to those of hyperthyroidism. Possibly the first two cases (Cases 118 and 119) might better be placed among the encephalopsychoses. Case 118, one of rabies, was that of a farmer without history of having been bitten by a dog, who eventually came to autopsy and received the Pasteur Institute diagnosis of rabies. A diagnosis of angina was at first made. When the symptoms became more serious and masseter spasm developed, a question of tetanus arose. Later Case 119 was one of seven cases reported by LumiÈre and Astier, in which delirium and hallucinations appeared as a complication of tetanus. The case in question had been given anti-tetanic serum. (Another case showed identical symptoms without having been given anti-tetanic serum.) That a local tetanus could be mistaken for hysteria might seem À priori unlikely, but Cases 120 and 121 indicate as much; and Case 121 is interesting on account of the officer’s own description of his local tetanus and its treatment. A psychosis apparently related with dysentery occurred in Case 122. Hysteria followed typhoid fever in Case 123. Another form of typhoid fever complication is perhaps shown in Case 124, wherein the diagnostic question lay between dementia praecox and a post-typhoid encephalitis. Paratyphoid fever has diagnostic complications, as shown in Cases 125 and 126, wherein the mental symptoms outlasted the fever (Case 125), and psychopathic taint was brought out (Case 126). Diphtheria was also represented in the matter of nervous and mental symptoms in Cases 127 and 128. In Case 127 the nervous symptoms appeared eight days after evacuation for diphtheria. There were a few sensory symptoms (hypalgesia, hypoacusia, and peculiar bone sensations) in this subject. The phenomenon in Case 128 was apparently one of hysterical paraparesis; nor does it appear in this case that the hysterical paralysis was preceded by polyneuritis. Malarial effects are present in three cases (Cases 129-131), of which Case 129 showed an amnesia, Case 130 a Korsakow syndrome, and Case 131 anterior horn symptoms. Case 132 exemplifies 15 instances of acroparesthetic disorders in so-called trench foot. This case, like several others, is inserted in this group, not because the symptoms are psychotic, but because they might cause diagnostic difficulty as against hysterical phenomena. Case 133 is an autopsied case of bronchopneumonia following bullet injury of the spine. Microscopic examination of the spinal cord showed small cavities in the first and fourth The reflex hemiplegia with double ulnar syndrome in Case 136 seemed to have followed a bullet wound of the pleura. According to the authors, Phocas and Gutmann, there is considerable literature upon nerve complications of pleura trauma, including syncope, epilepsy, and (more rarely) hemiplegia. Heart cases are illustrated by Cases 137-139: the first one of hysterical tachypnoea, and the others of the so-called soldiers’ heart. Diabetes mellitus seems to have followed war strain and shell wound in Case 140. It is doubtful whether shell-shock and burial had anything to do with the appearance ten days later of lipomata, which proved to be the initial phenomenon in a pronounced Dercum’s disease. (Case 141). Hyperthyroidism is illustrated in four cases (Cases 142-144). The first (Case 142) appears to have been cured by inducing deep somnambulism (Tombleson claims cures by suggestion in eight cases of hyperthyroidism). Neurasthenia or questionable Graves’ disease (Case 145) followed Shell-shock. That A somewhat curious somatic complication in a case of Shell-shock hysteria was the finding of a needle in the left upper arm, which was then extracted. (Case 146). The Nature of War Neuroses40. Regarding our rough delimitation of the Shell-shock group as well in hand, having put upon one side three of the most disturbing groups (save one) in our process of demarcation, we must proceed to the Shell-shock material itself: a material now definable as assuredly non-syphilitic, non-epileptic, non-somatic, Note that in this epicrisis I have designedly not followed the order of presentation of the text materials. The process of diagnosis per exclusionem in ordine which I find most serviceable in civilian psychopathic hospital practice is the elimination of possibilities in the order presented in Chart 1 or in Paragraph 10 of this epicrisis. Because this book will find its greatest use in peace times as a kind of illustrative commentary on the peace material that presents itself in general practice or in psychopathic hospital voluntary, temporary-care, and out-patient practice, I chose to arrange the delimiting material according to the order of the practical key devised for civilian practice. We may now profitably change our order of consideration and consider whether 41. The most practical key or sequence of consideration in the endeavor to delimit Shell-shock neuroses is probably: Exclude (1) syphilis, (2) epilepsy, (3) somatic disease (of a sort able to produce “symptomatic” effects somewhat like those of Shell-shock). Below I shall still permit myself some general words concerning the other more easily excluded groups because of the light which feeble-mindedness, alcoholism, schizophrenia, cyclothymia, and even old age can theoretically throw on the nature of Shell-shock. 42. Suppose then that syphilis, epilepsy, and somatic (non-nervous) disease are out of the running, we come practically down to the psychoneuroses, knowing that knotty problems are at hand in telling them from structural traumatic effects: But, after all, what are functional neuroses? What do we really know about the neuroses other than to say that they are not distinguished by the existence of the structural lesions which characterize organic disease of the nervous system? Is not the definition of neurosis purely by negatives? However true this definition by negatives may be from the genetic and general pathological viewpoint, the work of Charcot and in particular of Babinski has yielded a number of positive features from the clinical viewpoint, which to some degree make up for the lack of anything positive in the neurones themselves as studied post-mortem. An eminent German has recently declared that the data of this war itself go far to prove some of the long dubious contentions of the Frenchman, Charcot; and the work of Babinski during the war has strengthened and developed the conceptions of his master, Charcot, as well as the ante-bellum conceptions of Babinski himself. 43. Let me insist that the problem is practical enough: Organic versus functional neurosis. The point I want to make is that, when so much theoretical doubt concerning organic and functional neuropathy holds sway, the practical doubts in the individual case under the varying conditions of civilian practice and in the upheavals of military practice, must be still more in evidence. Case after case described in the literature of every belligerent has passed from pillar to post and from post to pillar before diagnostic resolution and therapeutic success. Colleagues meeting, for example, at the Paris Neurological Society, find themselves reporting the same case from different standpoints,—the one announcing a semi-miraculous cure of a case which another had 44. In cases of alleged Shell-shock, the hypothesis of focal structural damage to the nervous system or its membranes has to be raised. Shell bursts and other detonations can produce hemorrhage in the nervous system and in various organs without external injury. Thus a man died from having both his lungs burst from the effects of a shell exploding a meter away. Hemorrhage into the urinary bladder has been identically produced. Lumbar puncture yields blood in sundry cases of shell explosion without external wound, and Babinski has a case of hematomyelia produced while the victim was lying down, so that the factor of direct violence through fall can be excluded. In sundry cases, not only blood but also lymphocytes have been found, sometimes in a hypertensive puncture fluid. 45. Moreover, in cases of alleged Shell-shock there may be a combination of structural and functional disease. A herpes or the graying-out of hair overnight can suggest organic changes. A case may combine lost knee-jerks (suggesting organic disease) with urinary retention (suggesting functional disorder). 46. Again, there is a group of war neuroses, especially clearly brought out in cases of ear injury, in which the functional disorder surrounds the organic as a nucleus. But these “periorganic” neuroses are no proof that the neuroses in question are organic in nature. Hysterical anesthesia, paralysis, or contracture may occur on the side of the body which has received a wound: the process of such a peritraumatic disorder is, nevertheless, a functional process. 47. But, when the problem is statistically taken, the majority of cases of alleged Shell-shock without external wound prove to be functional, as indicated by their clinical pictures. Thus, after a mine explosion, a man was hemiplegic, tremulous and mute. After sundry vicissitudes, the tremors were hypnotized away. Then the mutism vanished, to be supplanted by stuttering. Finally the hemiplegia remained. So far as 48. But do we not know all we need to know or all we are likely to know about the neuroses already from old civilian studies? There are some cases without very close relations to the war: Thus, we conceive of (a) psychoneuroses incidental to the war and such that they might very probably have developed without the entrance of war factors; and on the other hand, we conceive of (b) psychoneuroses (to be dealt with in extenso later) in which war factors (either physical Shell-shock or other factors) forcibly enter. There are in this group of incidental psychoneuroses 12 cases. The first, described as a constitutional intimiste, a psychasthenic en herbe, was one in which a hallucination was developed in the field, and in which three phases of a psychopathic nature—(a) over-emotionality, (b) obsessions, (c) loss of feeling of reality—developed. In this case the war work at first seemed to better the man’s general condition, and he gave two years of effective service. This officer in effect invented his own Shell-shock equivalent in a hallucination of Germans appearing in his trench. The case may be compared with one described in Section B, namely, Case 347: that of a Russian soldier who developed perfectly characteristic war dreams, though his entire service had been rendered in the rear and he had not had experiences in action. Possibly Case 171, that of hysterical fugue, might be regarded as one of Shell-shock, since two shells burst near him prior to his fugue. The man had had analogous crises, certified by RÉgis, in adolescence, and had received the diagnosis hysteria. In this instance, we are dealing merely with an habitual somnambulist who has a characteristic fugue following explosion of two shells. The war is in a sense responsible for the fugue, yet not directly, and the fugue would, without the stress and strain of war, probably never have developed (see sundry cases in the group in which ante-bellum phenomena are newly evoked in war: Cases 286-301). The hysterical psychosis of an Adventist (Case 172) might be regarded as liberated by military service; the terrible fear of the guns shown by the psychoneurotic (Case 173) proceeded to the point of fugue. A Shell-shock victim whose war bride was pregnant, developed fugue with amnesia and mutism (Case 174). Under hypnosis, it appeared that his fugue began with his running away from shells. Case 175 was that of a neurasthenic who volunteered and had to be sent back from the front after three months. In this case, war dreams were supplanted by sex dreams, and the fear of insanity became ingrained. The phenomena here were largely ante-bellum and the war brought them out once more, as might other disturbing experiences. Case 176 is here introduced to show that neurasthenia may develop in a man without hereditary taint or acquired soil. There was a very slight shrapnel injury of the skull, which somewhat clouds the diagnosis in the case. Five months’ war experience brought out the neurasthenia. Case 177 deals with a point in the diagnosis of psychasthenia, which, according to Crouzon, shows arterial hypotension, a condition important to distinguish from that of pulmonary tuberculosis and of Addison’s disease. Compare this case with Case 169: a case of depression treated by pituitrin. Case 178 is a case of psychasthenia following several months’ service by a man who probably should never have entered military service. Another case of ante-bellum origin is Case 179. Antityphoid inoculation appears to have been the initial factor in the case of neurasthenia No. 180. Compare Case 65, epilepsy after antityphoid inoculation. Case 181 was that of a non-commissioned reserve German officer whose neurasthenia was distinguished by sympathy with the enemy. He did not want to let his men shoot at the enemy because the idea came forcibly to him that the enemy soldiers had wives and children. This symptom of sympathy with the enemy was also shown by another German (Case 229). Compare the sentiments of a Russian under narcosis (Case 555). To sum up concerning the small group of psychoneuroses presented in the section on Psychoses Incidental in the War, Examples are available of hysteria (Cases 171, 172, 173, 174), of neurasthenia (Cases 175, 176, 179, 180, and 181), and of psychasthenia (Cases 177, 178, and possibly 170). 