Chapter XXXIII: Section C: but passim in Sections B and D; by delimitation we may (2)

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, may be necessary. I speak of this problem here not because these persons are hypophrenic or feeble-minded in the ordinary sense, but we must constantly bear in mind our experience in the teaching of hypophrenics (both in the schools for the feeble-minded and in the community) when we are facing problems of mental reconstruction.

=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 morphinism, illustrating the effects of the war upon the fate of morphinists.

=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 diagnosis of some form of psychogenic disease, possibly hysterical, but had eventually to alter the diagnosis to hebephrenia or catatonia. Case 156 was possibly one of Shell-shock, though the man remained on duty for a month with but one symptom, trembling of the arm. For nine months he showed a variety of symptoms apparently consistent with the diagnosis hysteria, but then developed catatonic and paranoic symptoms clearly warranting the diagnosis dementia praecox.

=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 very possibly should be regarded as one of psychoneurosis. At all events, it would be dangerous to found a doctrine to the effect that dementia praecox can be initiated by shell-shock upon such a case as 160. Case 161 is similarly doubtful. There are a number of symptoms in this man (the sole survivor of an explosion in a blockhouse) consistent with the diagnosis Shell-shock, and a number of others which hardly can be given any other interpretation than that of catatonic dementia praecox. But the available medical data do not begin until five months after the shell explosion. We must conclude here also that no definite evidence exists that dementia praecox can be initiated by the physical factor shell-shock. Case 162 is one in which there are shell-shock factors and fatigue factors in a man who had once ante-bellum shown signs of mental disorder, and who developed delusions subsequent to a fugue following shell-shock. The most one could make of this case would be to say that a latent schizophrenia had been liberated by shell-shock.

=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 of great weight from the relative number of cases found in the different groups; and it might well happen that psychiatrists would not report cases of an everyday and commonplace nature which might yet be very frequent. On the whole, however, it would not appear that dementia praecox is at all a frequent phenomenon in the war.

=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). One of the ideas in the literature concerning the manic-depressive group has been that it is very possibly remotely allied to Graves’ disease, a hypothesis upheld by Stransky in Aschaffenburg’s Handbook. Hyperthyroidism itself has been, of course, a rather striking feature in the foreground or background of many sick patients in the war. However, war factors have proved able to bring out very few instances of cyclothymic (manic-depressive) disease. Amongst our seven cases, the first (Case 163) was that of a maniacal Alsatian of 59 years, who volunteered because of his hypomania. Case 165, the case of a German who pelted French trenches with apples from an appletree in No Man’s Land, was another case in which the war had little or nothing to do with the development of the mania. One of fugue (Case 164) was a case of melancholia and anxiety not closely related with war experience. In three further cases trench life and war stress may be thought to have liberated the cyclothymic phenomena. Case 166 was that of a man of 38, previously referred to, who developed arteriosclerosis and whose depression and hallucinations had followed four months of trench life devoid of battles or injury. It is possible that this case should be regarded rather as syphilitic or of some unknown organic origin. At all events, it is not clear that it could be made to bear a heavy weight of hypothesis concerning the genesis of cyclothymic psychoses. Case 167, a naval officer who distinguished himself greatly by work on land in Belgium, was regarded by its reporter as one of manic-depressive psychosis with the fatigue of war as its base. It might be queried whether the man’s distinguished work was not due to an early phase of hypomania, after which the cyclothymic effects began. In Case 168 there was some evidence of the effect of war stress, as certain hallucinations grew more intense after the bombardment of Dunkirk; but in point of fact, this man had shown a predisposition and indeed a period of so-called neurasthenia ante-bellum. It is doubtful, therefore, whether there is any case here abstracted which can be used to support the hypothesis that the manic-depressive (cyclothymic) group of mental diseases has had or is likely to have its genesis in war stress. The remaining case (Case 169) is one illustrating a method of treating low blood pressure in depression.

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=.

