Shell-shock and other neuropsychiatric problems

(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.

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

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.

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.

Rather often quoted in this relation is Case 201, a case of Sencert, in which a shell exploded one metre away from a soldier and injured him so that he died that night through the bursting of the pleura of both lungs within a thoracic cage which was quite intact. This sort of finding reminds one of cases in which the inner partitions of houses are burst by explosion when the outer walls remain intact. In particular, one thinks of the physical changes within an aneroid barometer, which have been shown to come about when something is exploded near by. If such an event may happen as the bursting of the lungs within an otherwise intact body, so also is there evidence that a similar event occurs in the nervous system. Clinical evidence of this is obtained in the hemorrhage and pleocytosis of spinal fluid obtained early in the clinical examination of certain cases. In fact, in Case 205 (one of Souques), there is a pleocytosis of the fluid as late as a month after shell-shock. When there is no pleocytosis or hemorrhage, there may be a hypertension of the fluid,—a finding sometimes attributed to Dejerine (see, for example, Case 207, of Leriche). It might be inquired whether the fall sustained by the patient as a result of the shell explosion could not be responsible for the hemorrhage, and this may indeed be the fact in certain instances. Babinski has offered in Case 209, an instance in which hematomyelia (with later partial recovery) was produced in a subject who was lying prone in the performance of machine-gun duty (the phenomena in this case were well described by the victim himself, a veterinary student who was six months a captive in Germany). Doubtless, it would not be difficult to produce a complete series of cases with and without trauma to the tissues investing the nervous system, with definite clinical or autopsy evidence of organic lesions of the nervous system, whether by mechanical impact, by the concussion (windage) of the air, or even by the effects of muscular contractions.

93. A case of Chavigny’s (Case 198), in which there was an extremely careful autopsy, showed a strongly blood-stained cerebrospinal fluid; in fact, there was an intradural hemorrhage, though of minor degree and possibly not the cause of death; and throughout the brain substance there were slight hemorrhagic points. But there was no sign whatever of fracture of the cranial vault or base. Another case of similar meningeal hemorrhage but sharply localized, was Case 199, an instance of minor explosion in which neither skin nor muscles, bone or viscera showed any lesion; and the death, which occurred in seven days, seemed hardly explicable on the basis of hemorrhage itself. In fact, this case would require the sort of microscopic examination performed by Mott in Case 197 for a proof of the cause of death, which was thought by the reporters themselves (Roussy and Boisseau) to be within the field of histology.

94. Case 200 seems to bring proof that there may be areas of gross softening within the spinal cord produced by the concussion of the cord from shell-burst, although there had been no fracture of the spine itself and no penetration of splinters of shell or of bone into the spinal canal or the substance of the cord itself. The argument here is that the tissues that lie between the agent of violence and the interior of the spinal cord are affected en bloc by the impact, the resultant gross or molar lesions being several millimetres or centimetres from the point reached by the impinging body or force. How complicated such a situation might be, we may recall from a case previously studied, namely, Case 103 (Lhermitte), wherein a missile struck the left side of the skull and produced lesions beneath its point of impact, but at the same time apparently caused a contre-coup effect upon the opposite hemisphere. That particular case did not come to autopsy, but Lhermitte’s explanation of its queer association of aphasia with ipsilateral hemiplegia seems sound enough. In fine, what with the mechanical trauma to which many victims of shell explosion are subject, what with the findings in sundry autopsies, and what with the determination of hemorrhage in the spinal fluid early after the shock, it might be conceived that the majority of cases of Shell-shock are actually cases of mechanical injury to the brain or spinal cord in which hemorrhage or laceration and overriding of neuronic tissues would be found. Nor would such a hypothesis be prima facie absurd with the evidence afforded by certain cases of Shell-shock having an admixture of reflex phenomena and other symptoms proved by the older neurologists to be beyond peradventure organic. (Compare, for example, such a case as that of Case 210, with herpes zoster and segmentary symptoms.) It should be remembered, however, that Mott in the case cited above (Case 197) sharply distinguishes between the hemorrhages (especially the bulbar hemorrhage which caused death) and the nerve cell chromatolysis which he regarded as possibly at the basis of Shell-shock symptoms. It is decidedly doubtful whether the hypothesis of microscopic or larger hemorrhages, or of local areas of destruction of neurones will suffice for the explanation of true Shell-shock. This is not to say that in the diagnosis of true Shell-shock (that is, roughly speaking, the psychoneurosis), we shall not need to concede and consider in every case the possibility of traumatic focal brain disease. This will always need to be faithfully excluded in all cases unless the initial set-up of symptoms is so suggestive of immediately curable psychoneurosis that without further ado miracle-therapy is undertaken and executed. But in virtually all the slower cases, an exclusion of organic brain and cord disease is undertaken. Admixtures of organic and focal phenomena are quite in the order of everyday occurrence.

