Chapter XXXII: Section C: but passim in Sections B and D; by delimitation we may (1)

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 handle these greater groups, having in mind all the while the appropriate temporary calling-in of the specialist. But there are two more groups, in addition to these seven, in which I am not so sure that the general profession knows as much as it should. I refer to VIII, the schizophrenic group, commonly known as the dementia praecox group; and IX, the cyclothymic group, sometimes termed the manic-depressive group. It is the victims of the diseases that constitute these latter groups that ought unconditionally to be excluded with few exceptions from the army; and it is the study of these conditions which ought to be carried out as a part of every man’s post-graduate training, not merely for his work on draft boards, but for his work in civilian and reconstruction practice. There is another group of, X, psychoneuroses, with which the profession regards itself as familiar, and with which it doubtless is familiar, in what might be called _blooming examples_ of hysteria, neurasthenia, and psychasthenia. But the nub of the situation lies in the fact that the diagnosis of instances which are not such blooming examples is difficult, and hence it was that I qualified my statement as to the competence of the practitioner in this tenth group. It is, of course, the tenth group, of psychoneuroses, into which the majority of the Shell-shock cases fall.

=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 problem. For convenience of reference, a few out-standing remarks concerning the general relations of these divisions to war and peace conditions are inserted here. We dealt in the diagnostic order of exclusion with 190 cases, distributed as in the table below (bear in mind that the method of this book precludes attaching great statistical weight to the comparative figures, since the various authors published their cases for their special rather than their typical interest).

I. Syphilopsychoses 34
II. Hypophrenoses (feeble-mindedness and imbecility) 18
III. Epileptoses 33
VI. Pharmacopsychoses (alcohol; morphine) 17
V. Encephalopsychoses (focal brain lesion cases) 15[9]
VI. Somatopsychoses 29
VII. Geriopsychoses (senile--a null class) 0
VIII. Schizophrenoses 16
IX. Cyclothymoses 7
X. Psychoneuroses 12[9]
XI. Psychopathoses 15
-----
196

[9] The numbers of focal brain lesion cases and of
psychoneuroses must naturally be considered in relation to the
great groups of these cases in Sections B and C.

=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 _pseudo_tabes and _pseudo_paresis (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 series (under Section B: Nature and Causes, Cases 286-301) in which _ante-bellum_ weak spots were picked out by shell-shock and war conditions. But Case 28 is placed here for its syphilitic interest.

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 through the retreat from Mons and through two years of active warfare without having a single epileptic convulsion. In fact, in September, 1916, he was put in charge of eight men on guard duty. Apparently the new responsibilities worried him, and two months later he had become epileptic to the extent of petit mal.

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.[10] There does not appear to have been any increase in epileptics as the result of the war, either from the standpoint of Shell-shock or from the standpoint of brain injury, so far as the records of the National Hospital for the Paralyzed and Epileptic in London are able to show.

[10] In one instance, fugue and other minor symptoms were
later replaced by epilepsy; in another, an epileptic confusion
developed eight months after an explosion, and in a third,
a case of mine explosion, stammering resolved into mutism
and mutism finally into epilepsy. Of course there is a
so-called general resemblance among all forms of hyperkinesis
or irritative discharge of the nervous system. If we term
epileptic all the things that various authors have termed
epileptoid, we may be doing nothing more than to say that we
believe these cases all subject to epileptic hyperkinesis.
In that direction, of course, it has long been said that
dipsomania was really a form of epilepsy. Whether Shell-shock
is ordinarily subject to recurrence in such wise as to imitate
the recurrence of attacks of dipsomania, of manic-depressive
psychosis or of epilepsy, is, to say the least, doubtful at
this time.

=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 nearby. On the whole, however, the relation between epilepsy and Shell-shock is not a close one.

=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 belong in an account of psychoses incidental in the war. Case 66 is one with recovery from Jacksonian seizures after decompression of the upper Rolandic region, which was edematous following an (apparently very slight) scalp wound and shell-shock.

=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 such as may be found in cardiorenal cases, and of glandular phenomena such as we are familiar with in the thyroid disorders.