CHART 17

DIAGNOSTIC ALLIANCES OF THE SHELL-SHOCK NEUROSES

+---------------+ +----------+ +---------------+
| SCHIZOPHRENIA | | SHELL | | NEUROSYPHILIS |
| CYCLOTHYMIA |<------| SHOCK |--->| EPILEPSY |
| MORONITY |<------| NEUROSES |--->| SOMATOPATHY |
| ALCOHOLISM | | | | |
+---------------+ +----------+ +---------------+

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 | | SHELL | | NEUROSYPHILIS |
| CYCLOTHYMIA |<---| SHOCK |------>| EPILEPSY |
| MORONITY |<---| NEUROSES |------>| SOMATOPATHY |
| ALCOHOLISM | | | | |
+---------------+ +----------+ +---------------+

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

LOGICAL PLACE OF THE “REFLEX” DISORDERS (OF BABINSKI-FROMENT)

e.g. neurosyphilis paretica | Hysteria e.g.
\ | /
\ | /
\ | /
\ | /
ORGANO- | DYNAMO-
PSYCHOPATHIC | PSYCHOPATHIC
|
|
|
-------------------------------+-----------------------------
|
|
|
|
ORGANO- | DYNAMO-
NEUROPATHIC | NEUROPATHIC
/ | \
/ | \
/ | \
/ | \
/ | Babinski’s “reflex” \
e.g. neurosyphilis tabetica | 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 “organic” is too often used to mean “subcortical.” In another diagram the truer relations are depicted, with four classes of phenomena (Chart 18).

(_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 nervous-system disease, such as that shown in cases with heightened intracranial pressure or in cases with asymmetry of reflexes and other forms of parareflexia. In military practice these logical questions of prior elimination of syphilis, feeble-mindedness, epilepsy, and alcoholism must go a-glimmering at first, unless their signs are so obvious as to permit diagnosis by inspection.

=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 a =hemiplegia= on the same (=left=) side, =with aphasia=. Now aphasia ought to be the result of a lesion on the left side of the brain in the common run of cases, whereas left-sided hemiplegia ought to be the result of lesion on the right side of the brain. In point of fact, the analyst of this case felt that he was dealing with a direct injury on the left side of the brain, leading to aphasia, and a lesion by =contrecoup= on the right side of the brain, leading to a left-sided hemiplegia.

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 by contrecoup. The case not only has surgical implications and suggestions of importance, but also it throws some light on the possibilities in concussion of minor degree. As the cases in Section B (On the Nature and Causes of Shell-shock) show, shell-shock, the physical factor, is apt to produce anesthesia and paralysis or contracture on the side exposed to the shell-shock. The means by which these symptoms ipsilateral with the shock are produced is commonly thought to be the “hysterical mechanism,” whatever that may be. Lhermitte, however, suggests that in some cases such phenomena might be due to an actual brain jarring with contrecoup effects. However, it must be granted that Case 103 did not come to autopsy.

=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 phenomenon in the case was the absence of knee-jerks in the early part of the day; later in the day, they would appear once more. Possibly Case 111, a case of somewhat doubtful nature but presumably of organic hemiplegia, ought to be aligned more with the group of cases illustrating the nature and causes of Shell-shock. The case was not one with the physical factor shell-shock, since the phenomena began ten days after a serene convalescence following an operation for chronic appendicitis. Perhaps the case was one of organic lesion grafted upon a neurosis.

=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 co-existence of hysterical and organic symptoms is illustrated in Case 116, one of mine explosion, and Case 117, one of injury to back. Case 116 somewhat resembled another case of Smyly (Case 219).

=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., 2. Paralysis sometimes symptomatic;
_e.g._, in unilateral facial facial paralysis almost always
paresis, the paresis occurs also symptomatic. With complete
when bilateral synergic movements unilateral paralysis, the muscles
are being performed. of the paralyzed side may
function normally during the
performance of bilateral synergic
movements.

3. Paralysis affects voluntary, 3. Voluntary, unconscious, or
conscious, and unconscious or sub-conscious movements not
sub-conscious movements; hence, disordered. Absence of platysma
(_a_) platysma sign,[12] (_b_) sign and combined flexion of
sign of combined flexion of thigh thigh and trunk. The active
and trunk, and (_c_) absence of balance movements of arm may be
active balancing arm movements lacking but there is no
in walking contrasted with exaggeration of passive balance
exaggeration of passive balancing movements.
movements (limb inert on sudden
turn of body).