95. Especially good instances of this co-existence of functional and organic symptoms are found in ear cases; and it may be suspected that when, after the war, all these data can be suitably gathered and compared, it will be from the field of otology that some of the most fruitful hypotheses will be developed. In the cases of Shell-shock deafness, mechanical peripheral factors are admixed with central factors in phenomena admitting in some ways more exact diagnosis than in other fields. We may await the correlation of these data by some worker, equally skilled in otology and neurology, with the profoundest interest. Analogous results may be hoped from a correlation of neurological and ophthalmological conceptions.

96. Suffice it to say that the differentiation of organic and functional phenomena has long been possible on the basis of what we know concerning various reflexes (e.g., the Babinski reflex and its congeners); and the net result of this work is that the majority of Shell-shock cases,—that is, cases in which the physical factor shell-shock has entered,—are probably not cases in which a coarse organic disease could be proved to exist, or assumed with any color of likelihood to exist. Even limiting ourselves to cases in which the physical factor shell-shock or some sort of impact with or without an external wound occurred, we shall find cases enough of a truly functional nature, as indicated by their reflexes, to render it quite impossible to assert that they are in the classical sense “organic” cases. Putting these cases with the physical shell-shock factors together with the other large series of cases in which precisely similar symptoms occur without the presence of the physical shell-shock factor, we shall find ourselves convinced that classical Shell-shock phenomena are by and large what is called functional. We shall arrive at the hypothesis that they are cases of hysteria or other form of psychoneurosis, entitled to the diagnosis of traumatic hysteria (or hysterotraumatism, in the sense of Charcot), or not, according to whether the physical factor shell-shock was in evidence. What now underlies the concept functional, as we use it in Charcot’s sense of hysterotraumatism, or in the more modern phrase traumatic hysteria? Do we perhaps mean some microchemical or microphysical change of a reversible nature, similar to that described by Mott, e.g., in Case 197? It is not possible to answer this question at this time.

97. But if we give up the hypothesis of organic disease of the nervous system (that is, the hypothesis of coarse lesions, small or large, conceived to be the direct effect of mechanical impact), can we incriminate any other factor? Chemical factors from the gas of bursting shells may be thought of; yet in abundant cases there is no evidence that these have been in play. They and a variety of other special causes may be found working in a few instances but have nothing to do with the moot question.

98. Upon giving up the organic hypothesis, the modern functionalist is very apt to run directly into the embrace of hysteria. If a thing is not physical, it must be psychical in its genesis, so runs the argument. What, after all, is a neurosis? We mean ordinarily by neurosis, something functional rather than structural. We often mean something psychical rather than peripheral. Accordingly, as we have seen, many writers rush to the hypothesis that Shell-shock effects, except in a few unusual instances of organic disease, are functional; and not only are they functional but psychic, and maintained by some of the so-called “mechanisms” which abound in modern speculative writing.