49. Let us now contrast with these specified ante-bellum or non-war cases the situation which will face us in the war group. Section B contains 174 cases (Cases 197-370). Autopsied cases (Cases 197-201) are put first and are followed by cases in which lumbar puncture data are available (Cases 202-207). A third group of cases is that in which so-called organic symptoms are much in evidence, either independently or in association with functional symptoms (Cases 208-219). There follows a small group of three cases with shrapnel wound (Cases 220-222), in which hysterical symptoms were prominent, as against the prevalent and correct conception that wounded cases are not so prone to psychoneurosis as non-wounded cases. Three cases specially marked by tremors (Cases 223-225) follow, the last of which gives the victim’s (a French artist) own account of his feelings. The next two cases (Cases 226 and 227) give respectively a German and a British soldier’s account of Shell-shock symptoms. There then follows a great group of cases (Cases 228-273) arranged according to the part of the body chiefly affected by hysterical symptoms. The arrangement is one of toe to top, or as one might more technically say, cephalad. This cephalad arrangement naturally begins with cases with symptoms affecting one leg or foot (Cases 228-235). Then follow cases of paraplegia (Cases 236-241). As we proceed cephalad then follow four cases of the so-called hysterical The idea of the above arrangement of 46 cases (Cases 228-273) is that the reader dealing with cases of hysterical disorder due to physical shell-shock, or some equivalent thereof, may inspect the data in a few analogous cases described more or less fully in the literature. By reference to the index, the reader will be able to find still further cases to illustrate the symptom in question. The next series of cases (Cases 274-281) are to illustrate the contentions of Babinski concerning the elective exaggeration of reflexes under chloroform, and the conception of reflex or physiopathic disorders based thereon—a topic to which return is made in Section C on Diagnosis, and elsewhere. A small group of cases (Cases 282-285) illustrate the delay of Shell-shock and kindred symptoms in certain instances, cases that suggest a refractory period of greater length than usual, or the interposition of some unusual factor. The next group of cases (Cases 286-301) is of special note, bringing out what is discussed below, namely, the emphasis, reminiscence, or repetition of antebellum phenomena, and the picking out of weak spots in the organism by Shell-shock. Possibly Cases 302-303 belong in the same group of illustrations of the driving in of ante-bellum effects. Cases 304 and 305 are definitively cases in which hereditary instability is a factor, whereas Cases 306 and 307 form a foil to these, in that the phenomena develop in subjects confidently stated to be without hereditary or acquired psychopathic tendency. The next series of cases (Cases 308-320) shows peculiar phenomena; e.g., monocular diplopia, shell-shock psoriasis, 50. Rehearsing more briefly these findings, what is the nature of these disorders? The literature is practically unanimous on the point: We have to do merely with the classical problem of the neuroses, and when all the data are some day united, we shall doubtless know a great deal more about the neuroses. 51. Locus minoris resistentiae. That the process, whatever else it does, is rather apt to pick out pre-existent weak spots in the patient (the habitual gastropath becoming subject to vomiting; the old stammerer stammering once more or even becoming mute; the man always “hit in the legs” by exertion, now becoming paraplegic) is obvious. The striking instances in which an old cured syphilitic monoplegia, or an old hysterical hemichorea, comes back under the influence of shell explosion in precisely the limits and with precisely the appearance of the former disease, indicate how various a factor may be the locus minoris resistentiae. 52. But, without weak spot, without acquired soil, without heredity, we must now erect the hypothesis that, the classical neuroses may in some, though certainly a minority of cases, afflict normal men. Under the war conditions of investigation touching the family and personal histories of the men, perhaps we should not be too sure of this hypothesis; but the army records will after the war allow us to make or break the point forever and thereby throw the clearest light upon the vexing problems of industrial medicine, wherein progress in general has been so slow on account of the partisanship of the corporation and plaintiff’s attorneys. 53. Purely psychogenic war cases exist: Though Shell-shock denotes, to say the least, shocks and shells—yet we know Shell-shock sans any shock and sans any shell, nay sans either shell or shock. The fact that a soldier may get war dreams though he has never been in the fighting zone and never by any chance observed the circumstance of war, or the fact that a man can become mute on the second day after a shell explosion because the night before he had dreamed of some hysterically mute patients in his ward—these facts again, although they argue a psychogenic origin for the phenomena of so-called “Shell-shock,” do not at all mean that actual physical explosion in other cases may not be tremendously important. 54. This is shown by the exceedingly interesting phenomena of localization or determination of symptoms to a given region under the special local influence of the explosion. Thus, in the schematic case, an explosion to the left of the soldier produces anesthesia and paralysis on the left or exposed side. Now and again a case will show such anesthetic and paralytic phenomena upon the side exposed to the explosion and some hypertonic, irritative phenomena upon the other side. One gets the figure in one’s mind of an organism fixed, immobile and numb, on the spot by the explosion—and the other half of the body, as it were, attempting to run away from the situation. One side of the body, as it were, plays ’possum, the other tends to flight. 55. Of course these physical phenomena should not blind us to the emotional ones. Now and then the multiple causes of a case may be analyzed, as, for example, one of blindness in which a series of factors emerged, such as excitement, blinding flashes, fear, disgust and fatigue. I cannot here go further into these details, and I need no longer insist upon the fact that surrounding the problem of Shell-shock means surrounding the problem of nervous and mental diseases as a whole, and that thus to be a Shell-shock analyst means to be a neuropsychiatrist. 56. The organic problems of the nervous system are brought up constantly in differential diagnosis, but the functional problems divide themselves up in a perturbing manner into a fraction properly termed the “psychopathic” (that is, after the manner of hysteria), and “non-psychopathic” (that is, after the manner of reflex disorders of Charcot, newly named “physiopathic” by Babinski). 57. For the moment we are not discussing differential diagnosis, but are merely trying to circumscribe the features we wish to call Shell-shock features: We have concluded to call them functional—but what is it to be functional? Too simple is the reply: Functional = Non-Organic. Inaccurate and misleading is the reply Functional = Psychic. We may more correctly express the situation, pathologically speaking, in the following categories (see chart, page 870): ORGANOPATHIC (Lesional, destructive): (a) gross, or (b) microscopic, or perhaps (c) chemical. DYNAMOPATHIC (functional, irritative, inhibitory,—but reversible ad originem): (a) psychopathic; (b) physiopathic (“reflex”). 58. As to the high psychic functions, we had thought of them as split in hysteria, in dissociation of personality. And we had roughly distinguished these conditions as psychopathic from conditions we called neuropathic, regarding the latter neuropathic disorders as on the model of the effects of cutting off or destroying certain necessary neurons. However clear or unclear we were as to the nature of the neuropathic, it does not here matter. Babinski’s point is that there is another kind of dynamic disease that operates, not after the manner of hysteria, but after a manner reminding one of the forgotten “reflex” disorders of Charcot—disorders that fitted the textbooks so poorly that the textbooks dropped them out. In short, what you might call the dynamopathic or functional in nervous disease has been shown to fall into two parts—a psychopathic fraction and a non-psychopathic fraction. Babinski calls this non-psychopathic fraction physiopathic or reflex. And these reflex or physiopathic disorders have a different order of curability from that of hysterical or psychopathic disorders. By what simple device did Babinski prove this? By chloroforming the patient. Under chloroform, when all the other reflexes were stilled, Babinski could bring out, in relief as it were, certain reflexes, or even hypertonuses, that were in the waking Whoever wins the great war from the military point of view, there can be no doubt as to what writers contributed most from the war data concerning the doctrine of hysteria, especially concerning the theoretical delimitation of hysteria from other forms of functional nervous disease: There can be no other answer than that, in theoretical neurology at least, the French have already won the war, if only by means of the remarkable concept set up by Babinski of the so-called physiopathic (that is, non-neuropathic and non-psychopathic). But how has this splitting of functional neuroses into psychopathic and physiopathic been rendered certain? By the tremendous modern sharpening of differential diagnosis dating from, e.g., the discovery of the Babinski reflex. This brings us to the brink of considerations concerning the differential diagnostic problem. First it may be well to regard the whole problem in the light of those mental diseases that we slid over when we were delimiting Shell-shock as against syphilis, epilepsy and somatic disease. 