4. Tongue usually slightly deviated 4. Tongue sometimes slightly
to the paralyzed side. deviated to the paralyzed side;
but sometimes contralateral
deviation.

5. Hypertonicity of muscles, 5. No hypertonicity of muscles. If
especially at first. The buccal facial asymmetry exists, it is
commissure may be lowered, the due to spasm. No exaggerated
eyebrow lowered; there may be flexion of forearm, and no
exaggerated flexion of the pronation sign.
forearm, and the sign of
pronation may occur (hand left to
itself lies in pronation).

6. Tendon and bone reflexes often 6. No alteration of tendon or bone
disturbed at the beginning, reflexes. No trepidation of the
either absent, weakened, or foot.
exaggerated (almost always
exaggerated.) In many cases,
there is epileptoid trepidation
of the foot.

7. Skin reflexes usually disordered. 7. No disturbance of skin reflexes.
Abdominal and cremasteric reflexes, Abdominal and cremasteric
especially at first, weakened or reflexes normal. Babinski toe
abolished. On stimulation of sole, reflex and fan sign absent.
toes, and especially the great toe, Defense reflexes not
are extended on the metatarsals. exaggerated.
Babinski toe reflex. Extension of
great toe often associated with
abduction of other toes (fan sign).
Sometimes exaggeration of reflexes
of defence.

8. Contracture characteristic and 8. The contracture can be
non-reproducible by voluntary reproduced by voluntary
contractions. The hand-grip contractions.
yields a sensation of elastic
resistance, automatically
accentuated on passive
extension of the hand.

9. Evolution of diseased regular 9. Evolution of disease
contracture follows flaccidity. capricious. Paralysis may
When regression of disorder remain indefinitely flaccid
occurs, it is progressive. or may be spastic from the
beginning. Spastic phenomena
may sometimes be associated
Paralysis not subject to ups (particularly in the face)
and downs (motor defect fixed). 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).

[12] More energetic contraction of platysma on healthy side
when mouth is opened or when head is flexed against resistance.

=87.= =Differential between Reflex (Physiopathic) Contracture and Paralysis, and Hysterical Contracture and Paralysis. Babinski, 1917.=

_Reflex_ _Hysterical_

1. Paralysis usually limited but 1. Paralysis usually extensive
severe and obstinate even when but superficial and transient
methodically treated. if treated.

2. In the hypertonic forms attitude 2. The hysterical contracture as
of the limb does not correspond a rule resembles a natural
to any natural attitude. attitude fixed.

3. Amyotrophy marked and of rapid 3. Amyotrophy, as a rule, absent,
development. even when the paralysis is of
long standing. If existent, it
is not marked.

4. Vasomotor and thermic disorder 4. There may be thermo-asymmetry
often very marked, accompanied by but it is slight. There are no
an often very pronounced reduction very characteristic vasomotor
in amplitude of oscillations disorders nor modifications in
measured by oscillometer. amplitude of oscillations.

5. Sometimes very marked 5. No sharply defined
hyperidrosis. hyperidrosis.

6. Tendon reflexes often 6. No modifications of tendon
exaggerated. reflexes.

7. Hypotonia sometimes very well 7. Hypotonia absent.
marked, and in arm paralysis
_main ballante_.

8. Mechanical over excitability of 8. Over-excitability of muscles
muscles, often accompanied by absent.
slow response (?).

9. Fibrotendinous retractions of 9. No retractions even if
rapid development except in the paralysis is of long
rare completely flaccid forms. duration.