99. Case 253, a case of Tinel, may serve to illustrate this point. Tinel’s patient was not subject to shell-shock at all, but was wounded in the arm. Three weeks later, he was able to flex his forearm only by means of the supinator longus. It was found that the biceps was soft and flaccid, though the electrical reactions of the biceps were normal. Now, since flexion of the forearm is normally produced by a synergic contraction of the biceps and supinator longus, the situation in Tinel’s case was striking in that the functions of the biceps and supinator longus had been separated out by a process which could not be hysterica. The hypothesis is that in hysteria it has always been found impossible to split the synergic action of these two muscles. What has happened? In Tinel’s picturesque phrase, the biceps muscle has been stupefied by a process which involved no destruction of a nerve trunk or any important nerve elements. This process of stupefaction passed away with a few weeks’ massage and rhythmic faradism. But what is this process of stupefaction, as Tinel calls it? No definite answer can be given. But is not the process analogous to what may happen in a variety of cases of shell explosion in which, for one reason or another, sundry neurones are, as it were, stupefied, stunned, anesthetized, or thrown out of gear by some internal physico-chemical readjustment of unknown nature? Perhaps that readjustment, though in Tinel’s case it probably took place within the tissues of the arm itself, is analogous to the chromatolytic process in nerve-cell bodies suspected by Mott to be at the bottom of certain Shell-shock symptoms as in Case 197.

100. Are there, then, phenomena of peripheral nerve shock analogous to the phenomena of spinal cord and brain shock which we find in so many cases? But if so, it is clearly unnecessary, and indeed injurious for us to conceive that cases proved not to be organic must necessarily be hysterical. Several authors have called a halt upon this undue extension of the concept of hysteria to include all the non-organic phenomena. Take, for example, the case of the Victoria Cross winner (Case 529), reported by Eder, in which a contracture was shown by hypnosis to be a representation of the patient’s clutch upon his bayonet (he had been at Gallipoli and was wounded in fourteen places during a bayonet fight with Turks). It would not be possible—in fact, it would seem almost impolite—to refuse to entertain the hypothesis of a kind of symbolism in the bayonet-clutch contracture of Eder’s case; but it would, on the contrary, be far from exact to consider all cases of contracture to be even probably or possibly symbolic in the manner of the bayonet-clutch. There are, many workers feel, many functional phenomena that are non-hysterical, and as it were infra-hysterical in the sense that the “mechanisms” (to use that over-worked term) are in neurones below the level of complexity required by hysteria. This theoretical possibility (that the functional should be divided into the psychical and the infrapsychical) has been given a new status by the work of Babinski and his associates. That work seems to show that the older doctrines of Charcot concerning the existence of “reflex” disorders, are perfectly sound.

101. Babinski has been able to bring into the light of observation the morbid operation of certain of these reflex arcs. Even in cases where in the waking life the central nervous system is able to overpower the reflex arcs in question and permit the limb or limbs to work reasonably well and smoothly, the process of chloroform anesthesia will quickly bring out an odd and unsuspected interior situation. The chloroform suspends the operation of numerous neurones, including those that have to do with the downflow of cerebral inhibitions, those silent streams of impulse that serve to keep the knee-jerks, for example, in leash. Now at a time when all the other muscles of the body are relaxed, the withdrawal of the cerebral inhibitions by chloroform anesthesia may cause a phenomenon to appear in certain reflex arcs that argues an excess of activity; thus in the leg, for example, an ankle-clonus, or a patella-clonus, or a degree of contracture, may be brought about early in chloroform anesthesia, though there had been little or no suspicion of such a tendency in the waking life. The cerebral inhibitions in the waking life have been enough to dampen the ardor of the reflex arc in question. It must be remarked that these cases of reflex, or, as Babinski termed them, physiopathic disorders, as a rule occur in cases locally wounded. It is the locally wounded limb that develops functional excess of contained reflex arcs. Does this occur by a process of neuritis, or by some other unknown process? Whatever the answer to this question, Babinski and his associates appear to have shown the existence of a group of physiopathic or reflex disorders; disorders below the level of the psyche and below the theatre of operations of hysteria.