59. Why do some authors think of Shell-shock as an “officer’s disease”? It is clear that they cannot be thinking so much of the physiopathic cases as of the psychopathic ones. But psychopathic conditions are obviously more readily brought about in complex and labile apparatus. This point comes out strongly in relation with the comparative stability of the feeble-minded, at least of most feeble-minded, that get into war relations. The possible relations of Shell-shock to feeble-mindedness are of some interest. We know that Shell-shock picks out There are rumors of experiments to show that if in an aquarium containing some jelly fish alongside bony fishes, you explode a substance, the jelly fish ride through unscathed whereas the bony fishes are killed by the shock. The jelly fish presumably had too simple an organization. There is something to be said for the idea that in man also the higher and more complex specimens are more susceptible to Shell-shock, that is, to the neuroses of war, than are the lower and more simple combatants. Some statistics indicate that officers, who are in the main of a higher and more complex organization than the private soldiers, are much more susceptible than are private soldiers to the neuroses of war. Doubtless we shall not be able to verify these statistics until long after the war and, so far as I know, no very inclusive statistics have been presented. On the whole, I judge from the case history literature that the feeble-minded, unless they be of that very high level sometimes called subnormal, are not particularly susceptible to the neuroses. It is obvious that idiots and, for the most part, imbeciles, do not get into military service. As for what the English term the feeble-minded or what we in America are now terming morons, it may well be that our draft boards do not always exclude. High French authorities have specifically determined in certain instances that the high-grade feeble-minded would be perfectly suitable for certain branches of the service. There is the case, for example, of a sandwich man of Paris who somehow got into the French army and was being perpetually sent to look for the squad’s umbrella and the key to the drill ground, but sang and swung his gun with joy as he went to the front, and apparently did very well there. This man had been a state ward and, as you know, well-trained state wards are frequently exceedingly good at elementary forms of drill. Then there is another case of an obvious imbecile who was quite without any idea of military rank and often got punished for treating his superiors like his comrades and was the butt of his section, but on the firing-line remained cool, careless of danger—a magnificent example to his comrades—at last surrounded and taken prisoner. Here the story might have ended and the folly of enlisting imbeciles in the army might have seemed perfectly plain, except that our imbecile forthwith escaped from the Germans, swam the Meuse and got back to his regiment! Here then are cases in which the slight degree of hypophrenia—it seems unwise to give it the opprobrious title “feeble-mindedness”—would have been entirely inconsistent with the development of Shell-shock. Such men are, perhaps, too simple to develop neuroses. On the other hand, it would appear that certain of the slight degrees of hypophrenia, such as we might find in so-called subnormal or stupid persons, would prove capable of “catching Shell-shock” as it were, and then find themselves entirely incapable of rationalizing the situation. In short, there may be a group of psychic weaklings, just complex enough to fall into the zone of potential neurotics, but just simple enough to render the processes of rationalization (or what one author terms autognosis) and of psychotherapy in general entirely unavailing. After the war we may be confronted with a number of persons with their edges dulled by the war experiences. One has met even brave officers who, after months of furlough, still maintain that they will never get back to their normal will and initiative. Whether these hypoboulic persons have not been reduced to subnormality so as to resemble the slighter degrees of hypophrenia or feeble-mindedness can hardly be determined now. They will form important problems in mental reconstruction, for with the best will in the world, the occupation-therapeutist with all her technic, may be unable to force or coax the will of such hypoboulics into proper action. Nor will the ordinary environment of home and neighborhood turn the trick properly. Expert social work in adjustment, both of the returned soldier to his environment and of the environment to the returned soldier, 60. As for alcoholism, LÉpine’s figures bespeak its importance as a hospital-filler and a good deal of prime interest surrounding alcoholism has been developed in the war; but on the whole, so far as I can determine from the war case literature, there is little or no direct relation between alcoholism and Shell-shock, despite the fact that in a number of instances alcohol has complicated the issue and very possibly helped in a general demoralization of the victim. However, the alcoholic amnesias and particularly a few instances of the so-called pathological intoxication have exhibited a certain medicolegal interest, recalling what was just said above about the responsibility of a drunken epileptic. Alcohol remains, I should say, pending exact monographic work upon this topic, purely a contributory factor for the war neuroses. It must be that the exigencies of the war have prevented full reports of alcoholic cases; or perhaps they are regarded as of such every-day occurrence as not to demand case reports. The alcohol and drug group is represented by 17 cases (Cases 86-102). The so-called pathological intoxication is illustrated in Cases 86 and 87. Case 86 was entirely amnestic for an attack of hallucinations in which he tried to transfix comrades with a bayonet. Cases 87-97 are cases of disciplinary nature,—the majority from a German writer, Kastan. Case 88 illustrates desertion in alcoholic fugue, and Cases 90-92 are three further cases of desertion in alcoholism. Cases 94 and 95 give a partial explanation of some German atrocities. At least, here are cases in which the atrocities, with attempted murder and rape, are described more or less fully in transcripts of medicolegal reports. Case 98 throws a curious cross-light upon the war, in that a drunken soldier got an unmerited long leave after paying 100 sous for an injection of petrol in his hand. Cases 99-102 are cases of 61. That war makes nobody go mad in the asylum or lay sense of the term has been abundantly proved by the data of this war—and this conclusion is of value in our medical endeavors to establish a proper lay conception of the nature of Shell-shock. Consider first schizophrenia (dementia praecox). That the causes of dementia prÆcox, still unknown as they are, lodge more in the interior of the body or in special individual reactions of the victim’s mind, seems to be shown by the phenomena of this war, since there seems to be no great number of dementia prÆcox cases therein produced. To be sure, some schizophrenic subjects do get into the service, and sometimes their delusions and hallucinations get their content and coloring from the war. Thus a Russian, wounded in the army, developed delusions concerning currents running from his arm to the German lines and felt that he was, so to say, the Jonah of the Russian front, as he could determine shell fire to the spot where he was by the arm currents. Now and then a case shows a scientifically beautiful admixture of ordinary dementia prÆcox phenomena with the effects of shell wound or shock. A picturesque case from the standpoint of German psychiatric diagnosis is one of a soldier who boxed the ear of a kindly sister who tried to steer him from a room where the examination of another patient, a woman, was going on. On the whole, the eminent German psychiatrist who examined him felt that the case was really one of psychopathic constitution, as he had shown somewhat similar irascibility on a slight occasion before. However, much to the astonishment of all, the patient developed further symptoms. His ego got terribly swollen. At last he was fain to utter a denunciation of the entire Junkertum and of the Kaiser: he said in fact that he was an Inhabitant of the World and not of Prussia merely. Over here we allow such persons to edit newspapers and write books with impunity, but the eminent German psychiatrist, before mentioned, was constrained to alter his diagnosis of this cosmopolite from psychopathic constitution to dementia praecox! The group is represented by 16 cases (Cases 147-162). 62. There are four cases (Cases 148-151) of a disciplinary nature. The first (Case 148) was actually arrested as a spy because he was making drawings near a petroleum tank. Of two cases of desertion, one was due to a fugue of catatonic nature (Case 149), and the other (Case 150) was one of desertion with behavior suggesting schizophrenia. However, this man was determined to be responsible for his act, and condemned to 20 years in prison. This latter case might be considered also in connection with Group III (the epilepsies), Group IV (the pharmacopsychoses), and possibly Group XI (the unresolved psychopathias). Case 151 was likewise alcoholic and disciplinary: the man went so far as to keep a cigar in his mouth while the captain was rebuking him and was, in fact, an old sanatorium case, afflicted with some sort of degenerative disease, presumably dementia praecox. 63. That schizophrenic symptoms may be aggravated by service is shown likewise in the case that follows, namely, Case 152, a man who had been hearing false voices for some two years, had heard his own thoughts, and felt his personality changing. The military board decided that the mental disease had been aggravated by service. Case 153 might offhand be regarded as a malingerer, as he shot himself in the hand. Upon military review, a delusional state set in, and in the course of no very long time a state of schizophrenic apathy. In point of fact, however, this man had already been in several hospitals for previous examination, and had served in the army in relatively normal intervals. Case 154 is that of a dementia praecox who volunteered for three years in French infantry but forthwith gave indications of mental deterioration. This case of a dementia praecox volunteer may be compared with Case 36: that of a superbrave imbecile who swam the Meuse, back from a German prison; with Case 47, that of the feeble-minded person with an insubordinate desire to remain at the front; with Case 163, a maniacal volunteer; and Case 175, a neurasthenic volunteer. 64. Diagnostic questions are brought up by Cases 155-166, in the former of which Bonhoeffer made at first a 65. Schizophrenia may not only be aggravated by service, but as Case 157 shows, war experience may have a definite effect upon the content of hallucinations and delusions. Thus, a man wounded in the left shoulder built up the idea of currents running from his left arm to the Germans, such that if anything were touched by the arm, bombardment of the Russians would at once start up. The arm, in short, was charmed. 66. Psychopathic bravery is not shown in the feeble-minded only: Case 158 is that of an Iron Cross winner who, after an hysterical-looking attack with hallucinatory reminiscences of a Gurkha whom he had bayoneted, turned out to be hebephrenic. Case 159 might at first sight have been placed among the encephalopsychoses on account of the trauma to the occiput, and in fact the mystical hallucinations shown were of a visual nature (a rainbow-colored bird with the face of the Holy Virgin). In point of fact, there was probably no causal relation between the mystical delusions and the brain injury. 