10. Trophic disorders of bone, 10. No trophic disorders.
decalcification of the hairs
and of the phanères.

=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 structural disease= is in question, is found in Cases 410-415. =Peripheral nerve injuries= of a sort which might be confused with Shell-shock phenomena, including one of light =tetanus=, are considered in Cases 416-419. A variety of cases bearing upon the question of the =reflex or physiopathic disorders of Babinski= is found in the series of Cases 420-432. Peculiar =eye phenomena= are presented by Cases 433-438; and cases of =otological= interest are 439 and 440. =Epileptoid=, =obsessive=, =fugue=, and =amnestic phenomena= follow in Cases 441-450; 451 and 452 are cases of =soldier’s heart=. The =simulation question= is presented in a series of 20 cases (Cases 453-472).

GENERAL NATURE OF SHELL-SHOCK

=89.= We are now ready to consider in how far Shell-shock[13] is a distinctive disease. The physical event, shell-shock[13] we have seen at work in most of the major groups of mental disease and in some groups of nervous disease. Shell-shock, the physical event, has started up a “Shell-shock” paresis, a “Shell-shock” epilepsy, a “Shell-shock” Graves’ disease, a “Shell-shock” dementia praecox, wherein the term “Shell-shock” is merely a more specific term than the term “traumatic.” The physical event, shell-shock, has in special ways also changed the responses of the feeble-minded, the alcoholic, the cyclothymic, and the psychopathic person of whatever ill-defined sort may get into military service.

[13] I capitalize Shell-shock here (as elsewhere) to indicate
the name of a supposed disease entity and leave shell-shock
without an initial capital to indicate the physical event.

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 event, takes part in a great number of pathological events and as such lapses from noun to adjective.

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 of as done for. The spirit of the language is against the thought of shock as destruction or even as permanent irritation. Shock ought to be a “functional” rather than an “organic” thing, as medicine bandies these terms about. Shell-shock or Surgical Shock, it is all one to the logic of shock, which is thought of as a physical or chemical disturbance of mechanisms and arrangements that are, or ought to be readjustable. The one character which the late Professor Royce told me (in conversation) he could find in the term “functional” was the idea “reversible.” Shock is or ought to be, as a pathological event, reversible.

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 puncture data; then cases with prominent admixture of organic phenomena; a few cases to illustrate the victims’ own impressions of their disease; the long toe to top, or “cephalad” series (crural monoplegias and paraplegias, campto-cormias, astasia-abasias, brachial monoplegias, brachial paraplegias, deafmutism, blindness); the series to illustrate the idea of reflex or physiopathic disorders; the series of delayed Shell-shock phenomena; the series to show the picking out by Shell-shock of ante-bellum weak spots and tendencies in the organism; cases touching the hereditary question; peculiar and unique cases; examples of Shell-shock equivalents; and cases of a psychopathic rather than local hystero-traumatic trend.

=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 possibly indeed have been the direct cause of death or an indicator of its direct cause. Here again, to accord full justice to Mott’s contention, we are dealing perhaps more with a phenomenon of the cause of death than with a Shell-shock phenomenon. According to Mott, the Shell-shock symptoms themselves are due to capillary anemia and to nerve cell changes such as he found in various regions. These nerve cell lesions were of the nature of chromatolysis and identical with those of the vago-accessorius nucleus. In this connection, one thinks of the ideas of Crile concerning exhaustion and its effect upon certain nerve cells and other cells, and indeed the whole conception runs back to the early years of discussion of the meaning of chromatin deposits in nerve cells, and to the work on fatigue of such cells. It may well be that Mott’s suggestion is sound, and that changes of the order of chromatolysis are what subtend some, if not most, of the phenomena of Shell-shock. On account of the myriad interconnections of neurones and the remote effects upon normal neurones of disturbances of a microchemical or microphysical nature in a few neurones, it would not do to throw out of court forthwith such a contention as that of Mott by triumphantly pointing to the miracle cures of certain Shell-shock phenomena; for it will not necessarily be the chromatolytic (or otherwise microchemically or physically altered) cells that will be directly responsible for the symptoms in question. Cells whose activity is but temporarily in abeyance (perhaps by phenomena akin to diaschisis) might be reached from an unusual source in the process of “miracle cure,” whereupon the newly opened paths of energy might conceivably remain open. Nevertheless, it cannot be denied that there are considerable stretches of speculation in the thread of this hypothesis.

=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.