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 the diagnosis of meningitis was suggested. At this point, the symptoms became predominantly psychotic.

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 dorsal segments. This myelomalacia was doubtless related with the bullet injury of the spine, although the spinal cord was not itself directly touched by the bullet. Case 134 might be regarded perhaps as one of Shell-shock and should be considered in relation with the cases at the head of Section B (Cases 197-209). The case might be regarded as functional, except for a decubitus that developed. Despite this decubitus, there was recovery. The case is placed in the somatic group on account of _pulmonary phenomena_ which it seemed well to relate with those of Case 133. Compare also Case 136, in which reflex phenomena are associated with a bullet wound of the pleura. Case 135 is a many-sided case, with ante-bellum hysteria and certain Shell-shock phenomena. While under observation, the patient caught typhoid fever and then developed neuritis. This neuritis was very probably not post-typhoidal so much as hysterical. Accordingly, the case should be considered in connection with the ante-bellum weak spot series, Section B (Cases 286-301). There was in this case a cure by reëducation.

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 of Case 144 followed 10 months’ service, at times under protracted shell fire. A _forme fruste_ of Graves’ disease is shown in Case 145, in which the phenomena followed gassing and shelling.

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 NEUROSES

=40.= 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=,[11] as beyond question without narrow relations with feeble-mindedness, alcohol and drug states, schizophrenia and cyclothymia, and =as probably of the general nature of the psychoneuroses=.

[11] In the limited _non-encephalic_ sense of the term somatic
(“symptomatic”) of some writers.

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 months before claimed only as a diagnostic curiosity. In the midst of such discussions and controversies, there must inevitably be a renaissance in neurology.

=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 the mutism and the tremors went, this man might belong in the =majority group of Shell-shock cases, namely, the functional group=. Assuming the hemiplegia to be really organic, we should regard this man as a mixed case, organic and functional.

=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, we are dealing with cases in which the phenomena are either continuous with ante-bellum phenomena, or are of such a nature that they might well have been brought out by other factors than those of war. These cases by the design of their choice throw little or no light upon the relation of physical shell-shock or its equivalent to the psychoneuroses, though in a few instances the factor of shell explosion is not entirely to be excluded, and in one instance (Case 170) a hallucination may be regarded as a virtual equivalent of an emotional shock of great compelling power.

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 bent back, or camptocormia (Souques). Then come walking disorders (Cases 246-248). Still proceeding cephalad, disorders of one arm and hand are considered in a series of six cases (Cases 249-254). Bilateral phenomena, symmetrical or asymmetrical, follow in Cases 255-258. Now reaching the head, we deal with cases of deafness (Cases 259-260), of deafmutism (Cases 261-263), of speech disorder (Cases 264 and 265), with two special cases (Cases 266 and 267). Eye symptoms are dealt with in a series of cases (Cases 268-272), and Case 273 deals with cranial nerve disorder supposed to be due to shell windage without explosion.

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, synesthesia, puerilism, and the like. Shell-shock equivalents of various sorts are placed in a group of cases (Cases 321-325). The next series of cases (Cases 326 to the end of this Section: 370) show tendencies to general neurasthenic, psychasthenic, and other psychopathic phenomena, rather than the more definite phenomena discussed in the early part of this section in the series arranged “cephalad.”

=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 life wholly concealed,--yet at the same time consciousness, in the usual sense of that term, had vanished. Accordingly, the proof of a new type of functional disease, at times concealed by the overlay of higher neurones, was now plain. Does not this offer new leads of the greatest value in that most intricate of fields, psychopathology? Is not the model here offered of diseased =nervous functions=, =non-psychic= in nature (in the ordinary sense of psychic) =but of almost equally complex nature=:

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 certain nervous and mental weaklings and indeed that one author claims as high a percentage as 74 for war neuroses having a hereditary or acquired neuropathic basis. How far does feeble-mindedness itself count among these supposedly susceptible nervous and mental weaklings? Is a feeble-minded person especially in condition for Shell-shock?

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=.