67. Case 156, above mentioned, might perhaps be interpreted as one of Shell-shock dementia praecox, but the interval of nine months, though filled with hysterical symptoms, is decidedly long in which to suppose that shell-shock factors could be in process of causing dementia praecox. Cases 160 and 161 are more suspicious. Six German soldiers were killed by a German shell within the zone of German fire, two steps away from the subaltern officer (Case 160), who carried on for some hours, made his report duly, but thereafter developed tremors and lost consciousness. According to Weygandt, the case is one suggestive of dementia praecox, but 68. To sum up concerning the schizophrenias (dementia praecox group), there are cases of great disciplinary interest in which alleged espionage and desertion turn out actually to be schizophrenic phenomena. Again, there are interesting diagnostic problems in the differential diagnosis of hysteria and catatonia. There is evidence that experience in the war may be woven into the hallucinatory and delusional contents of cases of pre-existent psychosis. 69. As to the important question whether shell-shock can initiate dementia praecox, the evidence from these reported cases is against the hypothesis; but if the query be, whether Shell-shock might not aggravate dementia praecox, it may be stated that a military board has decided that dementia praecox may be aggravated by some forms of military service. There is no reason to suppose that shell-shock factors might not operate in this way. Cases 152 and 162 will be of service in the proof of this contention; and Case 162 seems to be definitely one in which a latent schizophrenia, showing itself in one ante-bellum attack, was liberated once more after shell-shock. Of course, the plan of this book and the method of choice of its cases precludes any statistical conclusions 70. Nor can the cyclothymias (manic-depressive psychoses) be charged up to war factors to any important extent. On account of the somewhat close resemblance between the phenomenon of manic-depressive psychosis and what we ordinarily feel ourselves—a logical situation reflecting merely the fact that the phenomena of over-activity (mania) and of under-activity (depression) are merely quantitative variations from the normal—it might be supposed that the war life and its shock and strain would start up the cyclothymias in some numbers. Why should not a shell explosion start up a mania or throw a man into a depression? In point of fact the literature somehow does not agree with this presupposition. Some years ago in Massachusetts a brief investigation was made of the assigned causes of the successive attacks in a great number of cyclothymic (manic-depressive) cases, and it was found that each successive attack progressively had less of the physical in the previous history. Something like 45% of all the first attacks had a pretty obvious cause in the soma, such as a kidney disease, a heart disease, a puerperal condition and the like, but the second attacks failed to show even 20% of such obvious somatic causes, and the third attacks even less than 10%, and so on. Now war conditions and even the shell explosions themselves have apparently not set up any such conditions as those of mania or of depression. Most of the instances of cyclothymia are instances of men who are cyclothymic before they enter the army. These experiences, when after the war we can sift them all out, may allow us to form better ideas as to the etiology of many of the psychoses, and the great war may thus prove a gigantic experimental reagent which will aid in solving some of the major problems of mental hygiene. 71. The cyclothymic or manic-depressive group is represented in strikingly few cases, seven in number (Cases 163-169). To sum up concerning the cyclothymias: War stress seems to have had singularly little effect in the production of fresh attacks, and so far as we are aware, no effect in starting up a manic-depressive diathesis, unless Case 167,—that of the naval officer who distinguished himself in land battles,—looks in that direction. It is, of course, to be conceded that hypomania might readily be overlooked under war conditions, and that suicidal melancholias, belonging in this group, might be interpreted as natural war-made depressions. Very possibly, therefore, this result (running to the effect that the cyclothymic forms of mental disease are rare in military life) may need revision. 72. Summary of general considerations concerning the nature of the Shell-shock neuroses (paragraphs 40-71). Having (a) roughly delimited the Shell-shock neuroses from syphilis, epilepsy, and somatic disease, we inquired (b) What, after all, are functional neuroses? We remained dissatisfied with a definition by negatives. But we found that (c) practically the problem seemed to reduce to telling the organic apart from the functional and we found that (d) in almost all cases we have to raise the hypothesis of the organic. Also that (e) the absence of external injury is no guarantee against the existence of internal injury. Also that (f) cases are frequent enough in which organic and functional phenomena are combined. Also that (g) essentially functional cases may be peritraumatic or metatraumatic (in the sense of Charcot’s hysterotraumatism). But (h) the statistical majority of cases remains essentially functional. (i) We then looked over a series of cases developing incidentally in the war and (j) we compared these with the war cases, the latter arranged cephalad. Note arrow lengths: Practically we find shell-shock neuroses very different from certain functional (or but mildly organic) disorders and not so different from certain seriously organic disorders. SCHIZOPHRENIA <--- CYCLOTHYMIA MORONITY ALCOHOLISM SHELL ---------> SHOCK NEUROSES NEUROSYPHILIS EPILEPSY SOMATOPATHY Note arrow lengths: Theoretically, shell-shock neuroses, being presumably in large part functional, ought to ally themselves more closely with the left-hand group than with the right-hand group. But they do not! In short, these functional diseases are not so hard to distinguish from various other functional diseases as they are from certain organic diseases. The most serious diagnostic problem is between the war neuroses and organic brain disorders. Chart 18 |
| e.g. neurosyphilis paretica ORGANO- PSYCHOPATHIC | Hysteria e.g. DYNAMO- PSYCHOPATHIC |
| ORGANO- NEUROPATHIC e.g. neurosyphilis tabetica | DYNAMO- NEUROPATHIC Babinski’s “reflex” or physiopathic disorders e.g. |
A frequent error of neurologists has been to identify “functional” with “psychic” when it came to a question of the classical functional neuroses. The above diagram indicates that “functional” contains more than “psychic.” Doubtless much that goes under the name “unconscious” belongs in the right lower quadrant of this diagram. See discussion in text.
(k) We found many war cases showing emphasis, reminiscence, or repetition of ante-bellum phenomena (weak spots, locus minoris resistentiae, imitation), but
(l) we also found that perfectly sound untainted men could succumb to Shell-shock neurosis.
(m) We found a few purely psychogenic cases without sign or suspicion of physical shock.
(n) We studied the localization (traumatotropic) group.
(o) We arrived, with the aid of Babinski, at the necessity of splitting functional cases into psychopathic and physiopathic.
73. Summary of general considerations: continued.
We found ourselves looking on the Shell-shock neuroses as, like other functional neuroses, in a sense mental diseases. Perhaps we would better say (to get rid of all suspicion of medicolegal “insanity”) that the Shell-shock neuroses seemed to us in some sense psychopathic. But, though the Shell-shock neuroses looked psychopathic and were presumably more functional than organic in nature, it was a curious thing that, practically speaking, the Shell-shock neuroses proved to be farther away from the more functional of the psychoses than from certain organic psychosis.
In particular, we found reliable authors insisting on the practical diagnostic necessity of excluding syphilis, epilepsy, somatic disease—whereas the nature and causes of the Shell-shock neurosis seemed theoretically to withdraw them most remotely from that triad of mainly organic disorders. By the same token, theoretically one might have supposed these Shell-shock neuroses to draw very near to those far less organic disorders (schizophrenia, cyclothymia, feeble-mindedness (i.e., the slighter degrees likely to be found in military service, alcoholism))—yet practically few large diagnostic problems came to light as between the Shell-shock neuroses and the tetrad of dynamic or lightly organic diseases above listed.
74. Diagrammatically this situation is presented in Chart 17.
But why should the Shell-shock neuroses seem so “organic”? Partly, it is probable, because the term
(a) Organic mental (cortical), e.g., general paresis.
(b) Functional mental (cortical), e.g., hysteria.
(c) Organic neural (subcortical), e.g., tabes dorsalis.
(d) Functional neural (subcortical), e.g., “reflex” disorders.
Diagnostic Differentiation Problem
75. Having disposed of the problem of the rougher Delimitation of the Shell-shock neuroses, we approach the problem of their finer Differentiation. For the sake of the present argument we propose to regard the Shell-shock neuroses as essentially Dynamopathic, i.e., functional whether in the ordinary mind-born (psychogenic) sense of classical hysteria or in the modern nerve-born (neurogenic) sense of Babinski. The problem of this differentiation will accordingly be that between the dynamopathic and the organopathic.
In the orderly diagnosis of mental disease, from the standpoint of the major orders or groups, we ordinarily come at this point to the focal brain diseases. In analyzing the neuro-psychiatric problem of a so-called Shell-shocker, it is, of course, our bounden duty to exclude syphilis. Even though the percentage of syphilitic victims of Shell-shock is not high, yet these cases promise so much from treatment that they deserve to get their diagnosis as early as possible, and the English workers who have worked most in the syphilitic field insist upon this point.
We next proceed, as above indicated, to the elimination of hypophrenia with all the various grades of feeble-mindedness. Thirdly, we try to exclude the various forms of epilepsy; and fourthly, the effects of alcohol, drugs and poisons.
In ordinary civilian practice, such as that at the Psychopathic Hospital, the orderly elimination for diagnostic purposes of the great groups of the syphilitic, hypophrenic (feeble-minded), epileptic and alcoholic, leaves us with cases in which there either is or is not important evidence of organic
76. But the nervous and mental cases almost one and all give rise to the suspicion at least of organic disease, possibly traumatic in origin. Even when a man falls to the ground without a scratch upon his skin, there is some question whether in his fall he has not sustained some slight intracranial hemorrhage which the lumbar puncture fluid might show. Add to this that the signs of hysteria are very often unilateral, and it will readily be conceived how much like an organic case an hysteric in the casualty clearing station may look. Rapid decision may be necessary in order to get immediate effects in psychotherapy a few minutes or hours after the shell explosion, and one may need to choose between applying a possibly unsuccessful psychotherapy forthwith and making a thorough neurological examination. As Babinski has pointed out, making a thorough neurological examination gives opportunity for all sorts of medical suggestion to be conveyed to the patient. It would appear that many an hysterical anesthesia has been given to a patient by the very suggestion of the physician testing sensation. Here one does not refer to malingering in the conscious and designed sense of the term, but to the operation of some genuinely psychopathic, that is to say, hysterical process.