102. Practically speaking, also, it is important not to consider every functional situation hysterical, since the non-hysterical functional changes may be extremely obstinate to treatment. Both physician and patient suffer if the patient is treated along psychotherapeutic lines for hysterical symptoms, some of which turn out on investigation to be functional enough but non-psychic. The peculiar configuration of symptoms shown in cases with the physical shell-shock or its equivalent, is perhaps dependent upon what neurones are locally affected. If there has been good evidence of near-by explosion or of wound, it will be especially important to learn just what parts of the nervous system and just what synergic neurones and other structures were affected. Whether the process within these neurones be one analogous to the dissolution of chromatin, or whether the process is more like one of narcosis, or narcosis and stupefaction, or whether the process is more like that of a stun, or like the plight of the nerves in a foot for a long time “asleep,” it may be impossible to say; but it is entirely unnecessary to soar directly to the higher mental process, unnecessary in short, to assume a hysterical dissociation when the dissociation may be far lower down in the nervous system.

The Treatment of Shell-shock Neuroses

103. We have pictured the practical situation in which the neuroses of the war find themselves—a situation bristling with diagnostic difficulties. The great proposition deducible therefrom is,

The diagnostic problem in Shell-shock is the diagnostic problem of neuropsychiatry at large.

The neuroses of war have this in common with the neuroses of peace—that they need to be distinguished from all other nervous and mental diseases. One cannot be a specialist in Shell-shock unless one is a neuropsychiatric specialist; even the neuropsychiatrist has much to learn from the internist, the orthopedist, the neurosurgeon, as well as from the psychologist.

But however wide the diagnostic field for Shell-shock, the therapeutic field is wider still. For the neuropsychiatric reconstructionist has to face the peculiarities of the military status of his ward, the difficulties of demobilization into civilian life (a canal system with very precise technic for the opening and closing of locks), the choice and timing of the proper measures of bedside occupation, of occupation therapy in a broader sense, of prevocational and vocational training—the whole complicated by the character changes that may have set in to bowl over all one’s preconceptions. The nub of the matter, after the era of the manière forte, the brusque psychotherapy, the rough jarring of the man back into approximate normality is, perhaps, this potentiality of subtle character changes defying possibly anybody’s analysis, but stimulating us all to our best endeavor, whether we are physicians, psychologists, occupation-workers, social workers, or nurses. Now that all sorts of reconstruction programs are in the air, each claiming its share, or more than its share, of attention, let us not forget that no one can stake out in any small plot the measures of refitting, readjustment, readaptation, rehabilitation—all these terms with slightly differing denotation have been used—especially when we take into account that not only must the patient be refitted to his entourage, but also not seldom the entourage to its returned Shell-shocker.

104. It is proper to place these general considerations first because the slow, patient, prosaic measures of reëducation are apt to be forgotten in our enthusiasm for the lightning-like cures of the hypnotic, the psychoelectric, the pseudo-operative, and other psychotherapeutic forms. Psychotherapy in all its forms has come into its own in Shell-shock. Miracles or their equivalents are daily wrought by men who are not prophets. Lourdes and Christian Science have their unassuming rivals. Let us remember, however, that even Lourdes and Christian Science never solved 100% of the problems placed before them, even though the votaries have the best will in the world to be cured. If the will itself is disordered, what can be done save investigate? And the mauvaise volonté is by no means absent from some of our prospective patients; witness one man, a Frenchman, who so resented being cured by torpillage, i.e., by the electric brush, that he carried his case against Clovis Vincent, who cured him of his hysteria, clear to the Academy! And, even after we have cured our cases by these modern miracles, let us not be too proud of ourselves! One soldier sent back to Australia, hysterically mute for months, got his voice back after killing a snake—a peculiar instance of occupation-therapy, not enumerated in courses on reconstruction. And remember the man who jumped the wall and got drunk, breaking back into the hospital to show his doctor how his refractory voice had at last come back. Thus there are cures and cures (even a newspaper cure of mutism by a moving picture vision of the antics of Charlie Chaplin), and spontaneous non-medical cures as well as medical ones, and slow cures due to vis medicatrix, as well as to shrewd reëducation measures.