77. In the case of head injury, naturally the majority of nerve phenomena will ordinarily be upon the opposite side of the body to the side of the head that is injured. The reverse situation holds for hysterical cases, wherein it would appear that the bursting of a shell, let us say upon the left side of the body, seems to determine contractures, paralyses and anesthesias to that same left side of the body; now and then complicated cases appear which put the neurologist through his best paces. Such a case is that of a man who was wounded on the left side of the head and promptly developed
It is not only at the casualty clearing stations and along the lines of communication that the difficulties in telling Shell-shock in the neurotic sense from traumatic psychosis and the effects of focal brain lesions are found, since the literature amply shows that diagnostic problems remain open for weeks or months in the various institutions of the interior, to which all the belligerents have been forced to send their cases.
78. A glance at the differential tables that have been developed, for example, by the French neurologists, will show how fine the diagnosis betwixt a hysterical and an organic disease may be, especially when we consider how often there are admixtures of the two. The rule holds for the vast majority of cases that absolute bullet wounds or shrapnel wounds do not produce Shell-shock; and the statistical story is so clear that one might almost think of the wounds as in some sense protective against shock, that is, against Shell-shock, not against traumatic or surgical shock. Nevertheless, by some process whose nature is obscure, the hysteric is apt to pick up some slight wound and, as it were, surround this wound with hysterical anesthesia, hyperesthesia, paralysis or contractures.
The chances are, if we should collect all our civilian cases of Railway Spine and of industrial accident with traumatic neuroses, we should be able to prove this same strange relation between slight wound in a particular part of the body and the local determination of hysterical symptoms to that region. Of course, the determination follows no known laws of nerve distribution to skin or muscles, and the effect is apparently a psychopathic or, at all events, a dynamic process without clear relations to the accepted landmarks.
I do not mean to suggest, that aside from the hurry of war, the differential diagnoses here are more difficult than those in civilian practice; but the difficulties are at least as great as those that have faced the civilian practitioner. What needs emphasis is that just because we have concluded that the statistical majority of the cases of so-called Shell-shock belongs in the division of the neuroses, we should not feel too cock-sure that a given case of alleged Shell-shock appearing in the war zone or behind it is necessarily a case of neurosis.
After the early “period of election” for psychotherapy in the war zone has passed, there can be no excuse except general war conditions for not according to every case of alleged Shell-shock a complete neuropsychiatric examination, having due regard to the ideas of Babinski concerning medical suggestion of new increments and appendices to the original hysteria, developed in battle or shortly thereafter.
We have, however, been able to find in the literature good instances of puzzling diagnosis in which such conditions are in evidence as acute meningitis of various forms, hydrophobia, tetanus, and the like.
Especially in the diagnosis against Shell-shock hysterias we may need to think of the abnormal forms of tetanus, to which an entire book in the Collection Horizon has been devoted. The differential diagnostic tables here draw up distinctions between local tetanus, involving, let us say, the contracture of one arm, as against a hysterical monoplegia.
79. The focal brain group of psychoses here termed encephalopsychoses, is illustrated by a comparatively short series of cases, 16 in number (Cases 103-117). Many more cases of this group are presented in Section B, On the Nature and Causes of Shell-shock. The motive here is to show sundry effects of focal brain lesions produced in the war and not related with shell-shock. Case 103 was the curious case (see above) of aphasia with hemiplegia—not upon the right side, but upon the left side. There had been a wound in the left parietal region, and the aphasia was presumably consequent upon a direct affection of the left hemisphere. On the other hand, the left-sided hemiplegia may probably be regarded as due to lesions on the right side of the brain produced
80. Case 104 might perhaps better be considered in the section on alcoholism, since a gun-shot wound of the head may be regarded as having produced intolerance of alcohol in the classical manner, similar to that described in Case 97, wherein, however, the trauma was ante-bellum. Peculiar crises associated with cortical blindness, vertigo, and hallucinations, characterized a case of brain trauma by bullet (Case 105). Case 106 is that of a Tunisian, who before the war had had a number of theopathic traits with mystical hallucinations, but after a gun-shot wound of the occiput developed lilliputian hallucinations and micromegalopsia.
81. Cases 107-112 are cases of infection or probable infection. Cases 107 and 108 are instances of meningococcus meningitis, the second of which appears to have followed shell-shock (?). Case 107 led to psychosis with dementia. Case 109 developed a meningitic syndrome, which followed shell explosion a metre away, the syndrome lasting 14 months. The spinal puncture fluid was several times found to contain blood. There was apparently no infection of the fluid as in Case 112. Possibly Case 109 should be set down as an unusual example of shell-shock psychosis, chiefly dependent upon meningeal hemorrhage.
82. A syphilitic (Case 110) in which appropriate tests were made and found positive, showed at autopsy a yellowish abscess or area of softening in the right hemisphere. The curious point about this case was that the only neurological
83. Case 112 is the one noted above of infection of the spinal fluid. It is the only case of infected meningeal hemorrhage observed by Guillain and BarrÉ in a wide experience. As a rule, these hemorrhages remain aseptic and have a favorable prognosis. The organism cultivated from the spinal fluid proved to be the pneumococcus. Case 113 yielded a somewhat remarkable phenomenon and perhaps would be more logically considered in relation with the series of cases in Section B that show the picking up of ante-bellum weak spots (Cases 287-301); for this subject had had two serious affections of the brain ante-bellum. He had had a poliomyelitis at five, affecting the left leg, and he had had a right hemiplegia with aphasia following pneumonia, at 20. He was struck (but apparently not wounded) by shrapnel on the right shoulder, and developed athetotic movements of the right hand, as well as a general weakness of the left leg. In this case, according to Batten, the stress had been sufficient to bring into prominence symptoms due to an old cerebral lesion. Whether the mechanism in this case is hysterical is doubtful.
84. That not every case of hemianesthesia is hysterical is suggested by Case 114, in which the diagnosis of hysteria was actually made; but the diagnosis was soon rendered doubtful by the fact that there was no evidence of autosuggestion or heterosuggestion. Other phenomena make a diagnosis of thalamic hemianesthesia more likely.
85. Although Shell-shock is not the subject of this section, yet a case of syndrome strongly suggesting multiple sclerosis is here inserted, following shell-shock (Case 115). The
86. Differential Diagnosis between Organic and Hysteric Hemiplegia. Babinski, 1900.
| Organic Hemiplegia | Hysterical Hemiplegia |
|---|---|
| 1. Paralysis unilateral. | 1. Paralysis not always unilateral; especially facial paralysis, usually bilateral. |
| 2. Paralysis not symptomatic., e.g., in unilateral facial paresis, the paresis occurs also when bilateral synergic movements are being performed. | 2. Paralysis sometimes symptomatic; facial paralysis almost always symptomatic. With complete unilateral paralysis, the muscles of the paralyzed side may function normally during the performance of bilateral synergic movements. |
| 3. Paralysis affects voluntary, conscious, and unconscious or sub-conscious movements; hence, (a) platysma sign, | 3. Voluntary, unconscious, or sub-conscious movements not disordered. Absence of platysma sign and combined flexion of thigh and trunk. The active balance movements of arm may be lacking but there is no exaggeration of passive balance movements. |
| 4. Tongue usually slightly deviated to the paralyzed side. | 4. Tongue sometimes slightly deviated to the paralyzed side; but sometimes contralateral deviation. |
| 5. Hypertonicity of muscles, especially at first. The buccal commissure may be lowered, the eyebrow lowered; there may be exaggerated flexion of the forearm, and the sign of pronation may occur (hand left to itself lies in pronation). | 5. No hypertonicity of muscles. If facial asymmetry exists, it is due to spasm. No exaggerated flexion of forearm, and no pronation sign. |
| 6. Tendon and bone reflexes often disturbed at the beginning, either absent, weakened, or exaggerated (almost always exaggerated.) In many cases, there is epileptoid trepidation of the foot. | 6. No alteration of tendon or bone reflexes. No trepidation of the foot. |
| 7. Skin reflexes usually disordered. Abdominal and cremasteric reflexes, especially at first, weakened or abolished. On stimulation of sole, toes, and especially the great toe, are extended on the metatarsals. Babinski toe reflex. Extension of great toe often associated with abduction of other toes (fan sign). Sometimes exaggeration of reflexes of defence. | 7. No disturbance of skin reflexes. Abdominal and cremasteric reflexes normal. Babinski toe reflex and fan sign absent. Defense reflexes not exaggerated. |
| 8. Contracture characteristic and non-reproducible by voluntary contractions. The hand-grip yields a sensation of elastic resistance, automatically accentuated on passive extension of the hand. | 8. The contracture can be reproduced by voluntary contractions. |
| 9. Evolution of diseased regular contracture follows flaccidity. When regression of disorder occurs, it is progressive. Paralysis not subject to ups and downs (motor defect fixed). | 9. Evolution of disease capricious. Paralysis may remain indefinitely flaccid or may be spastic from the beginning. Spastic phenomena may sometimes be associated (particularly in the face) with characteristic phenomena. The disorder may get better and worse alternately several times, alter rapidly in intensity, and present transitory remissions which may last even but a few moments (motor defect variable). |
87. Differential between Reflex (Physiopathic) Contracture and Paralysis, and Hysterical Contracture and Paralysis. Babinski, 1917.
| Reflex | Hysterical |
|---|---|
| 1. Paralysis usually limited but severe and obstinate even when methodically treated. | 1. Paralysis usually extensive but superficial and transient if treated. |
| 2. In the hypertonic forms attitude of the limb does not correspond to any natural attitude. | 2. The hysterical contracture as a rule resembles a natural attitude fixed. |
| 3. Amyotrophy marked and of rapid development. | 3. Amyotrophy, as a rule, absent, even when the paralysis is of long standing. If existent, it is not marked. |
| 4. Vasomotor and thermic disorder often very marked, accompanied by an often very pronounced reduction in amplitude of oscillations measured by oscillometer. | 4. There may be thermo-asymmetry but it is slight. There are no very characteristic vasomotor disorders nor modifications in amplitude of oscillations. |
| 5. Sometimes very marked hyperidrosis. | 5. No sharply defined hyperidrosis. |
| 6. Tendon reflexes often exaggerated. | 6. No modifications of tendon reflexes. |
| 7. Hypotonia sometimes very well marked, and in arm paralysis main ballante. | 7. Hypotonia absent. |
| 8. Mechanical over excitability of muscles, often accompanied by slow response (?). | 8. Over-excitability of muscles absent. |
| 9. Fibrotendinous retractions of rapid development except in the rare completely flaccid forms. | 9. No retractions even if paralysis is of long duration. |
| 10. Trophic disorders of bone, decalcification of the hairs and of the phanÈres. | 10. No trophic disorders. |
88. The section on Shell-shock diagnosis contains 102 cases (Cases 371-472). These cases differ in no respect from those of Section B except that many of them are more puzzling and dubious and have been presented by their reporters more from the standpoint of diagnosis than from that of etiology or therapeutics. In general arrangement, the cases roughly correspond to those of Section B. First are four cases illustrating the value of lumbar puncture data (Cases 371-374). There follow cases with either a mixture of organic and functional symptoms, or such a constellation of symptoms as might readily lead to erroneous diagnosis (Cases 375-381). Retention and incontinence of urine after shell-shock are illustrated in Cases 382-384. Crural monoplegia, monocontractures, and other affections of one leg are shown in Cases 385-392; but these monocrural cases are in many respects peculiar or even unique as compared with the monocrural cases of Section B. Peculiar paraplegias or spasms affecting both legs are found in the series 393-395. Then follow (Cases 396-400) other cases of doubtful spinal cord lesion or shock, including several with dysbasia. Camptocormia, astasia-abasia and abdominothoracic contracture are found respectively in 401, 402, and 403. Affections of one arm follow (Cases 404-409). An assortment of peculiar cases in which the differentiation between hysteria and
General Nature of Shell-shock
89. We are now ready to consider in how far Shell-shock
The physical event, shell-shock, has likewise caused focal irritative and destructive brain disease, spinal cord disease, peripheral nerve disease; and many well-recognized species of the so-called “organic” diseases of the nervous system have been produced. Shell-shock “organic” diseases have proved as difficult to tell from all sorts of Shell-shock “functional” diseases as ever have been the organic and functional analogues of these diseases in peace practice.
But, besides (a) sharing in the cause of mental and nervous disease (in the sense of “Shell-shock” general paresis and “Shell-shock” tabes, wherein at least one other factor, viz. the spirochete, is known to be at work) and (b) producing mental and nervous disease by killing or weakening or sensitizing neurones in the classical manner of the “focal” lesion, the physical event, Shell-shock, (c) appears able to bring out the subtler diseases and dispositions of mind which we term psychoneuroses, that is, hysteria, neurasthenia, psychasthenia. Just as we have for years spoken of “traumatic” psychoneuroses, so we may now speak of “Shell-shock” psychoneuroses—nor should anyone believe we cheat ourselves with the idea that the adjective “Shell-shock” has helped us more re genesis than the adjective “traumatic.” “Shell-shock hysteria” and “traumatic hysteria” are on precisely the same—slippery—footing in the matter of their origin. The physics and chemistry of the psychoneuroses remain in Egyptian darkness.
The physical event, shell-shock, then, as the common man might say, affects body, brain, and mind in a great number of familiar ways; and these familiar ways remain as plain or as blind as the neuropathology and the psychopathology of today leave them. If thunderstorms and earthquakes got suddenly more frequent, we should have numbers of “lightning neuroses” and “earthquake hysterias,” neither of which would render the physics and chemistry of the psychoneuroses immediately a whit clearer.
When the common man speaks of some one as suffering from lightning stroke or earthquake, he is entitled to be met halfway by his hearer, who readily understands that the victim is suffering some sort of transient or permanent effects of the stroke or quake. In a like common sense should the term shell-shock be taken. Stroke, quake, or shock, each physical event is recognized as a factor in the situation. An event has become a factor. A condition for which the noun “shell-shock” was descriptive, in the present tense of some event, has passed into history; and the adjective “shell-shock” is now explanatory of the past cause, or one of the past causes, of a new situation. Shell-shock, the physical
But what are these pathological events, viz., the conditions of disease, that supervene? So far, in our consideration of psychoses incidental in the war, we have found Shell-shock varieties, perhaps, of mental disease; again, possibly a few Shell-shock species, using both these terms, variety and species, in a quasi botanical or zoÖlogical sense. But in either instance we do not rise, under the ordinary principles of nomenclature, beyond the adjective: Is there any evidence that shell-shock, the physical happening, has issued in a pathological event of greater dignity, namely, a genus of disease? Can shell-shock rise to the dignity of a proper noun, Shell-shock, so that we might think of e.g., a new genus of the psychoneuroses, something coÖrdinate with hysteria, neurasthenia, psychasthenia? None, I believe, has the hardihood to propose a new genus of mental or nervous disease for Shell-shock regarded as a pathological event. A fortiori, it is unheard-of to think of Shell-shock, the pathological event, as representing a new order of such events, coÖrdinate with the psychoneuroses or the epilepsies, for example.
Shell-shock, the pathological event, we conclude, is a variety or a species, hardly a genus or an order of mental or nervous diseases. If we can keep in mind the obvious distinction between shell-shock, the physical event, and Shell-shock, the pathological event, we shall save ourselves much trouble. And if we can apply the ordinary criteria for the differentiation of the great groups (or orders) and the lesser groups (or genera) of mental and nervous disease to the given concrete case, we shall not go far wrong therapeutically in any case of so-called Shell-shock. For Shell-shock, the pathological event, becomes a humble variety or species of disease whose therapeutic indications are in larger part those of higher and comparatively well-recognized genera of disease, e.g., hysteria, neurasthenia, psychasthenia.
A shock is not a smash, a crush, a breach. A shock literally shakes. The shaken thing stays, for a time at least. Shaken up or down, the victim of shock is not at first thought
If this thought is in the backs of our minds as we think of Shell-shock, it can readily be seen why the “organic,” that is, non-reversible diseases, do not take kindly to the term Shell-shock. Shell-shock, the pathological event, prefers to be an item in the pathology of function. Can we further specify? The pathology of function, neuropsychically taken, considers such great groups as the psychoneuroses; (so far as we know) the cyclothymias; some of the symptomatic psychoses; a portion of the alcohol and drug group; some of the epilepsies; perhaps the dementia prÆcox group; not to mention various unresolved psychopathias. The psychoneuroses are the group most innocent of every “organic” taint: the machinery is assumed to be most normal in them and presumably the effects of disorder most reversible.
Shall we not therefore accept the psychoneuroses as the group in which to place those pathological happenings called Shell-shock? It will do no harm to make this choice if we do it humbly in the spirit of acknowledgment that we know next to nothing about the psychoneuroses. The psychoneuroses should fall on their knees to Shell-shock rather than that Shell-shock make obeisance to the psychoneuroses. For what is a psychoneurosis? It is a functional disease of the nervous system in which the mind plays an important part—it is also probably much else. But the “much else” is as likely to be found in Shell-shock as anywhere else during these particular years.
Thus, rehearsing in a broad way the case arrangement of Section B, we find, first, autopsied cases and cases with lumbar
90. At the outset of Section B (Shell-shock: Nature and Causes), we face the question of the possibly organic nature of Shell-shock. It is safe to say that the vast majority of cases of Shell-shock do not die of Shell-shock, and the collection of material from true Shell-shock cases that are killed by accident or intercurrent disease has proved a matter of great difficulty under military conditions. Of course, it is possible to answer the question À priori, by agreeing that any case with structural lesion of whatever sort, is by the same token not a case of Shell-shock.
91. Apparently the most informatory case yet presented is that of Mott (Case 197). In this case, death came in 24 hours, and the immediate cause of death was doubtless a small hemorrhage of the spinal bulb. There was a congestion of veins in the bulb, as well as a congestion of the pia mater over all other parts of the brain. Nor was the bulbar hemorrhage unique, for there were a number of superficial punctate hemorrhages. In short, the brain was not even grossly normal, such as one might desire in a case of true Shell-shock as conceived by À priori workers. Yet, according to Mott, there are microscopic changes of an intimate nature that lie nearer to the microscopic possibilities in true Shell-shock. For example, in the bulb itself there was a distinct and photographable change of nerve cells: the vago-accessorius nucleus had cells in a state of chromatolysis. The internal alterations of these cells, with dissolution of chromatic material, may
92. Particularly important is the question, how frequently such hemorrhages as those found by Mott in Case 197 occur. Cases are given in the text which show such hemorrhages.