105. I shall not attempt to cover systematically the topic of Shell-shock therapy in this epicrisis. The reader must go through the treated cases, especially in Section D but passim elsewhere, if he is to obtain a proper conception of all the methods so far employed—and at the end he cannot know the ultimate outcome of the cases. Patrons of the miracle cures and the manière forte are having their day: on the whole, the law of sudden onset, sudden ending has much to say for itself in the hysterical (pithiatic) group. Forebodings of relapse in these torpedoed cases may indeed have some foundation: but figures are yet lacking, and relapses may be as expectantly predicted in the slow-onset, slow-cure group. The decision must be post-bellum. Nor must the fact that a few absolutely normal subjects have succumbed de novo to Shell-shock blind us to the fact that, statistically speaking, most cases are ab ovo psychopaths in whom relapses, recurrences, or new instances of neurosis may be confidently expected. For these ab ovo psychopaths, what can suffice but (a) removal of the disease by the vis medicatrix naturae; or (b) reëducation, intellectual or (c) moral (as the case may be); or else (d) some plan of environmental shielding from new occasions of disease?

106. I shall content myself with a brief survey (insisting that the details be read of at least the leading cases in each treatment subgroup) of the cases offered in Section D (Shell-shock: Treatment and Results), consisting of 117 cases (Cases 473-589). The cases are in general arranged with the spontaneous and quasi-natural cures at the outset,—a series of 11 cases (Cases 473-483). The remainder of the section deals with cures under medical conditions, although many cases naturally show an interplay of non-medical factors in the cure or persistence of one or more symptoms.

A few cases illustrative of the physical value of hydrotherapy, mechanical therapy, and drugs are given in a short series (Cases 484-489). A treatment of hysterical contractures by induced fatigue is dealt with in Cases 489-493; and the occasional value of surgery is shown by Case 494.

The simpler methods of persuasion and explanation follow in a series of 19 cases (Cases 495-513).

Pseudo-operations and suggestive operative manipulation of avail in the treatment of certain local hysterical phenomena are considered in a series of eight cases (Cases 514-521). The comparatively long hypnotic series follows: 27 cases (Cases 522-548). The above-mentioned cures by pseudo-operation and by hypnosis may be classified with those that follow, i.e., mainly rapid cures by psychoelectric methods and by suggestion on emergence from anesthesia (Cases 549-574), as modern miracles. These cases of modern miracle are followed by a briefer set of reëducative cases (Cases 575-589).

Throughout the treatment section are scattered instances in which, not a cure, but merely a modification or even a persistence of symptoms was the outcome. It is useful to bear in mind, while reading cases in the etiological and diagnostic sections, these main divisions of treatment into what might be called (1) spontaneous, (2) rapid (or “miraculous”) and (3) slow or reëducative.

107. It is beyond the scope of this book to deal systematically with the hospital and administrative side of these questions. Especially the zone question is of practical importance, that is, the question of arrangements at the front, on evacuation lines, and in the interior. Roussy and Lhermitte have particularly discussed these matters.

After thirty months’ experience in the psychiatric centers of two armies, Damaye suggested an organization of psychiatric centers in two parts,—First, a service draining patients from the firing line, rapidly give them first care and evacuate them, in charge of special attendants, to: Second, a psychiatric or neurological center in the communication zone (étapes) without danger of bombardment and at a distance from the guns. The more serious cases will then be evacuated, thirdly, into the interior from these centers along communication lines. But most will have gotten well at the front.