Rather often quoted in this relation is Case 201, a case of Sencert, in which a shell exploded one metre away from a soldier and injured him so that he died that night through the bursting of the pleura of both lungs within a thoracic
93. A case of Chavigny’s (Case 198), in which there was an extremely careful autopsy, showed a strongly blood-stained cerebrospinal fluid; in fact, there was an intradural hemorrhage, though of minor degree and possibly not the cause of death; and throughout the brain substance there were slight hemorrhagic points. But there was no sign whatever of fracture of the cranial vault or base. Another case of similar meningeal hemorrhage but sharply localized, was Case 199, an instance of minor explosion in which neither skin nor muscles,
94. Case 200 seems to bring proof that there may be areas of gross softening within the spinal cord produced by the concussion of the cord from shell-burst, although there had been no fracture of the spine itself and no penetration of splinters of shell or of bone into the spinal canal or the substance of the cord itself. The argument here is that the tissues that lie between the agent of violence and the interior of the spinal cord are affected en bloc by the impact, the resultant gross or molar lesions being several millimetres or centimetres from the point reached by the impinging body or force. How complicated such a situation might be, we may recall from a case previously studied, namely, Case 103 (Lhermitte), wherein a missile struck the left side of the skull and produced lesions beneath its point of impact, but at the same time apparently caused a contre-coup effect upon the opposite hemisphere. That particular case did not come to autopsy, but Lhermitte’s explanation of its queer association of aphasia with ipsilateral hemiplegia seems sound enough. In fine, what with the mechanical trauma to which many victims of shell explosion are subject, what with the findings in sundry autopsies, and what with the determination of hemorrhage in the spinal fluid early after the shock, it might be conceived that the majority of cases of Shell-shock are actually cases of mechanical injury to the brain or spinal cord in which hemorrhage or laceration and overriding of neuronic tissues would be found. Nor would such a hypothesis be prima facie absurd with the evidence afforded by certain cases of Shell-shock having an admixture of reflex phenomena and other symptoms proved by the older neurologists to be beyond peradventure organic. (Compare, for example, such a case as that of Case 210, with herpes zoster and segmentary symptoms.) It should be remembered, however,
95. Especially good instances of this co-existence of functional and organic symptoms are found in ear cases; and it may be suspected that when, after the war, all these data can be suitably gathered and compared, it will be from the field of otology that some of the most fruitful hypotheses will be developed. In the cases of Shell-shock deafness, mechanical peripheral factors are admixed with central factors in phenomena admitting in some ways more exact diagnosis than in other fields. We may await the correlation of these data by some worker, equally skilled in otology and neurology, with the profoundest interest. Analogous results may be hoped from a correlation of neurological and ophthalmological conceptions.
96. Suffice it to say that the differentiation of organic and functional phenomena has long been possible on the basis of what we know concerning various reflexes (e.g., the Babinski reflex and its congeners); and the net result of this work is that the majority of Shell-shock cases,—that is, cases in which the physical factor shell-shock has entered,—are probably not cases in which a coarse organic disease could be
97. But if we give up the hypothesis of organic disease of the nervous system (that is, the hypothesis of coarse lesions, small or large, conceived to be the direct effect of mechanical impact), can we incriminate any other factor? Chemical factors from the gas of bursting shells may be thought of; yet in abundant cases there is no evidence that these have been in play. They and a variety of other special causes may be found working in a few instances but have nothing to do with the moot question.
98. Upon giving up the organic hypothesis, the modern functionalist is very apt to run directly into the embrace of hysteria. If a thing is not physical, it must be psychical in its genesis, so runs the argument. What, after all, is a neurosis? We mean ordinarily by neurosis, something functional rather than structural. We often mean something psychical rather than peripheral. Accordingly, as we have seen, many
99. Case 253, a case of Tinel, may serve to illustrate this point. Tinel’s patient was not subject to shell-shock at all, but was wounded in the arm. Three weeks later, he was able to flex his forearm only by means of the supinator longus. It was found that the biceps was soft and flaccid, though the electrical reactions of the biceps were normal. Now, since flexion of the forearm is normally produced by a synergic contraction of the biceps and supinator longus, the situation in Tinel’s case was striking in that the functions of the biceps and supinator longus had been separated out by a process which could not be hysterica. The hypothesis is that in hysteria it has always been found impossible to split the synergic action of these two muscles. What has happened? In Tinel’s picturesque phrase, the biceps muscle has been stupefied by a process which involved no destruction of a nerve trunk or any important nerve elements. This process of stupefaction passed away with a few weeks’ massage and rhythmic faradism. But what is this process of stupefaction, as Tinel calls it? No definite answer can be given. But is not the process analogous to what may happen in a variety of cases of shell explosion in which, for one reason or another, sundry neurones are, as it were, stupefied, stunned, anesthetized, or thrown out of gear by some internal physico-chemical readjustment of unknown nature? Perhaps that readjustment, though in Tinel’s case it probably took place within the tissues of the arm itself, is analogous to the chromatolytic process in nerve-cell bodies suspected by Mott to be at the bottom of certain Shell-shock symptoms as in Case 197.
100. Are there, then, phenomena of peripheral nerve shock analogous to the phenomena of spinal cord and brain shock which we find in so many cases? But if so, it is clearly unnecessary, and indeed injurious for us to conceive that cases proved not to be organic must necessarily be hysterical.
101. Babinski has been able to bring into the light of observation the morbid operation of certain of these reflex arcs. Even in cases where in the waking life the central nervous system is able to overpower the reflex arcs in question and permit the limb or limbs to work reasonably well and smoothly, the process of chloroform anesthesia will quickly bring out an odd and unsuspected interior situation. The chloroform suspends the operation of numerous neurones, including those that have to do with the downflow of cerebral inhibitions, those silent streams of impulse that serve to keep the knee-jerks, for example, in leash. Now at a time when all the other muscles of the body are relaxed, the withdrawal of the cerebral inhibitions by chloroform anesthesia may cause a phenomenon to appear in certain reflex arcs that argues an excess of activity; thus in the leg, for example, an ankle-clonus, or a patella-clonus, or a degree of contracture,
102. Practically speaking, also, it is important not to consider every functional situation hysterical, since the non-hysterical functional changes may be extremely obstinate to treatment. Both physician and patient suffer if the patient is treated along psychotherapeutic lines for hysterical symptoms, some of which turn out on investigation to be functional enough but non-psychic. The peculiar configuration of symptoms shown in cases with the physical shell-shock or its equivalent, is perhaps dependent upon what neurones are locally affected. If there has been good evidence of near-by explosion or of wound, it will be especially important to learn just what parts of the nervous system and just what synergic neurones and other structures were affected. Whether the process within these neurones be one analogous to the dissolution of chromatin, or whether the process is more like one of narcosis, or narcosis and stupefaction, or whether the process is more like that of a stun, or like the plight of the nerves in a foot for a long time “asleep,” it may be impossible to say; but it is entirely unnecessary to soar directly to the higher mental process, unnecessary in short, to assume a hysterical dissociation when the dissociation may be far lower down in the nervous system.
The Treatment of Shell-shock Neuroses
103. We have pictured the practical situation in which the neuroses of the war find themselves—a situation bristling with diagnostic difficulties. The great proposition deducible therefrom is,
The diagnostic problem in Shell-shock is the diagnostic problem of neuropsychiatry at large.
The neuroses of war have this in common with the neuroses of peace—that they need to be distinguished from all other nervous and mental diseases. One cannot be a specialist in Shell-shock unless one is a neuropsychiatric specialist; even the neuropsychiatrist has much to learn from the internist, the orthopedist, the neurosurgeon, as well as from the psychologist.
But however wide the diagnostic field for Shell-shock, the therapeutic field is wider still. For the neuropsychiatric reconstructionist has to face the peculiarities of the military status of his ward, the difficulties of demobilization into civilian life (a canal system with very precise technic for the opening and closing of locks), the choice and timing of the proper measures of bedside occupation, of occupation therapy in a broader sense, of prevocational and vocational training—the whole complicated by the character changes that may have set in to bowl over all one’s preconceptions. The nub of the matter, after the era of the maniÈre forte, the brusque psychotherapy, the rough jarring of the man back into approximate normality is, perhaps, this potentiality of subtle character changes defying possibly anybody’s analysis, but stimulating us all to our best endeavor, whether we are physicians, psychologists, occupation-workers, social workers, or nurses. Now that all sorts of reconstruction programs are in the air, each claiming its share, or more than its share, of attention, let us not forget that no one can stake out in any small plot the measures of refitting, readjustment, readaptation, rehabilitation—all these terms with slightly differing denotation have been used—especially when we take into account that not only must the patient be refitted to his entourage,
104. It is proper to place these general considerations first because the slow, patient, prosaic measures of reËducation are apt to be forgotten in our enthusiasm for the lightning-like cures of the hypnotic, the psychoelectric, the pseudo-operative, and other psychotherapeutic forms. Psychotherapy in all its forms has come into its own in Shell-shock. Miracles or their equivalents are daily wrought by men who are not prophets. Lourdes and Christian Science have their unassuming rivals. Let us remember, however, that even Lourdes and Christian Science never solved 100% of the problems placed before them, even though the votaries have the best will in the world to be cured. If the will itself is disordered, what can be done save investigate? And the mauvaise volontÉ is by no means absent from some of our prospective patients; witness one man, a Frenchman, who so resented being cured by torpillage, i.e., by the electric brush, that he carried his case against Clovis Vincent, who cured him of his hysteria, clear to the Academy! And, even after we have cured our cases by these modern miracles, let us not be too proud of ourselves! One soldier sent back to Australia, hysterically mute for months, got his voice back after killing a snake—a peculiar instance of occupation-therapy, not enumerated in courses on reconstruction. And remember the man who jumped the wall and got drunk, breaking back into the hospital to show his doctor how his refractory voice had at last come back. Thus there are cures and cures (even a newspaper cure of mutism by a moving picture vision of the antics of Charlie Chaplin), and spontaneous non-medical cures as well as medical ones, and slow cures due to vis medicatrix, as well as to shrewd reËducation measures.
105. I shall not attempt to cover systematically the topic of Shell-shock therapy in this epicrisis. The reader must go through the treated cases, especially in Section D but passim elsewhere, if he is to obtain a proper conception of all the methods so far employed—and at the end he cannot know the ultimate outcome of the cases. Patrons of the miracle
106. I shall content myself with a brief survey (insisting that the details be read of at least the leading cases in each treatment subgroup) of the cases offered in Section D (Shell-shock: Treatment and Results), consisting of 117 cases (Cases 473-589). The cases are in general arranged with the spontaneous and quasi-natural cures at the outset,—a series of 11 cases (Cases 473-483). The remainder of the section deals with cures under medical conditions, although many cases naturally show an interplay of non-medical factors in the cure or persistence of one or more symptoms.
A few cases illustrative of the physical value of hydrotherapy, mechanical therapy, and drugs are given in a short series (Cases 484-489). A treatment of hysterical contractures by induced fatigue is dealt with in Cases 489-493; and the occasional value of surgery is shown by Case 494.
The simpler methods of persuasion and explanation follow in a series of 19 cases (Cases 495-513).
Pseudo-operations and suggestive operative manipulation of avail in the treatment of certain local hysterical phenomena are considered in a series of eight cases (Cases 514-521). The comparatively long hypnotic series follows: 27 cases (Cases 522-548). The above-mentioned cures by pseudo-operation and by hypnosis may be classified with those that follow, i.e.,
Throughout the treatment section are scattered instances in which, not a cure, but merely a modification or even a persistence of symptoms was the outcome. It is useful to bear in mind, while reading cases in the etiological and diagnostic sections, these main divisions of treatment into what might be called (1) spontaneous, (2) rapid (or “miraculous”) and (3) slow or reËducative.
107. It is beyond the scope of this book to deal systematically with the hospital and administrative side of these questions. Especially the zone question is of practical importance, that is, the question of arrangements at the front, on evacuation lines, and in the interior. Roussy and Lhermitte have particularly discussed these matters.
After thirty months’ experience in the psychiatric centers of two armies, Damaye suggested an organization of psychiatric centers in two parts,—First, a service draining patients from the firing line, rapidly give them first care and evacuate them, in charge of special attendants, to: Second, a psychiatric or neurological center in the communication zone (Étapes) without danger of bombardment and at a distance from the guns. The more serious cases will then be evacuated, thirdly, into the interior from these centers along communication lines. But most will have gotten well at the front.
108. By orthopedists and mechanotherapeutists too much stress may indeed be laid on non-psychiatric measures, as Duprat hints. Yet perhaps neuropsychiatrists may need as much coaching in the opposite direction. One must remember the non-psychopathic fraction of these Shell-shock disorders and their need of diathermy (Babinski). Duprat says that the centers for physiotherapy cannot effectively do the work of all Shell-shock therapy, as the physiotherapists have their aims fixed on nerves and muscles rather than the mind. Each case requiring psychotherapy ought to be studied in an experimental psychological laboratory from a number of points of view such as mechano-motor capacity, the sensibility, emotional and intellectual sides, memory, impulses and the like. Testing apparatus should be available together with dynamometers, sphygmometers, chronoscopes, ergographs, pneumographs, cardiographs and recording apparatus.
Chart 19
PSYCHOELECTRIC AND REËDUCATIVE TREATMENT
| Phase | I. | PERSUASIVE TALK IN CONSULTING ROOM |
| Phase | II. | ISOLATION, REST IN BED, MILK DIET (a few days) |
| Phase | III. | FARADIZATION |
| Phase | IV. | REËDUCATION (Physiotherapy and Psychotherapy) |
| Phase | V. | AFTER-CARE |
Curing a psychoneuropath means victory in a moral battle!
After Roussy and Lhermitte
Chart 20
TREATMENT FOR INVETERATE HYSTERICS
| Phase | I. | “TORPILLAGE” AND INTENSIVE REËDUCATION |
| Phase | II. | FIXATION OF PROGRESS BY EXERCISES |
| Phase | III. | PROLONGED SPECIAL TRAINING |
After Clovis Vincent
Specialists for consultation should be available, including ophthalmologists, otologists, laryngologists and electrical specialists. The tests over, the patient should be examined as it were, in a free state and his habits and character noted. Hypnosis may be tried but it should not be prolonged. Psychic contagion is to be avoided especially in the case of subjects with epileptoid crises.
It would be well to establish for the cases regarded as susceptible to psychotherapy, reËducation centers like those for the re-adaptation of the tuberculous. The improved tuberculous are sent to health centers under the Ministry of the Interior for three months at the maximum and emerge much better able to support the exigencies of life. According to Duprat, there ought to be psychotherapy centers which should not in any sense recall asylums for the insane. Set in the country but not far from the city, managed by the psychological physicians and “mÉdecins psychologues, plus Éducateurs que mÉdecins.” The personnel should consist of students going into psychiatry and of teachers whose pedagogical practice ought to enable them to second the efforts of the psychiatrists. In this way we might avoid the perpetuation of some of the psychopathies of war.
109. Possibly “putting forward the best foot” may yield a wrong impression of the proportion of what I have termed “miracle cures.” Other devices of a slower nature are mentioned throughout the book. Perhaps much depends on the temperament of the psychotherapeutist, as e.g., Laignel-Lavastine has remarked about the method of psychotherapy by means of conversation: that one might easily remain in a honeymoon state in military psychotherapy. When hundreds and thousands of functional nervous cases pass through one’s hands it is necessary to remember that behind the conversation there stands the imposing finger of material force.
Compare the work of Clovis Vincent, Yealland, Kaufmann.
110. On the other hand, Rows points out that shock is a term that does not explain at all adequately the great variety of mental illnesses occurring in the soldiers at the front. The term is popularly used for cases which recover quickly, but in the majority of cases there is a residuum after the shock has disappeared. Accordingly Rows’ work has dealt chiefly with underlying causes, conditions, and factors. Here we may consider
(a) The war strain before breakdown;
(b) Special causes of shock, such as death of comrades near by, near-by shell explosions and blowing up of trenches;
(c) Fatigue and exhaustion with lowered capacity of resistance.
The men themselves find that they have
(d) undergone a change of character, having become irascible, unable to sustain interest and attention; solitary and morose, and less capable of self-control. Anxiety, worry and a state of morbid expectancy set in. Everyday trifles are exaggerated.
But below these cases are still deeper ones, such as
(e) revival of horrible memories and terrifying dreams of war scenes, together with memories of incidents of past life.
(Rows attributes to Dejerine the idea that the cause of all cases of hysteria and neurasthenia must be sought in antecedent emotion.)
Emotion compels attention, and to such a degree in some cases that the memories and attendant fears and anxieties cannot be expelled. Hallucinations and delusions may then develop. The patient is largely incapable of reasoning about his status; he lacks
Rows’ work has been done at the Red Cross Hospital at Maghull, and several of the Maghull cases have been reported in Elliot Smith and T. H. Pear’s book on Shell-shock. A somewhat similar point of view has been maintained by Wm. Brown, who has suggested the neat term autognosis for psychoanalysis. W. A. Turner speaks of the Maghull point of view as one of modified psychoanalysis.
111. Or again a species of combination of the maniÈre forte and the maniÈre douce (operations, shall we say with William James, of the “tough-minded” and the “tender-minded” respectively?) may be used as in the formula
SYMPATHY + FIRMNESS (Mott).
112. More special devices, suggesting faintly the methods of animal training, may be used, as described in the following account of a new isolation and psychotherapeutic service established in May, 1915, at the SalpÊtriÈre for soldiers with functional nervous diseases. The basic idea has long been held by Dejerine,—the avoidance of heterosuggestion by other patients, imitation, ill effects of visits from members of the family. The functional additions that come from near-by organic patients are among the disadvantages of the ordinary treatment. The isolation service of the neurological center is composed of 34 beds, arranged in two halls, with three extra rooms. Each bed is isolated. The rÉgime in one of the rooms is more rigorous than in the other, and it is an advance for a patient to be moved from the first to the second room. The patient on wakening has no right to leave his box or communicate
Women nurses care for the patients. A system of control and of progressive rewards has been installed, being a sort of metric evaluation of the process of cure. As the cure proceeds the patient’s lot is progressively mitigated, or if he gets worse the regime is clamped down. Suppose a man a victim of paralysis of leg—the height to which he can lift his leg is measured in centimeters daily as well as the time during which he can hold the leg in air; or, the progress of an ankle, or of the forearm or the arm in a case of arm contracture, is measured. The grade obtained by our scholar in psychotherapy is inscribed upon a slate. Finally, walks, concerts, visits and eventually permission to go out into the town are granted.
113. Can Shell-shock neuroses be prevented, other than by stopping or modifying the war or by weeding out Shell-shock candidates as they volunteer or are drafted? Morton Prince offers points of some suggestive value. The very various proportions of neurosis observed in different units and arms of the service suggest that various degrees of preparedness may have played a part. Bernheim says suggestion is an idea accepted. Aside from a possible increase of simulation, much might depend on what idea administered really got accepted! Morton Prince’s plan is that the prevention must be based upon the education of the mind. This therapeutic education should be based, however, on a preliminary systematic study by a board of specialists in the psychoneuroses of (a) the mental attitude of minds generally toward shell fire, and (b) clinical varieties of this “shock” neurosis as it occurs in trench warfare, (c) its frequency and disabling incidence, and (d) the state of mind previous to the trauma of those suffering from it.
On the basis of the findings of such a study, first, the regimental surgeon through lectures and clinical demonstrations would be instructed systematically in the symptoms and
Second, soldiers, including officers, could then, in units of say 100, in turn be instructed in the nature of the disease through lectures by regimental surgeons. Shell-shock, they should be told, is a form of hysteria caused by mental factors. The work of the instruction should be done in France in the atmosphere of the war, wherein would be formed an attitude of healthy mental preparedness instead of an attitude of fear and mystery. Has mental hygiene this great scope? Is morale merely education?
114. What after all, is Morale? We hope to learn a little about it from this war for use hereafter, when we can say with the Florentine
